Every finding on record at Abbeville Crossing of Journey LLC

Based on observations, staff interviews, and review of the facility policy titled, Disposal of Garbage and Refuse, the facility failed to ensure outdoor garbage was secured in safe working conditions were upheld, and that the refuse area was kept free of litter through proper sanitation practices.Findings include: Review of the facility policy titled Disposal of Garbage and Refuse reviewed dated 01/04/2024, revealed under Policy Explanation and Compliance Guidelines: 7.Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.10.Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents.During the initial observation and interview of the dumpster on 07/24/2026 at 8:21 AM, with Dietary Aide DD it revealed two brown dumpsters were open. Upon facing the dumpsters, it was observed that the right dumpster had the left door ajar, while the left dumpster had the lid on the left, that exposed access to trash. The Dietary Manager confirmed at 9:30 AM, via observation of pictures, that the dumpsters were open and should be secured, ensuring that no trash was present on the ground or in the surrounding area. Observation on 07/24/2026 at 12:53 PM, facing the two brown dumpsters were open. Upon facing the dumpsters, it was observed that the right dumpster had the left door ajar that exposed a white/clear trash bag, while the left dumpster had the lid on the left, that exposed access to trash.An interview on 07/25/2026, at 2:22 PM, with the Dietary Manager revealed all department heads are responsible for checking the dumpsters, but it was not checked. On 07/25/2026, at 3:58 PM, an interview with the Administrator confirmed that the maintenance of dumpsters is a collaborative effort involving housekeeping, maintenance, and kitchen dietary manager. This is necessary due to the presence of stray dogs on the property, which can access open trash doors and scatter waste on the ground. The Administrator observed the photographic evidence showing that the dumpster doors were open, emphasizing that they should remain closed and that all trash must be kept off the ground.

Based on observations, staff interviews, and review of the facility's policies documented Food Safety Requirements and Emergency Menu the facility failed to appropriately discard active and emergency expired food items and did not properly store, label, or date. These deficiencies created a potential risk for 66 out of 67 residents who received an oral diet from the kitchen, increasing their risk of foodborne illnesses.Findings Include:Review of facility's policy titled, Food Safety Requirements dated reviewed 01/04/2024, documented.3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage.c. Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include:iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; andv. Keeping foods covered or in tight containers.Review of facility's policy titled, Emergency Menu dated 2022, documented.Please note that Emergency Menu food items need to be stored in a cool, dry storage area and the items are to be rotated out into service at least every 6 months except bottled water (see below).e. Although unopened bottled water has a shelf life of greater than 2 years and does not require an expiration date (except in the state of New Jersey), it is suggested that bottled water be rotated out of the emergency supply before any expiration date listed on the bottle or every two years.During the initial kitchen tour on 07/24/2026 at 7:40 AM, two uncovered and unbagged scoops located on top of the ice machine within the kitchen were revealed. The dry storage area contained one pre-used 32 ounce (oz) bag of light brown sugar that was labeled and dated. Additionally, there was one opened 5 pound (lb) bag of cornmeal that lacked proper labeling, as well as one 10 lb bag of tri-color pasta that was also unlabeled. Furthermore, two opened 36 oz containers of iodized salt were found without appropriate labeling, dating, or storage information. A 20 liter (L) container confirmed to be rice was present without any labeling or dating. There were two (8) quart (qt) containers of pasta with expiration dates of 06/27/2026 and 06/29/2026. One 20 L container of spaghetti had an expiration date of 07/18/2026, and one 20 L container of rotini also had an expiration date of 07/18/2026. Additionally, two opened (2) qt containers of soy sauce were found without labeling or dating, along with one opened 96 oz container of extra light amber honey that was unlabeled and undated.The walk-in refrigerator inspection revealed 35 half pints of whole milk with an expiration date of 07/23/2026 and 60 half pints of 2% reduced fat milk with an expiration date of 07/20/2026. Additionally, three 46 fluid (fl) oz containers of thickened iced tea beverage and one 2 L bottle of root beer lacked appropriate labeling and dating.The walk-in freezer tour revealed two-gallon bags containing previously used Kool Whip packages were found, with an expiration date of 07/12/2025. There was also one pre-packaged bag of diced chicken, which was documented and confirmed with the Dietary Manager, that was without a label or date.At 9:55 AM, an inspection of the emergency menu supply conducted with the Dietary Manager revealed the following items: two (5 lb) packages of hush puppies mix exhibiting black-like substances on the packaging, dated 06/09/2024; sixteen (16.9 fl oz) single water bottles with an expiration date of 5/31/2026; two cases containing forty (16.9 fl oz) bottles of water, with expiration date 05/18/2026; four cases with eighty (8 fl oz) bottles of water, with expiration date 5/31/2026; fourteen (48) count of 8 fl oz water bottles with an expiration date of 04/30/2026; two boxes with 96 counts of 0.63 oz assorted family cup packs, with an expiration date of 06/07/2025 and 06/10/2025; one box containing 96 counts of 0.63 oz [NAME] Krispies cereal cups, with an expiration date of 05/12/2025; one box with 96 counts of 0.75 oz corn flakes, with expiration date 06/13/2025; one box of 58 counts of 0.5 oz classic chips, with an expiration date of 01/28/2025; one box containing 120 counts of 0.5 oz classic chips, with expiration date 02/25/2025; six cans of sloppy joe, each 52 oz, with an expiration date of 12/17/2025; twelve (24 oz) quick grits, expiring on 12/11/2025; ninety-six (4.5 oz) containers of cinnamon unsweetened apple sauce, with an expiration date of 07/09/2026; five 108 oz cans of beef hash, with expiration date 07/16/2026; seven 24 oz bottles of sloppy joe sauce, with an expiration date of 05/10/2025; one box containing 96 counts of 4 oz apple juice, with expiration date of 04/21/2025; one box with 96 counts of 4 oz orange juice, with expiration date of 05/11/2025; forty-eight counts of 7.25 oz chicken noodle soup, with an expiration date of 02/13/2026; forty-eight counts of 7.25 oz vegetable soup, expiration date of 04/18/2026; four (5 lb) containers of creamy peanut butter, with an expiration date of 03/27/2026; four boxes containing 500 individual packages of two saltines each, expiration date of 01/25/2025; three (1 lb) packages of instant pudding, with an expiration date of 01/11/2025; three cans of chili weighing 6 lb 11 oz each, expiration date of 04/03/2026; and two (50 lb) bags of nonfat dry milk, with expiration dates of 04/23/2026 and 05/17/2026.On 07/25/2026, at 2:22 PM, an interview was conducted with the Dietary Manager (DM), who indicated that staff had been trained to label food items with the name, date opened, and discard date whenever they are stored. However, she noted that she had to frequently remind them of this procedure, but they have since become lax and often forget. She acknowledged that she did not follow up on this matter. The DM confirmed full responsibility for the oversight regarding the emergency menu supply, admitting that she failed to review the items in a timely manner. She expressed concern that if there were a need for these items, it could be devastating due to all food items being expired and discarded.On 07/25/2026, at 3:58 PM, an interview with the Administrator revealed that he had advised the Dietary Manager to check the emergency menu supply on 07/23/2026, but he also acknowledged that he did not follow up on this matter. The Administrator confirmed the presence of expired, unlabeled, and undated food items could pose a risk to the residents, particularly in the event of an emergency when none of the food items would be usable.

Based on observations, record review, and staff interviews, the facility failed to ensure a hazard-free environment for one of 33 sampled residents (R25) when a pair of scissors was observed on the resident's bedside table and were accessible within the resident environment. This deficient practice had the potential to place residents at risk for lacerations or other injuries from unsecured sharp objects. The facility census was 67.Findings include:Review of R25's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, need for assistance with personal care, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and major depressive disorder, single episode, unspecified.Review of R25's Minimum Data Set (MDS), quarterly assessment dated [DATE], documented Section C Cognitive Patterns, Brief Interview for Mental Status (BIMS), as 10, indicating moderate cognitive function. Section N Medications documented R25 as receiving opioids and Antidepressants.Review of R25's care plan revealed R25 needed assistance with all activities of daily living (ADLs).Observation on 07/24/2026 at 8:45 AM revealed the resident's room door was open. A pair of scissors were on the bedside table and was visible from the hallway. Observation on 07/24/2026 at 1:30 PM revealed the resident's room door was open. A pair of scissors were on the bedside table and was visible from the hallway. Observation and confirmation on 07/25/2026 at 9:03 AM with Licensed Practical Nurse AA revealed the resident was lying in bed with a blanket over his head. A pair of scissors remained on the bedside table. LPN AA stated that residents should not have scissors because they could use them to injure themselves or others. LPN AA also stated that other residents could access the scissors and use them to injure themselves or others. LPN AA removed the scissors from Resident 25's room during the observation.Interview on 07/26/2026 at 9:05 AM with the Director of Nursing revealed the resident had scissors (she looked at pictures). She stated the resident had a high enough bims to have them, when asked about other residents who wander, she confirmed the scissors should not be out in the open, not on the bedside table where they were for other residents to get. During an interview on 07/26/2026 at 9:05 AM, the Director of Nursing (DON) reviewed photographs showing a pair of scissors on Resident 25's bedside table. The DON stated the resident's Brief Interview for Mental Status (BIMS) score was high enough to allow the resident to have scissors. When asked about the risk posed by other residents who wander, the DON confirmed the scissors should not have been left in the open on the bedside table where other residents could access them.

Based on staff interviews, record reviews, and the facility policy titled Resident Assessment-Coordination with PASARR Program, the facility failed to ensure submission to the state-designated authority for a Preadmission Screening and Resident Review (PASRR) Level II for six residents (R) (R1, R3, R8, R30, and R57) reviewed for PASRR from a sample of 33 residents. This deficient practice increased the potential to place R1, R3, R8, R30, and R57 at risk of not receiving services and/or care according to their needs. Findings include: The facility policy titled, Resident Assessment-Coordination with PASARR Program, dated revised 12/24/2023 revealed 1.a. PASARR Level I initial pre-screening that is completed prior to admission i. negative level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. 3. A record of the pres-screening shall be maintained in the resident's medical record. 5. If a resident who was not screened due to an exception above and the resident remails in the facility longer than 30 days: a. the facility must screen the individual using the State's Level I screening process and refer any resident who as or may have MD, ID, or a related condition to the appropriate state designated authority for level II PASARR evaluation and determination. B. The Level II resident must be completed within 40 calendar days of admission. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 1. Review of the electronic health record (EHR) under the Diagnosis tab for R57 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, bipolar disorder, current episode depressed, severe, without psychotic features, major depressive disorder, recurrent, severe with psychotic symptoms, and unspecified psychosis not due to a substance or known physiological condition. Review of the quarterly Minimum Data Set (MDS) assessment for R57, dated 04/13/2026, revealed that Section C (Cognitive Patterns) documented that R57 had a Brief Interview for Mental Status (BIMS) score of 15 (indicating cognition is intact). Section I (Active Diagnosis) documented diagnosis of anxiety disorder, depression, bipolar disorder, and psychotic disorder. Review of the PASRR Level I Assessment for R57, dated 11/19/2021, revealed that the diagnosis of bipolar disorder, anxiety disorder, or depressive disorder were marked. Review of the clinical record for R57 revealed no submissions for a PASRR Level II after admission. In an Interview on 07/26/2026 at 9:45 AM with the Social Services Director (SSD) revealed she is responsible for the submissions of PASSR level IIs. The SSD confirmed R1, R3, R8, R30, and R57 had qualifying mental illness diagnoses that were not marked on their level I screening. She also confirmed that the Level I screening had not been resubmitted to reflect these qualifying diagnoses. In an interview with the Administrator on 07/26/2026 at 10:00 AM, he revealed he expected the facility to complete the PASSR level one appropriately and accurately. He revealed if a newer qualifying diagnosis was documented, the facility would submit a level II application with the qualifying diagnosis, timely. He stated that Social Services was in charge of submitting PASSR level II's and admitted she had not received proper education or training on PASSRs. 2. Review of the EHR for R8 revealed, the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, schizophrenia and cognitive communication deficit Review of R8's quarterly MDS assessment, dated 07/03/2026 for Section A (Identification Information) documented No to the question asked, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Section C (Cognitive Patterns) documented that R8 had a BIMS score of 13, which indicated moderately impaired cognition; Section I (Active Diagnosis) revealed a diagnosis of schizophrenia. Review of the PASRR Level I Assessment for R8 dated 01/10/2022 did not indicate R8 having a diagnosis of schizophrenia. Review of the Physician's Orders for R8 dated for 06/17/2026-Haloperidol Lactate Oral Concentrate 2 mg/ml (milligrams per milliliter) given 2 mg by mouth with meals for schizophrenia. Review of the EHR for R1 revealed no submissions for a PASRR Level II after admission. 3. Review of the Electronic Health Record (EHR) for R1 revealed, the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, anoxic brain damage (2/13/2023), not elsewhere classified, attention-deficit hyperactivity disorder, unspecified type (11/16/2023), problem related to unspecified psychosocial circumstances (2/13/2023), and schizoaffective disorder, bipolar type (2/18/2025). Review of R1's Annual Minimum Data Set (MDS) assessment, dated 6/24/2026 for Section A (Identification Information) documented No to the question asked, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Section C (Cognitive Patterns) documented that R1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition; Section I (Active Diagnosis) revealed a diagnosis of schizophrenia. Review of the PASRR Level I Assessment for R1 dated 1/30/2023 revealed that the diagnosis of schizoaffective disorder, bipolar type, and other mental disorders was not indicated. Review of the EHR for R1 revealed no submissions for a PASRR Level II after admission. Review of the EHR for R3 revealed, the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, major depressive disorder, recurrent, unspecified (5/19/2022), bipolar disorder, unspecified (9/28/2020), anxiety disorder, unspecified (1/2/2020), and other psychotic disorder not due to a substance or known physiological condition (1/2/2020). Review of R3's Annual MDS assessment, dated 1/27/2026 for Section A (Identification Information) documented No to the question asked, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Section C (Cognitive Patterns) documented that R3 had a BIMS score of 14 which indicated intact cognition; Section I (Active Diagnosis) revealed a diagnosis of anxiety, depression, bipolar disorder, and psychotic disorder (other than schizophrenia). Review of the PASRR Level I Assessment for R3 dated 9/28/2020 revealed that the diagnosis of major depressive disorder, bipolar disorder, anxiety disorder, and other mental disorders was not indicated. Review of the EHR for R3 revealed no submissions for a PASRR Level II after admission. 4. Review of the electronic health record (EHR) under the Diagnosis tab for R30 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Schizophrenia, Unspecified Review of the quarterly Minimum Data Set (MDS) assessment for R30, dated 6/17/2026, revealed that Section C (Cognitive Patterns) documented that R30 had a Brief Interview for Mental Status (BIMS) score of 9. Section I (Active Diagnosis) documented a diagnosis of, but not all inclusive, Schizophrenia. Review of the PASRR Level I Assessment and DMA 6 for R30, dated 10/17/2019, revealed that diagnosis of other psychotic disorder was not marked. Review of the clinical record for R30 revealed no submissions for a PASRR Level II after admission.

Based on observations and staff interviews, the facility failed to provide a safe and comfortable environment for the residents, staff and the public as evidenced by an unpleasant odor on one hall (300 hall) of three halls. This deficient practice had the potential to cause diminished quality of life. The facility census was 67 residents.Findings include:Observations from 07/24/2026 through 07/26/2026 during the survey revealed a strong unpleasant odor coming from room [ROOM NUMBER] and were also present on the 300 hall.Interview on 07/25/2026 at 11:07 AM with the Activities Director and Wound Care Nurse confirmed the odor issue has been present for two to three weeks. Both confirmed housekeeping had been mopping the room, but the smell returned. They stated there is stubbing on the floor, and puddles of dirty appearing water come up through the flooring in room [ROOM NUMBER], and the 300 hall had spots of water puddling up. They confirmed the smell was bad and that they would not want any of their family members living in these conditions.Interview on 07/25/2026 at 11:30 AM with Licensed Practical Nurse{ LPN} AA confirmed that the odor was coming from room [ROOM NUMBER] and is also present on the 300 Hall.Interview on 07/25/2026 at 11:35 AM with Housekeeping Supervisor revealed he had been addressing the odor issue for the past two to three days and stated the smell has been present for approximately one week. He confirmed the odor was coming from the floor. He stated housekeeping staff continues to clean the room, but the smell consistently returns.Interview /Observation on 07/25/2026 at 11:45 AM with Certified Nursing Assistant (CNA) confirmed the brown substance coming up through the floor as you walk into room [ROOM NUMBER]. The unknown brown substance had a foul smell that lingered throughout the room and on Hall 300.Interview on 07/25/2026 at 11:52 AM with Housekeeping Aide CC confirmed she cleans room [ROOM NUMBER] two to three times per day. She reported that the water continues to puddle up on the floor and that the odor is ongoing.Interview/observation on 07/26/2026 at 8:35 AM with the Maintenance Director and the Administrator confirmed the odor and puddles of brown substance coming up through the flooring in room [ROOM NUMBER]. They both confirmed the smell on the 300 hall. The Administrator stated he decided to relocate the residents from room [ROOM NUMBER] to another room due to the odor. Both confirmed that the smell was unpleasant and was not a homelike environment for the residents, staff, or visitors.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide supervision to prevent accidents for one of one resident (Resident (R) 47) reviewed for accidents out of a total sample of 18. This failure caused actual harm on 06/9/25 when Certified Nursing Assistant (CNA) 3 gave R47 a bowl of hot ramen noodles and allowed him to go down the hallway with them on his lap to his room, which was on the other hallway. R47 had not been assessed to be able to safely handle hot liquids. R47 spilled the hot noodles on his leg and sustained a burn that resulted in a blister to his upper left thigh. Findings include: Review of a facility policy titled, Use and storage of food brought in by family or visitors, with a copyright date of 2025, revealed, . Foods may be reheated in a microwave and should be stirred during the reheating process and reheated to at least 165 F (Fahrenheit). 5. Ensure that reheated foods are cooled enough to a palatable temperature prior to consuming to prevent burns . Review of a facility policy titled, Incidents and Accidents, dated 01/09/25, revealed, . 'Accident' refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident . Review of R47's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R47 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, difficulty in walking, weakness, and need for assistance with personal care. Review of R47's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/25 and located in the Aspen MDS Viewer, revealed R47 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderately cognitively impaired. It was recorded that R47 had no bilateral upper body impairments and required supervision/touch assistance with activities of daily living. During an observation and interview on 06/09/25 at 2:56 PM, R47 approached the surveyor and Registered Nurse (RN) 1 and raised his left pant leg. R47 exposed a burn to his upper left thigh and stated the burn was caused by soup that he had last night. Review of R47's Progress Note, dated 06/09/25 at 4:43 PM and located under the Progress Notes tab of the EMR, indicated RN1 documented R47 stated he had burned himself with ramen noodles last night and did not report the incident to anyone. It was recorded that R47 stated he spilled soup onto his left upper leg. The resident was identified with a blister to the upper left thigh. It was documented that the blister was 1.8 long by 1.0 wide, but the unit of measure was not indicated. It was documented the skin was reddened around the blister. It was recorded that the area was cleansed with normal saline and triple-antibiotic ointment (TAO) applied to area. It was recorded that the Nurse Practitioner (NP) was notified and staff was to continue to monitor. Review of R47's entire clinical record failed to indicate an assessment to determine the resident's ability to handle hot liquids had been completed for the resident prior to 06/09/25. During an interview on 06/10/25 at 1:20 PM, R47 stated he had received a package of [NAME] noodles from another resident on 06/08/25 and had asked a staff member to cook them for him. During an interview on 06/10/25 at 2:05 PM, Licensed Practical Nurse (LPN) 1 stated food was being re-heated in the microwave located at the main desk prior to 06/09/25. LPN1 confirmed she had not received training on the reheating of food in a microwave prior to 06/09/25. During an interview on 06/10/25 at 2:14 PM, Infection Preventionist (IP) confirmed she had not received training on taking the temperature of food that was reheated. During an interview on 06/10/25 at 2:25 PM, Registered Nurse (RN) 1 confirmed she had not received training on taking the temperature of food that was reheated. During an interview on 06/10/25 at 3:15 PM, Certified Nurse Aide (CNA) 2 confirmed she had not received training on taking the temperature of food that was reheated. During an interview on 06/10/25 at 3:25 PM, CNA1 confirmed she had not received training on taking the temperature of food that was reheated. During an interview on 06/10/25 at 3:52 PM, the Administrator stated she had been in her position for the past month, and the staff had not been provided with any training on temping water for ramen noodles. The Administrator stated she was not aware of any electronic record assessment used to determine a resident's ability to safely handle hot liquids. During an interview on 06/10/25 at 5:11 PM, CNA3 confirmed she had not received training on taking the temperature of food that was reheated. CNA3 stated she took a bowl of ramen noodles from R47 and entered the nutrition room with the bowl of ramen noodles. CNA3 stated she filled a Styrofoam cup partially with water and placed it in the microwave to heat for 2.5 minutes. CNA3 stated she then exited the nutritional room while waiting for the water to heat. CNA3 stated that she let the water cool off prior to taking the bowl of ramen to R47. CNA3 stated the water was not hot to touch. CNA3 stated she placed the bowl of ramen inside a dome cover used to cover a plated meal. CNA3 confirmed she did not take the temperature of the ramen noodles prior to giving them to the resident. During an interview on 06/10/25 at 1:35 PM, the Administrator provided a policy titled, Hot Liquid Safety Policy, with a revision date of 2025, that read, . All residents are assessed for their ability to handle containers and consume hot liquids. Resident with difficulties will be individualized and noted on the resident's plan of care . Attached to this policy was an in-service/training sheet, dated 06/09/25 and documented as presented by the Assistant Director of Nursing (ADON), with the objectives, . 1. Hot liquid/food (heating) 2. Purple Ther. [thermometer] at microwave to temp food or liquids 3. 140 (degrees mark) is too hot to give to resident . During an interview on 06/11/25 at 2:10 PM, the Assistant Director of Nursing (ADON) confirmed the facility had not assessed all residents who handled hot liquids for safety prior to the incident. The DON stated as of 06/10/25, all residents had been assessed for safety with hot liquids and care plans had been developed. During an interview on 06/11/25 at 2:43 PM, the Dietary Manager (DM) confirmed that the residents had not been assessed for safety with hot liquids before 06/10/25. The DM confirmed all residents had been assessed as of 06/10/25.

Based on observation and interview, the facility failed to ensure the environment was free from flies. This created the potential for the harborage of insects and had the potential to affect 58 of 58 residents who resided at the facility. Findings include: 1. During the initial kitchen observation on 06/09/25 from 9:08 AM to 11:42 AM, the following observations were made with the Dietary Manager (DM): a. The dishwashing room was observed with approximately ten flies flying around in the kitchen around the dish machine. The DM confirmed these observations and voiced that maintenance had placed out bait. b. There were approximately ten flies observed flying around in the office/dry storage area and surrounding area. This was confirmed by the DM. c. There were flies observed flying around in the cook's preparation area. This was confirmed by the DM. d. Ten to 15 flies were noted in the hallways and in residents' rooms and also in the dining room areas while residents were eating. During an interview on 06/10/25 at 10:43 AM with the Maintenance Director (MD) and DM, the MD stated he baited for flies on Thursdays. The DM stated there were more flies in the kitchen than usual and was not sure where they were coming from. The MD stated he had last baited on 06/05/25.

Based on observation, interview, and review of facility policies, the facility failed to ensure protective equipment (PPE) was available for laundry staff in one of one laundry rooms while sorting soiled resident clothing and bed linens. This had the potential to infect the staff and/or 58 of 58 residents with pathogens which could potentially lead to the development of infectious diseases. Findings include: Review of a facility policy titled Handling Soiled Linens dated 01/07/25 indicated .It is the policy to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. This policy pertains to soiled linen.All used linen should be handled using standard precautions (i.e. gloves) and treated as potentially contaminated. Review of a website at https://www.ahcancal.org/Quality/Clinical-Practice/Documents/Tips%20for%20Meeting%20the%20Linen%20Requirements%20in%20SNF%20LTC.pdf titled Tips for Meeting the Linen Requirements in Skilled Nursing Facilities undated indicated .The proper handling, storing, processing, and transporting of all linens and laundry is necessary to produce hygienically clean laundry and reduce the risk of spreading infections in LTC (long-term care).handle, store, process, and transport linen so as to prevent the spread of infection.To protect all staff including nursing and housekeeping from contaminants during laundry operations, they must use PPE.Wear tear-resistant gloves when handling and laundering soiled linens.If there is risk of splashing (e.g. if laundry is washed by hand) when laundering soiled linens, staff should in addition to gowns and gloves always wear face protection (e.g. face shield, goggles). During a tour of the soiled laundry room on 06/11/25 at 9:10 AM, gloves were observed but no gowns. An immediate interview was conducted with Laundry 1, and she confirmed when she handled the soiled linens from the different units, she did not don (put on) a gown and only used disposable gloves. The Director of Housekeeping/Laundry (DHL) was present during this interview and confirmed the same information. Laundry 1 stated the soiled linens were in a bin on the outside of the facility and adjacent to the clean laundry room. Laundry 1 stated she would open the door to take the soiled laundry into the room and place the soiled laundry, which was contained in a bag, and empty it directly into the washing machine. Laundry 1 stated she did not use reuseable rubber gloves when handling soiled laundry. During an interview on 06/11/25 at 9:45 AM, the Infection Preventionist (IP) stated that she would expect the laundry staff to use PPE as needed for heavily soiled or for the protection of the staff if the laundry would splash.

Based on observation, interview, and policy review, the facility failed to follow proper sanitation methods for the prevention of foodborne illnesses when staff did not wear hair restraints while working in the kitchen and did not allow pans and dish covers to air dry before stacking them. This failure increased the risk of foodborne illness and had the potential to affect 58 of 58 residents who ate food from the kitchen. Findings include: 1. Review of the facility's policy titled, Maintaining a Sanitary Tray Line, dated 01/09/25, revealed, . Wear hair restraints (bonnets, caps, nets, to cover hair) when preparing or handling food . During an observation on 06/09/25 at 9:08 AM, during the initial tour of the kitchen, the Dietary Manager (DM) was observed with a scarf on her head, and her hair was coming out the back and hanging onto her shoulder. [NAME] 1 had a scarf on her head, and her hair was hanging out of the back and extended down past her knees. During an observation on 06/10/25 at 11:42 AM, Cook1 was observed to bring food from the kitchen to the serving line during lunch. [NAME] 1 was observed wearing a scarf with her hair hanging out on the back and down to her knees. She brought food out of the kitchen to the serving line. During an interview on 06/10/25 at 12:58 PM, the DM stated she had worn the scarf for some time. She stated she had been told by the former dietary staff manager that it was ok to wear the scarf. During an interview on 06/10/25 at 12:50 PM, the Registered Nurse (RN) Consultant stated the policy stipulated for bonnets, caps, or nets to be worn to cover the hair. RN Consultant stated what staff were wearing were scarves and not bonnets. 2. Review of the facility's policy titled, Maintaining a Sanitary Clean Pots, Pans and Dishes, dated 01/07/25, revealed, . Purpose: Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans and plate covers prevents them from drying and may allow an environment where microorganisms can begin to grow. Procedures . Equipment and utensils shall be air-dried using racks or storage stands in a self-draining position to permit air to pass around the items enabling them to 'air dry' . At no point can items be stored in a wet condition or 'wet nesting'. During an observation and interview on 06/09/25 at 10:06 AM, three metal pans, 20 inches by 12 inches by 2.5 inch deep, had been cleaned and stacked for use and were still wet. The DM confirmed the pans were still wet. During an observation and interview on 06/10/25 at 11:45 AM, the Cambro insulated plastic dome plate covers, that had been cleaned and stacked for use, were still wet. The DM confirmed the plate covers were still wet. The DM stated, The covers should be completely dry before being stacked for use. They should not be wet.

Based on interviews and record reviews, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) as required for two of three sampled residents (Resident (R)18 and R214) reviewed for beneficiary notices out of a sample of 18. Findings include: 1. Review of R18's undated admission Record located in the electronic medical record (EMR) under the Profile tab, indicated R18 was admitted on [DATE] with diagnoses including dementia with mood disturbance, chronic obstructive pulmonary disease, and metabolic encephalopathy. Review of R18's Notice of Medicare Non-Coverage (NOMNC) provided by the facility, revealed R18's skilled nursing and therapy services would end on 04/15/25, and the resident still had skilled benefit days remaining. It was recorded that the form was signed by R18 on 04/16/25, one day after R18's services would end. Review of R18's Progress Notes and Documents located in the EMR tab, indicated R18 remained in the facility, and there was no documented evidence the facility provided R18 a SNF ABN. 2. Review of R214's undated admission Record located in the EMR under the profile tab indicated R214 was admitted to the facility on [DATE], with diagnoses including cerebral infarction, dysphagia, and vascular dementia Review of R214's Notice of Medicare Non-Coverage (NOMNC) provided by the facility, revealed R214's skilled nursing and therapy services would end on 12/12/24, and the resident still had skilled benefit days remaining. It was recorded on the form that R214's representative was notified by phone call on 12/13/24 of services ending. Review of R214's Progress Notes and Documents located in the EMR tab, indicated R214 remained in the facility, and there was no documented evidence the facility provided R214 a SNF ABN. During an interview with the Business Office Manager (BOM) on 06/10/25 at 1:38 PM, BOM stated that R18, and R214 do not have SNF ABN forms because the BOM thought she only provided a NOMNC when residents are being discharged from Part A, and being placed on Part B, and that since they were still in the facility she didn't need to provide a SNF ABN form. During an interview conducted with the Administrator on 06/11/25 at 10:38 AM, Administrator was asked what her expectations related to the beneficiary notices being provided to resident and/or resident representatives? Administrator replied I would expect the staff to follow the guidelines for the notices to be provided.

Based on interviews, observations, and facility policy review, the facility failed to ensure for one of one medication rooms reviewed was free from expired medications and/or biologicals. This practice fails to ensure that biologicals stored in the medication storage room efficacy is maintained. Findings include: Review of the facility's policy titled Storage of Medication, dated 09/2018, revealed Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. During an observation conducted on 06/10/25 at 2:45 PM of the Medication Storage Room revealed four of four boxes of Lubricating Jelly were expired (one box expired 12/2022, and two boxes dated 03/2023, and one box dated 06/2023). This was confirmed by the Director of Nursing (DON) at the time of observation. During an interview conducted with the Administrator on 06/11/25 at 10:40 AM, the Administrator was asked what her expectations were related to expired medications and biologicals. The Administrator replied she would expect there not to be any expired medications and/or biologicals in the facility.

Based on observation and interview, the facility failed to ensure one resident (Resident (R) 2) of 18 sampled residents received required assistive devices during dining. This had the potential to cause a decrease in the resident's dietary intake. Findings include: Review of R2's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R2 was readmitted to the facility on [DATE] with diagnoses that included major depressive disorder and cerebral palsy. Review of R2's Care Plan, revised 03/26/25 and located under the Care Plan tab of the EMR, revealed a focus related to the resident being at risk for alteration in nutrition. It was recorded, . I request to use a large handle/built up spoon for meals . Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 04/16/25 and located under the MDS tab of the EMR, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. It was recorded that R2 required supervision or touching assistance with eating. During an observation on 06/10/25 at 12:50 PM, the test tray that was sent out without a name on the 300-hall cart was delivered to R2. There was regular silverware on the tray. During an observation on 06/10/25 at 1:20 PM, R2 was noted having difficulty eating with the spoon. He was asked about the way he was trying to eat with the spoon, and he stated, I don't have my spoon to eat with. This happens all the time when I'm in my room. During an interview on 06/10/25 at 3:31 PM, Certified Nurse Aide (CNA) 2 stated that she was not aware that R2 had any special equipment to eat with. She stated she did not know anything about the resident needing a built-up spoon for eating During an interview on 06/10/25 at 3:50 PM, the Dietary Manager (DM) stated, [R2] needs to have a large built-up spoon with meals. The DM stated CNA2 had delivered the resident's meal tray on 06/10/25, and he was not provided with his large built-up spoon.

Based on record review, staff interview and review of the facility policy titled Conducting and Accurate Resident Assessment, the facility failed to accurately assess and code behavior symptoms on the Minimum Data Set (MDS) for three residents (R) (R1, R4 and R10) from a sample of 14 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Assistant Director of Nursing were informed of the Immediate Jeopardy on [DATE], at 11:47 am. The noncompliance related to the Immediate Jeopardy (IJ) was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: Review of the facility's policy titled Conducting an Accurate Resident Assessment with a revision date of [DATE] revealed the purpose of the policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. 1. Review of the progress notes for R1 revealed the resident exhibited behavioral symptoms on [DATE], [DATE], [DATE], and on [DATE]. A [DATE] Behavior Note documented the resident continued to wander, enter other resident rooms, became agitated when staff attempted to redirect, regularly placed all belongings in a trash bag and asked How do I leave this place?. A [DATE] Health Status Note documented the resident continued to wander and enter other resident rooms. A [DATE] at 1:56 am Behavior Note documented the resident was observed taking off his pants and shoes in hallway, then laying the pants out flat on floor. He then lowered himself to the floor laying down on top of his pants. The writer attempted several times to redirect with no success. A [DATE] at 11:43 am documented the resident was refusing to leave the dining room eating off of resident's plates and undressing in the hallway. At 12:33 pm staff documented the resident was urinating on the dining room floor refusing to allow the Certified Nursing Assistant (CNA) to help change into clean clothes. A [DATE] Skilled Nurses Note documented the resident wanders in and out of other resident rooms, resists redirection and becomes aggressive when staff redirected. However, the physical and wandering behaviors were not coded in section E on the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of [DATE]. 2. A review of R4's progress notes in the electronic clinical record revealed that the resident exhibited behavioral symptoms on [DATE], [DATE], and [DATE]. A behavior note on [DATE] documented that R4 smeared fecal matter, urinated in the hallway, intentionally spilled a soda, and exhibited wandering behavior. A [DATE] behavior note documented that R4 had taken a pair of his roommate's pants, went outside to the courtyard, put the pants on over his clothes and began to yell out very loudly and periodically. A [DATE] incident note documented that R4 was observed with an abrasion to the left wrist and stated that he had cut himself and expressed that he wanted to hurt himself. However, the physical and verbal behavioral symptoms directed at others and the behavioral symptoms not directed towards others were not coded, in section E, on the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE]. 3. A review of R10's progress notes in the electronic clinical record revealed that the resident exhibited combative behavior during the provision of incontinence care and dressing. However, the physical behaviors were not coded, in section E, on the annual MDS assessment, with an ARD of [DATE]. During an interview on [DATE] at 3:30 pm, the Social Services Director was questioned about how she obtains information on residents' behaviors to code on the MDS assessments. The SSD responded that she obtained information from staff meetings, verbal reports from nurses and Certified Nursing Assistants (CNA's), and information from the 24-hour report brought up by the Director of Nursing (DON) and Assistant Director of Nursing (ADON). When the Social Services Director was asked if she reviewed resident progress notes (from the clinical record), her response was no. The facility implemented the following actions to remove the IJ: 1. Res. #1 eloped from the facility on [DATE] and was found deceased later in the day on [DATE]. 2. All residents that display wandering behavior could be affected. MDS Nurse completed an audit on all residents with wandering behaviors to ensure most recent MDS assessment is accurately coded to reflect documented behaviors of each resident. One MDS assessment was found to be mis-coded and was resubmitted by MDS Nurse and verified by DON for any errors identified to reflect accurate coding on [DATE]. 3. Administrator educated 1 MDS nurse and 1 Director of Nursing, on [DATE], on the need to accurately code MDS Assessments, utilizing documentation of residents that occurred during the assessment period. 4. MDS Policy, Conducting an Accurate Resident Assessment was reviewed by QAPI Committee on [DATE], no changes were made. Those is attendance will be Administrator, Director of Nursing, Medical Director and other members of the QA Committee. 5. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The facility implemented the following actions to remove the IJ: 1. Verified via review of the Coroner's Report dated [DATE] that documented R1 date and time of pronounced death as [DATE] at 12:50 pm. 2. Verified via review of a list titled, Residents at risk for elopement/Wandering which included nine residents and a statement that an audit was completed for MDS accuracy on [DATE]. The statement was signed by the DON and the ADON/MDS nurse. The nine residents identified with wandering behaviors were R3, R4, R5, R6, R8, R9, R10, R11, and R14. The resident identified as having a mis-coded MDS assessment was R4. The ADON/MDS nurse documented and signed, on a printed out copy of R4's electronic MDS list, that the [DATE] MDS assessment was modified for inaccurate coding in section E related to wandering behaviors. The printed out MDS list showed a [DATE] Quarterly MDS assessment and a [DATE] Modification of Quarterly MDS assessment that verified the correction had been completed. Review of the modification revealed that section E was changed to include wandering behavior exhibited 1-3 days. The coding change was completed on [DATE]. During an interview on [DATE] at 3:33 pm the ADON/MDS nurse confirmed that an audit was completed on all residents with wandering behaviors to ensure MDS accuracy, and R4 was identified with a mis-coded MDS which was corrected and resubmitted. 3. Verified via review of the Staff Development Education Sign In form, dated [DATE] and the accompanying education materials. The topic was MDS Coding Assessments and included signatures of the ADON/MDS nurse, DON, Social Services Director (SSD), and Activity Director. During an interview on [DATE] at 10:28 am, the SSD confirmed that she completes section E (Behaviors) of the MDS and had received re-education on accurate coding of the MDS assessments. During an interview on [DATE] at 3:33 pm, the ADON and DON confirmed they received education on MDS coding accuracy. During an interview on [DATE] at 4:07 pm the Administrator confirmed providing in-service education on accurate coding of the MDS. 4. Verified via review of the Conducting an Accurate Resident Assessment policy. Interviews on [DATE] at 3:33 pm with the ADON and DON and at 4:07 pm with the Administrator confirmed that the policy was reviewed on [DATE] by the QAPI committee with no changes made. 5. All corrective actions were completed on [DATE]. The facility alleges that the IJ was removed on [DATE].

Based on record review, staff interviews and review of the facility policy's titled Comprehensive Care Plans and Elopements and Wandering Residents, the facility failed to develop interventions in resident (R1) care plan to include supervision/monitoring and management of the resident's risk for elopement from a sample of 14 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Assistant Director of Nursing were informed of the Immediate Jeopardy on [DATE], at 11:47 am. The noncompliance related to the Immediate Jeopardy (IJ) was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: Review of the facility policy titled, Comprehensive Care Plans with a revision date of [DATE] revealed the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The policy documented the following definition of Professional standards of quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific situation or setting. The policy noted the care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of an undated policy titled Elopements and Wandering Residents revealed the following regarding Monitoring and Managing Residents at Risk for Elopement and Unsafe Wandering: The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan; and Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. R1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: anemia, glaucoma, mild neurocognitive disorder due to physiological condition with behavioral disturbance, Alzheimer's disease, and psychotic disorder with delusions. The resident had a Quarterly Minimum Data Set assessment completed on [DATE] indicating a Brief Interview for Mental Status (BIMS) of 5 indicating the resident had severely impaired cognition, having no behaviors or wandering behavior and required supervision with transfers and ambulation. Although the resident had a care plan since [DATE] for being at risk for elopement, the only interventions in place was to redirect resident as needed and picture added to Elopement book. The resident had an Elopement Evaluation completed on [DATE] with a score of 5 indicating the resident was at risk for elopement. Review of the Health Status Note dated [DATE] at 4:15 am documented that upon rounds noted resident not in his room. Staff immediately began search of facility. Resident was not found. The Administrator was notified, then the Director of Nursing (DON) and the local Police Department. Staff made another sweep of the facility with no results. The police arrived and was made aware of situation. The resident's sister was called and made aware of situation. The [DATE] at 4:36 pm Health Status Note documented that at 12:50 pm, the Chief of Police informed the facility the resident had been found at the base of the bridge near the facility deceased at 12:20 pm. During an interview with the Director of Nursing (DON) on [DATE] at 2:25 pm, she confirmed the only interventions in the resident's care plan for being at risk for elopement was picture added to Elopement book and redirect resident as needed. She stated the staff knew the resident and would give him things to do. She then stated she knew if it was not documented it wasn't done. Cross Reference to F689 The facility implemented the following actions to remove the IJ: 1. Res. #1 eloped from the facility on [DATE] and was found deceased later in the day on [DATE]. 2. 9 residents that have been identified as being at risk for elopement and have the potential to be affected by this. Nurse managers reviewed care plans for all 9 residents at risk for elopement to ensure their care plans are updated with individualized interventions. This audit will be completed on [DATE]. The Director of Nursing verified these care plans are in place. New admissions identified as elopement risk will be reviewed by the Director of Nursing to ensure that care plans are in place with appropriate interventions. 3. The administrator will educate 4 of 4 nurse managers, on [DATE], on the need to ensure residents that are at risk for elopement have care plan in place with individualized interventions to prevent elopement. 4. The Director of Nursing provided education to 46 of 46 Nursing Staff including 4 Registered Nurses, 16 Licensed Practical Nurses and 26 Certified Nursing Assistants regarding accessing care plans and interventions to provide care for residents on [DATE]. 5. Comprehensive Care Plan Policy was reviewed during QAPI meeting on [DATE], no changes were made to the policy. Those is attendance were the Administrator, Director of Nursing, Medical Director and other members of the QA Committee. 6. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The facility implemented the following actions to remove the IJ: 1. Verified via review of the Coroner's Report dated [DATE] that documented R1 date and time of pronounced death as [DATE] at 12:50 pm. 2. Verified via review of a list titled Residents at risk for elopement/Wandering which included nine residents and review of the nine residents' elopement-risk care plans with accompanying interventions. The nine residents identified with wandering behaviors/at risk for elopement were R3, R4, R5, R6, R8, R9, R10, R11, and R14. Review of the Elopement Risk Audit tool revealed that audits all nine residents were completed by [DATE]. During an interview on [DATE] at 3:33 pm, the DON and ADON confirmed that nine residents were identified as being at risk for elopement, their care plans had been updated, and audits completed. The DON stated there had not been any new resident admissions identified as an elopement risk, since [DATE]. 3. Verified via review of the [DATE] Staff Development Education Sign In form with topic, Care Plan Risk Assessments and accompanying education information. The in-service materials included information on elopement risk/exit seeking care plans, directions on completing elopement evaluation, and the Comprehensive Care Plans policy. The sign-in form included signatures for the DON, ADON, LPN unit manager UU, and LPN/Infection Preventionist XX. Interviews on [DATE] at 11:00 am with LPN UU, at 3:33 pm with the DON and ADON, at 4:07 pm with the Administrator and at 4:22 pm with LPN XX confirmed that the Administrator educated the four nurse managers on the need to ensure care plans are in place with individualized interventions for residents at work for elopement. 4. Verified via review of the in-service education sign-in forms with topics of Care Plans - [NAME] Access, dated [DATE], and review of the Comprehensive Care Plans policy. The sign-in forms were cross referenced with a master list of staff and confirmed that 46 nursing staff received the education regarding accessing care plans via text or in-person. During an interview on [DATE] at 2:45 pm the DON confirmed providing education to nursing staff and confirmed that they have access to residents' care plans, including those at risk for elopement. During an interview on [DATE] at 3:33 pm the ADON stated that care plan information on residents at risk for elopement also carries over to the [NAME] (which the CNAs access for resident care information). Interviews on [DATE] at 10:43 am with Certified Nursing Assistant (CNA) PP, at 10:45 am with CNA QQ, at 10:49 am with Licensed Practical Nurse (LPN) RR, at 10:53 am with Registered Nurse (RN) SS, at 10:56 am with LPN TT, at 11:00 am with LPN UU, at 11:20 am with CNA WW, at 11:22 am with LPN XX, at 11:28 am with CNA NNN, at 11:30 am with CNA OOO, at 11:33 am, at 11:35 am with CNA YY, at 11:38 am with LPN ZZ, at 11:48 am with LPN AAA, at 11:50 am with LPN BBB, at 12:07 pm with CNA CCC, at 12:13 pm with CNA DDD, at 12:15 pm with CNA CC, at 12:27 pm with CNA HH, at 12:36 pm with CNA EEE, at 12:39 pm with CNA FFF, at 12:43 pm with CNA GGG, at 1:15 pm with CNA HHH, and at 2:35 pm with RN LLL confirmed they had received education on accessing care plans and interventions to provide care for residents on [DATE]. 5. Verified via review of the QAPI meeting agenda and minutes, dated [DATE] and titled Ad hoc QAPI For Elopement Event and the Comprehensive Care Plans policy. The QAPI meeting information includes that the Medical Director joined the meeting by phone. Interviews conducted on [DATE] at 3:33 pm with the DON and ADON, at 4:07 pm with the Administrator, and at 4:22 pm with LPN Infection Preventionist XX confirmed that the QAPI meeting was held on [DATE] and the comprehensive care plan policy was reviewed with no changes. 6. All corrective actions were completed on [DATE]. The facility alleges that the IJ was removed on [DATE].

Based on interviews, record review and review of the facility policy titled, Elopements and Wandering Residents, the facility to provide adequate supervision and frequent monitoring of resident (R1) and failed to ensure a kitchen door was locked to prevent the elopement of R1. The facility also failed to provide adequate supervision of the steam table that was turned on and left unsupervised in the dining room. The sample was 14 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Assistant Director of Nursing were informed of the Immediate Jeopardy on [DATE], at 11:47 am. The noncompliance related to the Immediate Jeopardy (IJ) was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: Review of an undated policy titled, Elopements and Wandering Residents revealed the following: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk; the facility is equipped with door locks/alarms to help avoid elopements; The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary; Adequate supervision will be provided to help prevent accidents or elopements. R1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: anemia, glaucoma, mild neurocognitive disorder due to physiological condition with behavioral disturbance, Alzheimer's disease, and psychotic disorder with delusions. The resident had a Quarterly Minimum Data Set assessment completed on [DATE] indicating a Brief Interview for Mental Status (BIMS) of 5 indicating the resident had severely impaired cognition, having no behaviors or wandering behavior and required supervision with transfers and ambulation. Although the resident had a care plan since [DATE] for being at risk for elopement, the only interventions in place was to redirect resident as needed and picture added to Elopement book. The resident had an Elopement Evaluation completed on [DATE] with a score of 5 indicating the resident was at risk for elopement. Review of the Health Status Note dated [DATE] at 4:15 am documented that upon rounds noted resident not in his room. Staff immediately began search of facility. Resident was not found. The Administrator was notified, then the Director of Nursing (DON) and the Abbeville Police Department. Staff made another sweep of the facility with no results. The police arrived and was made aware of situation. The resident's sister was called and made aware of situation. The [DATE] at 4:36 pm Health Status Note documented that at 12:50 pm, the Chief of Police informed the facility the resident was found at the base of the bridge near the facility deceased at 12:20 pm. It also noted an autopsy would be performed. Review of the [DATE] neighboring county Sheriff's Office Incident Report/Narrative indicated the resident had been found under the HWY 280 bridge. A time was not specified in the report. The investigator noted he proceeded to the location of the subject and found an older black male lying flat on his back, arms partially extended in a boxing type position, extended. There were two minor scrapes on his forehead, eyes partially open. Subject was cold to the touch. After the Coroner completed getting photos the body was turned over to look for any marks consistent with being hit by a vehicle. No marks were visible on his back or chest and stomach area. No visible were noted. It appeared the subject had fallen over the edge of the bridge landing at the location he was positioned at. The fall was approximately 19 feet 3 inches. Looking at the bottom of the subjects shoes showed absolutely no dirt or mud even though the whole area was muddy, no shoe impressions were found matching the shoes he was wearing. The subject was directly in line with the bridge above as falling over the side. The investigator had made contact with the Sheriff, Chief of local Fire Department, Coroner and local Police department and was advised that the resident had left the facility through the kitchen door that leads outside, then left through kitchen door to outside kitchen that was not locked. The resident was seen on security cameras leaving the grounds at 12:05 am. The Sheriff advised him that 911 dispatch had received a call that a black male matching the resident's description was seen on the Ga HWY 30 bridge outside of the city at approximately 12:49 am of a male walking into traffic on US HWY 280 (also known as GA HWY 30) at the neighboring counties bridge and the description matches the resident. Review of the [DATE] Coroner's Report documented the date and time of pronounced death as [DATE] 12:50 pm. The Coroner's description of incident leading to death indicated the resident exited through the kitchen door with video review showing he left at 12:05 am walking down the drive to the highway. At 12:45 am 911 received a call of an unknown person walking east on the bridge. The resident was located at 12:21 pm by Department of Natural Resources and a neighboring county firefighter. The resident was found lying flat on his back. There seemed to have been no movement where he was lying. There was no mud or dirt on his shoes. The drop was 19 feet from the bottom of the bridge. He was transported on [DATE] for an autopsy. During an interview with the Administrator and the Director of Nursing on [DATE] at 11:45 am, they stated that on [DATE] at 6:45 pm, the last dietary staff person who left for the day, left the door unlocked that lead into the kitchen. The resident walked into the kitchen from the dining room because that door was left unlocked then walked out the second door which led him outside. The resident was last seen by CNA HH on [DATE] at 11:45 pm while she was clocking out. The Administrator stated some CNAs stated they last saw the resident at 1:30 am when they had to get him out of another resident's room. He stated he did not agree with those CNAs because the cameras caught the resident leaving on [DATE] at 12:05 pm. He then stated staff discovered the resident missing between 4:00 am and 4:30 am. The nurse and the CNA who were assigned to the resident that night have been suspended as well as the dietary staff person who did not lock the door. He stated the dietary staff is now supposed to report to nursing when they are leaving and must exit through the main doors at the time clock. Stated they think the dietary staff did not lock the kitchen door from the dining room. That lock has since been replaced. Review of the video surveillance revealed the following timeline: 1. [DATE] at 6:44 pm- two dietary staff observed entering the kitchen from the dining room. Dietary staff DD let the door slam but did not lock the door. At 6:45 pm the two dietary staff exit the building through the back kitchen door. 2. [DATE] at 10:20 pm R1 walks into the dining room talking to himself, looks in the tray carts, walks around the steamtable several times and picks up a plastic cutlery set. At 10:24 pm he opens the kitchen door and enters the kitchen. 3. [DATE] at 10:24 pm, although the resident was out of view, sounds could be heard of the resident humming, feet shuffling and could hear sounds of paper or plastic being moved around. At 10:27 the resident comes into view of the camera and is observed opening the chemical supply closet, looks in the closet for a few seconds, then closes the door closet door and walks out of view of the camera. Although the resident is out of view of the camera sounds could still be heard of the resident humming, shuffling footsteps and what sounded like metal cookware or metal cabinet doors slamming. At 10:35 the resident comes back in view and is seen turning on the lights in the kitchen next to the exit door then walks out of view. There were no more sounds heard in the kitchen after 10:36 pm. He is then seen on the dining room camera leaving the kitchen into the dining room and leaves the dining room. 4. [DATE] at 11:45 pm, CNA HH is seen leaving through the front main double doors at the time clock with the resident in view of camera. 5. [DATE] at 12:05 am, the resident is observed leaving the building through the kitchen exit door stepping outside onto the loading dock area. He then steps down off the loading dock and starts walking the driveway towards the highway. 6. [DATE] at 12:06 to 12:07 am- Front Patio Camera captures the resident briefly walking from the kitchen loading dock area down the driveway. The camera then briefly captures the resident walking east on the highway. During the time the resident was in the kitchen on [DATE] from 10:24 pm to 10:36 pm, the resident had turned on the oven and the oven timer. From review of the video surveillance the oven timer alarm started alarming on [DATE] at 11:05 pm and continued to alarm until [DATE] at 4:32 when staff entered the kitchen looking for the resident. During an interview with the Dietary Manager on [DATE] at 2:55 pm, she stated for the oven timer to alarm, the oven must be turned on. This confirmed the oven was left on and unsupervised from [DATE] at approximately 11:05 pm to [DATE] at 4:32 am when staff turned the alarm off. During an interview with Dietary staff DD on [DATE] at 1:41 pm she confirmed she did not lock the kitchen door. She stated she was rushing to get to her second job. She stated they had been instructed to lock the kitchen door when they were leaving which is usually at 7:00 pm. During an interview with CNA BB on [DATE] at 4:04 pm, she confirmed she was assigned to R1 on [DATE]. She stated she was not sure of the last time she saw the resident but guessed around 1:30 am when he was in another resident's room. When the surveyor asked her if she made rounds on the resident every two hours, she refused to answer the question and stated she was not sure how it all happened. She stated that night the resident was going door to door trying to pull the doors open. Two attempts were made on [DATE] at 1:20 pm and on [DATE] at 4:00 pm to call Licensed Practical Nurse AA who was assigned to R1 on [DATE] but was unsuccessful. During an interview with the Director of Nursing (DON) on [DATE] at 2:25 pm, she stated she expects the nurses and the CNAs to make rounds on the residents at least every two hours. Review of the LPN nurse job description noted the general purpose was to provide direct nursing care to the residents and supervise the day to day nursing activities performed by nursing assistants. Such supervision must be in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to maintain the highest degree of quality care at all times. It also listed the following administrative functions: Direct the day to day functions of the nursing assistants in accordance with rules, regulations, and guidelines that govern the longterm care industry. Nursing Care Functions: Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices, Make periodic checks to confirm that prescribed treatments are being properly administered by CNAs and to evaluate the resident's physical and emotional status, review care plans daily to confirm that appropriate care is being rendered, confirm that CNAs are aware of the resident care plans. Other Duties: Protect residents from neglect, mistreatment, and abuse. Review of the Certified Nursing Assistant job description noted the general purpose was to perform direct resident care duties under the supervision of licensed nursing personnel. Assist with promoting a compassionate physical and psychosocial environment for the residents. Essential Job Functions: Provide personal care of residents daily, Observe residents carefully and report changes in condition to Charge Nurse, promptly answer call lights and other resident needs, Protect residents from neglect, mistreatment and abuse, Others as directed by the supervisor or administrator. 2. A review of scheduled mealtimes for the residents' dining room revealed that breakfast started at 7:15 am, lunch started at 12:15 pm and dinner started at 5:15 pm. During an observation on [DATE] at 1:54 pm, the steam table that is located in the residents' dining room, had approximately an inch of water in four uncovered wells, with steam rising off the water. The dining room doors were open and the steam table was unsupervised and accessible to residents. During a check of the steam table water temperatures on [DATE] at 1:55 pm with dietary aide FF, the water temperatures in the wells of the steam table were 160 degrees, 156 degrees, 147 degrees, and 110 degrees Fahrenheit. Dietary aide FF confirmed that the steam table was turned on and reached down on the lower portion of the table and turned the knobs to turn it off. During the observations on [DATE] at 1:54 pm and 1:55 pm, two residents were observed in the dining room. During an interview on [DATE] at 4:00 pm, dietary aide FF was asked who is responsible for turning off the steam table. Dietary aide FF responded that it is the last person on the (steam table) line and indicated that dietary cook EE was the last person on the line for the previous lunch service. During an interview on [DATE] at 11:13 am, the Dietary Manager stated that the cook is supposed to turn off the steam table at the end of the meal service. The facility implemented the following actions to remove the IJ: 1. Res. #1 eloped from the facility on [DATE] and was found deceased later in the day on [DATE]. 2. Licensed Practical Nurse AA was suspended pending investigation on [DATE] and terminated on [DATE]. 3. Certified Nursing Assistant BB was suspended pending investigation on [DATE] and terminated on [DATE]. 4. Dietary Assistant was suspended pending investigation on [DATE] and terminated on [DATE]. 5. The facility conducted a house-wide head count to ensure all other residents were accounted for on [DATE]. 6. Law enforcement notified on [DATE] by Administrator. 7. State Agency was notified [DATE] by Administrator. 8. The resident's responsible party was notified on [DATE] by both the staff nurse and the Director of Nursing. 9. Administrator notified the Ombudsman on [DATE]. 10. Ad HOC QAPI held [DATE]. Reviewed incident and Elopement and Wandering Resident Policy during this meeting, no change were made to the policy. In attendance were the Administrator, Director of Nursing, Medical Director and QA Committee. During this meeting the committee determined the root cause of R1 eloping from the facility was related to the dietary staff not ensuring the kitchen was locked, nursing staff not conducting rounds every two hours on this resident and not providing redirection when resident displayed increase in wandering behaviors. 11. Camera footage of event reviewed and secured [DATE]. 12. Facility obtained statements from staff present during the event on [DATE]. 13. All residents re-assessed for elopement risk and had care plans updated to reflect risk on [DATE], by nurse managers. 14. Maintenance Director checked to ensure kitchen door lock is functioning properly on [DATE], it was functioning properly. 15. Maintenance Director checked to ensure doors throughout the facility were functioning properly on [DATE], all doors were functioning properly. 16. 100% Staff education on Elopement Protocol, Risk and Prevention, Abuse and Neglect and placing a work order when equipment fails and that if equipment is essential for resident safety, a phone call should be placed to Maintenance Director and Administrator to develop a plan to keep residents and staff safe, started [DATE] and completed on [DATE]. 82 of 82 staff educated: 1 Administrator, 1 Human Resources Director, 1 Social Services Director, 3 Activity Personnel, 1 Medical Records Coordinator, 1 Transportation Aide, 13 Therapy Personnel, 7 Dietary Personnel, 8 Housekeeping Staff, 4 Registered Nurses, 16 Licensed Practical Nurses, 26 Certified Nursing Assistants. All staff who have not been in-serviced will be in-serviced prior to their next shift. 17. 100% Nursing staff educated on Rounding every two hours on all residents and more frequently during periods of time which residents may require it started on [DATE] and completed by [DATE]. 46 of 46 educated: 4 Registered Nurses, 16 Licensed Practical Nurses and 26 Certified Nursing Assistants. 18. The kitchen front entrance door keypad door lock was replaced with upgraded locking device on [DATE]. 19. The facility ordered a double-sided keypad door lock for exterior kitchen door, installed on [DATE]. 20. The keypad lock installed on one dining room door on [DATE]. The dining room will be locked at 7:00pm by dietary staff daily. Then checked by nursing staff and logged into the door check log. 21. On [DATE], the steam table was left on after lunch service, with 1 resident present in dining room, when the cook realized the steam table was on, the steam table was turned off. 22. No residents identified as being harmed by steam table. 23. The administrator educated all 7 dietary staff on [DATE] on turning off the steam table after meals and staying with the steam table when hot and residents have access. 24. Ad HOC QAPI held [DATE] with Administrator, Director of Nursing, Medical Director and QA Committee to discuss findings of this investigation, survey and plan of action to address identified concerns. 25. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The facility implemented the following actions to remove the IJ: 1. Verified via review of the Coroner's Report dated [DATE] that documented R1 date and time of pronounced death as [DATE] at 12:50 pm. 2. Verified via review of the Status/Payroll Change Report, dated [DATE], that documented LPN AA was out pending investigation. Review of the Separation Notice, dated [DATE], revealed LPN AA's employment period was [DATE] through [DATE] with reason for separation documented as poor job performance. 3. Verified via review of the Status/Payroll Change Report, dated [DATE], that documented CNA BB was suspended due to investigation. Review of the Separation Notice, dated [DATE], revealed CNA BB's employment period was [DATE] through [DATE] with reason for separation documented as poor job performance. 4. Verified via review of the Status/Payroll Change Report, dated [DATE], that documented Dietary Assistant DD was suspended due to investigation. Review of the Separation Notice, dated [DATE], revealed that Dietary Assistant DD's employment period was from [DATE] through [DATE] with reason for separation documented as not following company procedures and poor job performance. 5. Verified via review of a [DATE] untitled document by the DON who documented that upon arrival to the facility, repeat head count performed with all other residents accounted for. 6. Verified via review of R1's clinical record that included a [DATE] Health Status progress note that the local police department was notified of R1's elopement. 7. Validated through review of the Facility Reported Incident (FRI) form dated [DATE] which reported R1 was missing. The FRI indicated the date and time of incident was [DATE] at 4:30 am. 8. Validated via review of the [DATE] at 4:15 am Health Status Note which documented the resident's sister was called and made aware of the situation. 9. Validated through interview with the Ombudsman on [DATE] at 2:05 pm, who stated the facility had notified her of R1's elopement. Review of the [DATE] Social Services note documented she spoke with the Ombudsman at 12:40 pm to inform her of R1's elopement. 10. During an interview on [DATE] at 4:07 pm the Administrator confirmed that an Ad Hoc QAPI meeting was held on [DATE] following R1's elopement and the Elopement and Wandering Resident Policy was reviewed with no changes. During an interview on [DATE] at 3:33 pm the DON and ADON also confirmed attending the Ad Hoc QAPI meeting on [DATE]. Review of the QAPI form with initial date of [DATE], confirmed the facility identified the root cause of R1's elopement from the facility. The [DATE] QAPI form included a problem statement of: A resident eloped the facility and had a negative outcome. The root causes included that the kitchen door was not locked prior to dietary staff leaving for the day and nursing staff were not rounding every two hours. 11. Confirmed by surveyor review of camera footage of event. 12. Verified via review of staff's written statements concerning the events on [DATE]. 13. Verified via review of the tnd1vIdual elopement evaluations, dated 315/2025, that were completed on all residents. A review of the assessments confirmed that nine residents were identified as at risk for elopement. The nine residents were R3, R4, RS, R6, RB, R9. R10, R11, and R14. Reviews of the clinical records for the nine residents identified at being at risk for elopement revealed that the resident care plans had been updated to include the risk with accompanying interventions. During an interview on [DATE] at 3:33 pm the DON and ADON confirmed that all residents were reassessed for elopement risk on 315/2025 14. Review of the typed statement dated [DATE] by the Maintenance Director noted he inspected the dining room to the kitchen door and that the deadbolt lock was in working order. 15. Validated via review of the [DATE] Daily Door Checks form which documented all exit doors, side dining room door, front kitchen door and the back kitchen door were functioning properly 16. Interviews on [DATE] at 10:10 am with Dietary [NAME] GG and Dietary Aide II, at 10:19 am with Houskeeper(HK) JJ, at 10:23 am with HK KK, at 10:25 am with HK LL, at 10:28 am with HK Supervisor MM, at 10:31 am with Activity Director NN, at 10:34 am with the Social Worker, at 10:37 am with Medical Records/Scheduler OO, at 10:40 with Human Resources/Payroll Manager, at 10:43 am with Certified Nursing Assistant (CNA) PP, at 10:45 am with CNA QQ, at 10:49 am with Licensed Practical Nurse (LPN) RR, at 10:53 am with Registered Nurse (RN) SS, at 10:56 am with LPN TT, at 11:00 am with LPN UU, at 11:10 am with the Maintenance Director, at 11:15 am with Director of Rehab, at 11:20 am with CNA WW, at 11:22 am with LPN XX, at 11:25 am with Activity Assistant MMM, at 11:28 am with CNA NNN, at 11:30 am with CNA OOO, at 11:33 am with Marketing/Admissions, at 11:35 am with CNA YY, at 11:38 am with LPN ZZ, at 11:48 am with LPN AAA, at 11:50 am with LPN BBB, at 12:07 pm with CNA CCC, at 12:13 pm with CNA DDD, at 12:15 pm with CNA CC, at 12:27 pm with CNA HH, at 12:36 pm with CNA EEE, at 12:39 pm with CNA FFF, at 12:43 pm with CNA GGG, at 1:15 pm with CNA HHH, at 1:27 pm with Laundry Aide III, at 1:35 pm with the Dietary Manager, at 1:41 pm with Dietary Aide JJJ, at 1:47 pm with Transportation Aide KKK, at 2:35 pm with RN LLL and at 3:33 pm with the Administrator and the DON confirmed they had received education on Elopement Protocol, Risk and Prevention, Abuse and Neglect, placing a work order when equipment fails and if the equipment is essential for resident safety and a phone call should be placed to the Maintenance Director and the Administrator to develop a plan to keep residents and staff safe. During an interview on [DATE] at 4:22 pm LPN Infection Preventionist XX clarified that housekeeping and dietary staff do not have access to the electronic system used for placing work orders, but their supervisors do have access. They were educated on notifying their supervisors immediately so that an (electronic) work order can be completed by the supervisor. LPN XX also stated that education with newly hired staff had also been completed. Verified via review of the in-service education sign-in forms with topics of elopement and two-hour rounding with sign-off forms and the accompanying education information. The sign-in forms were cross referenced with a master list of staff and confirmed that 46 nursing staff received the education regarding rounding every two hours on all residents. During an interview on [DATE] at 3:33 pm the DON and ADON confirmed education to nursing staff had been provided regarding two-hour rounding. Interviews on 3121/2025 at 10:43 am with Certtf1ed Nursing Assistant (CNAJ PP. at 10:45 am with CNA QQ, at 10:49 am with Licensed Practical Nurse (LPN) RR, at 10:53 am with Registered Nurse (RN) SS, at 10:56 am with LPN TT. at 11:00 am with LPN uu.at 11:20 am With CNA WW. at 11:22 am With LPN XX, at 11:28 am with CNA NNN, at 11:30 am with CNA 000. at 11:33 am. at 11:35 am With CNA YY. at 11:38 am with LPN zz.at 11:48 am With LPN AAA, at 11:50 am with LPN BBB, at 12:07 pm with CNA CCC, at 12:13 pm with CNA DD, at 12:15 pm with CNA CC, at 12:27 pm with CNA HH, at 12:36 pm with CNA EEE, at 12:39 pm with CNA FFF. at 12:43 pm with CNA GGG, at 1:15 pm with CNA HHH, and at 2:35 pm with RN LLL confirmed they had received education on accessing care plans and interventions to provide care for residents on [DATE]. A review of completed Rounds Sheets, from [DATE] through [DATE], tor all three halls (100, 200, and 300 halls with resident rooms, revealed that staff signed off as completing rounding on residents every two hours starting on [DATE] The form included instructions for nurses to document on even hours and CNAs document on odd hours. 17. Verified via observation on [DATE] at 1:50 pm with the Administrator and the Maintenance Director of the new keypad with a deadbolt lock on the kitchen front entrance door. The new lock was noted to be functioning properly. 18. Verified via review of the invoice dated [DATE] where the facility had ordered a new upgrade double sided keypad door lock. Also verified via observation on [DATE] at 12:10 pm of the new lock installed on the exterior kitchen door that was functioning properly. The facility had also installed an Exit Stopper Multifunction Door Alarm on the exterior kitchen door. 19. Verified via observation with the Administrator on [DATE] at 10:45 am of the new keypad lock on the main dining room door. The keypad lock was observed to be functioning properly. Also verified via review of documentation on the Daily Door Checks log dated [DATE] through [DATE] of staff checking all exit doors and the main dining room door in the morning and the afternoon. 20. This was observed by surveyor on [DATE]. 21. Per surveyor observation no resident was identified as being harmed. 22. Verified via review of in-service education document dated [DATE] with the topic of: steam table safety and shutdown procedures. The signatures on the form were cross-referenced with a master list of staff and confirmed that all seven dietary staff received the education. During an interview on [DATE] at 4:07 pm, the Administrator confirmed providing the education to dietary staff. The Administrator stated that the staff were receptive to the education and understood the importance of it. He stated that staff would remain in the dining room with the steamtable, while it cooled down. Interviews on [DATE] at 10:10 am with Dietary [NAME] GG and Dietary Aide II, at 1:35 pm with the Dietary Manager, at 1:41 pm with Dietary Aide JJJ, at 1:47 pm confirmed they had received education on steam table safety and shutdown procedures. During an observation on [DATE] at 10:15 am, the dining room was open with a few residents seated at tables, watching tv on the large screen. The steam table was roped off with a staff person seated, in front of it, within the roped off area. 23. Verified via review of the QAPI meeting agenda and minutes, dated [DATE] and titled Ad hoc QAPI For Elopement Event''. The QAPI meeting information includes that the Medical Director joined the meeting by phone. Interviews conducted on [DATE] at 3:33 pm with the DON and ADON, at 4:07 pm with the Administrator, and at 4:22 pm with LPN Infection Preventionist XX confirmed that the QAPI meeting was held on 3/ 19/2025. 24. All corrective actions were completed on [DATE]. The facility alleges that the IJ was removed on [DATE].

Based on interviews, record reviews, and review of the job descriptions for the Executive Director and the Director of Nursing (DON), the facility Administration failed to provide frequent monitoring and protective oversight of the facility environment to prevent the elopement of resident (R1) and prevent resident access to potentially hazardous kitchen equipment. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Assistant Director of Nursing were informed of the Immediate Jeopardy on [DATE], at 11:47 am. The noncompliance related to the Immediate Jeopardy (IJ) was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: A review of the Executive Director's job description revealed General Purpose: To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Section Facility Management: Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed. Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of facility; morale of the staff; and ensure resident needs are being addressed. Verify that the building and grounds are maintained appropriately and that equipment and work areas are clean, safe and orderly, and any hazardous conditions are addressed. A review of the DON's job description revealed General Purpose: To manage the overall operations of the Nursing Department in accordance with Company policies, standards od nursing practices and government regulations so as to maintain excellent care of all residents' needs. Section Administrative Functions: Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department. Section Personnel Functions: Delegate to nursing service supervisory personnel the administrative authority, responsibility, and accountability necessary to perform their assigned duties. Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Section Nursing Care Functions: Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with resident's request. Regularly inspect the facility and nursing practices for compliance with federal, state and local standards and regulations. Section Safety and Sanitation: Assure residents a comfortable, clean, orderly and safe environment. Section Care Plan and Assessment Functions, Documentation: Verify that medical and nursing care is administered in accordance with the resident's wishes. Assist with development of and approve final version of the Interdisciplinary Plan of Care for each resident in coordination with the physician, Medical Director, nursing staff, and outside consultants (i.e., nursing, dietary, pharmacy, therapists, etc.) and in accordance with corporate , state and federal guidelines. Confirm accurate completion of forms/reports for the admission, transfer and/or discharge of each resident including, but not limited to, the nursing portion of [NAME], Initial Nursing Assessment, Minimum Data Set (MDS), Resident Care Plan and the Annual MDS. R1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: anemia, glaucoma, mild neurocognitive disorder due to physiological condition with behavioral disturbance, Alzheimer's disease, and psychotic disorder with delusions. The resident had an Elopement Evaluation completed on [DATE] with a score of 5 indicating the resident was at risk for elopement. Review of the Health Status Note dated [DATE] at 4:15 am documented that upon rounds noted resident not in his room. Staff immediately began search of facility. Resident was not found. The Administrator was notified, then the Director of Nursing (DON) and the Abbeville Police Department. Staff made another sweep of the facility with no results. The police arrived and was made aware of situation. The resident's sister was called and made aware of situation. The [DATE] at 4:36 pm Health Status Note documented that at 12:50 pm, the Chief of Police informed the facility the resident was found at the base of the bridge near the facility deceased at 12:20 pm. During an interview with the Administrator and the Director of Nursing on [DATE] at 11:45 am, they stated that on [DATE] at 6:45 pm, the last dietary staff person who left for the day, left the door unlocked that lead into the kitchen. The resident walked into the kitchen from the dining room because that door was left unlocked then walked out the second door which led him outside. The resident was last seen by CNA HH on [DATE] at 11:45 pm while she was clocking out. The Administrator stated some CNAs stated they last saw the resident at 1:30 am when they had to get him out of another resident's room. He stated he did not agree with those CNAs because the cameras caught the resident leaving on [DATE] at 12:05 am. He then stated staff discovered the resident missing between 4:00 am and 4:30 am. The nurse and the CNA who were assigned to the resident that night have been suspended as well as the dietary staff person who did not lock the door. He stated the dietary staff is now supposed to report to nursing when they are leaving and must exit through the main doors at the time clock. It was further reported that they think the dietary staff did not lock the kitchen door from the dining room. During an interview with the Director of Nursing on [DATE] at 2:25 pm, she stated she expected the nurses and the CNAs to make rounds on the residents at least every two hours. Cross Refer to F641, F656, and F689. The facility implemented the following actions to remove the IJ: 1. Res. #1 eloped from the facility on [DATE] and was found deceased later in the day on [DATE]. 2. Administration failed to provide monitoring and protective oversight of the facility environment to prevent elopement of R1. Specifically, the facility administration failed to ensure the kitchen entry door was locked, failed to accurately assess and code R1's wandering behavior on the Minimum Data Set, and failed to develop interventions in the care plan to include management/supervision to address the resident's risk of elopement. 3. On [DATE], The Administrator and Director of Nursing were re-educated on the job description by the Human Resources Director. 4. On [DATE], The Administrator and Director of Nursing were educated by [NAME] President of Clinical Services on Elopement Prevention. 5. The Director of Nursing verified that all 9 residents identified as being at risk for elopement have been properly assessed for elopement risk, MDS's are that have been submitted are accurately coded and that residents have care plans in place with appropriate interventions. 6. Beginning [DATE], the Administrator has conducted rounds daily on all exit doors to ensure they are functioning appropriately Monday through Friday. On the weekends these same rounds are completed by the Nurse Supervisor and reviewed on Monday morning by the Director of Nursing. If issues or concerns are identified they are addressed immediately. The Administrator and/or Director of Nursing are available by phone to address any concerns 24/7 when not in the facility. 7. Beginning [DATE], The Administrator and Director of Nursing will conduct rounds over the phone with nurse supervisors during night shift to inquire about residents with wandering behaviors, what interventions are being utilized to deter the behavior, ensuring all doors are secure including the kitchen door, and to ensure residents don't have access to hazardous equipment. Nurse supervisor completes an audit form nightly, and the Director of Nursing is reviewing the following day. If issues or concerns are identified they are addressed immediately. The Administrator and/or Director of Nursing are available by phone to address any concerns 24/7 when not in the facility. 8. Elopement and Wandering Resident Policy was reviewed during QAPI meeting held [DATE] with the Administrator, Director of Nursing, Medical Director and QA Committee. No changes were made to this policy. The root cause of the events were discussed and plan put into place to address identified concerns. 9. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The facility implemented the following actions to remove the IJ: 1.Verified via review of the Coroner's Report dated [DATE] that documented R1 date and time of pronounced death as [DATE] at 12:50 pm. 2. This was confirmed as evidenced by R1 eloping from the facility on [DATE] and not being missed for at least four hours after he eloped. 3. This was verified via review of the Job Descriptions for the Executive Director (Administrator) and the Director of Nursing with their corresponding signatures and dated [DATE]. Also verified through interview with the Human Resources Director on [DATE] at 10:40 am who confirmed she had educated the Executive Director and the DON regarding their job descriptions. 4. Verified via review of the Inservice Sign In Sheet titled Elopement Prevention Procedures dated [DATE] by the [NAME] President of Clinical Services. Also verified via interview with The [NAME] President of Clinical Services on [DATE] at 3:23 pm who confirmed she provided the education to the Administrator and the DON. 5. Verified via review of a list titled, Residents at risk for elopement/Wandering which included nine residents and a statement that an audit was completed for MDS accuracy on [DATE]. The statement was signed by the DON and the ADON/MDS nurse. The nine residents identified with wandering behaviors were R3, R4, R5, R6, R8, R9, R10, R11, and R14. During an interview on [DATE] at 3:33 pm the ADON/MDS nurse confirmed that an audit was completed on all residents with wandering behaviors to ensure MDS accuracy. Verified via review of a list titled Residents at risk for elopement/Wandering which included nine residents and review of the nine residents' elopement-risk care plans with accompanying interventions. The nine residents identified with wandering behaviors/at risk for elopement were R3, R4, R5, R6, R8, R9, R10, R11, and R14. During an interview on [DATE] at 3:33 pm, the DON and ADON confirmed that nine residents were identified as being at risk for elopement, their care plans had been updated, and audits completed. The DON stated there had not been any new resident admissions identified as an elopement risk, since [DATE]. 6. Beginning [DATE], the Administrator has conducted rounds daily on all exit doors to ensure they are functioning appropriately Monday through Friday. On the weekends these same rounds are completed by the Nurse Supervisor and reviewed on Monday morning by the Director of Nursing. If issues or concerns are identified they are addressed immediately. The Administrator and/or Director of Nursing are available by phone to address any concerns 24/7 when not in the facility. This was verified via review of the daily Room Rounds Sheet that included all of the exit doors dated [DATE] through [DATE] Monday through Friday. Also, verified via review of the Daily Door Checks sheet that was done twice a day from [DATE] through [DATE]. The checks included all of the exit doors, front kitchen door, back kitchen door and the dining room second entrance. Also verified through interview with the Administrator and the DON on [DATE] at 3:33 pm that daily door checks were done and documented. 7. Verified through review of the Call Audit to Facility Off Shift form with documentation of audits from [DATE] through [DATE]. There was documentation from [DATE] through [DATE] of rounds conducted with nurse supervisors over the telephone with the DON's signature each day for review. During an interview with the DON on [DATE] at 3:33 pm she stated the nurses have been calling her every night to discuss any behaviors, securing all doors including the kitchen doors. 8. Verified via review of the [DATE] Ad Hoc QAPI meeting minutes that included the signatures of the Administrator, DON, Infection Preventionist, ADON, Unit Manager, Social Services, Housekeeping Supervisor, and the Activity Director. The Medical Director attended by Teams Meeting. Also verified through interviews with the Activity Director on [DATE] at 10:31 am, with the Social Worker on [DATE] at 10:34 am, at 11:22 am with LPN XX, with the Administrator and the DON on [DATE] at 3:33 pm, who all stated they were in attendance of the [DATE] Ad Hoc QAPI meeting and there were no changes made to the Elopement and Wandering Resident Policy. They also stated the root cause of the events were discussed and a plan was put in place. 9. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE].

Based on interviews, record reviews and policy titled Resident Trust Fund Account, the facility failed to ensure that four residents (R) (R5, R6, R7, and R8) were free from misappropriation of their resident trust account money, from a total sample of 10 residents. Findings include: 1. Review of R5's clinical record revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, schizophrenia, generalized anxiety disorder, and major depressive disorder. Review of the 1/22/2024 Quarterly Minimum Data Set (MDS) assessment revealed that R5 was assessed as having cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 0 out of 15. Further review of R5's clinical record revealed that, despite his severe cognitive impairment, R5 was listed as his own responsible party. Review of the Resident Fund Management Service form, dated 5/25/2021, revealed that R5 had a non-transferring resident fund account set up with the facility. Review of progress notes revealed a 2/1/2023 social service note, made by former Social Services employee LL, that the Business Office Manager (BOM) and a witness spoke with R5 regarding his interment on 1/26/2023. The BOM and witness asked R5 if he would allow the community to assist with preparing his final interment. R5 said yes. The BOM then reached out to a local interment vendor to meet with her on 2/1/2023 to discuss and finalize his interment. Review of the Statement of Funeral Goods and Services Selected form and pre-need funeral contract form revealed that a contract agreement was made with a funeral home on 2/1/2023 for $9853.00. Review of R5's resident fund account activity revealed that $9853 was deducted from his account for burial on 2/2/2023. Review of R6's clinical record revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, hemiplegia following cerebral infarction, dysphagia, schizophrenia, and dementia. Review of the 12/18/2023 Quarterly MDS assessment revealed that R6 was assessed as having cognitive impairment, with a BIMS score of 7 out of 15. Further review of MDS assessments revealed that on the previous 12/17/2022 Quarterly MDS assessment, he had a BIMS score of 9 out of 15. Review of the Attachment G - Resident Fund Management Service Authorization and Agreement To Handle Resident Funds form, dated 11/12/2021, revealed that R6 had a transferring resident fund account set up with the facility. Review of the Statement of Funeral Goods and Services Selected form and pre-need funeral contract form revealed that a contract agreement was made with the funeral home on 2/1/2023 for $5000. Review of R6's resident fund account activity revealed that $5000 was deducted from his account for burial on 2/2/2023. Review of R7's clinical record revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, chronic obstructive pulmonary disease, dementia, bipolar disorder and schizoaffective disorder. Review of the 12/21/2023 Quarterly MDS assessment revealed that R7 was assessed as having cognitive impairment, with a BIMS score of 5 out of 15. Review of the Resident Fund Management Service Authorization And Agreement To Handle Resident Funds form, dated 10/2/2019, revealed that R7 had a non-transferring resident fund account set up with the facility. Review of an insurance company letter for R7, dated 9/3/2020, revealed that R7 had a paid-in-full funeral plan. However, review of a Statement of Funeral Goods and Services Selected form and pre-need funeral contract forms revealed that the facility set up another funeral plan, with a different funeral home, for R7 on 2/1/2023 in the amount of $9200. Review of R7's resident fund activity revealed that $9200 was deducted from his account for burial on 2/2/2023. Review of check documentation revealed that a check for the contracted funeral services for R5, R6, and R7 was issued to the funeral home in the amount of $24,053.00. Review of facility reported incidents revealed a Facility Incident Report Form, dated 2/2/2024, that documented an allegation of exploitation/misappropriation of resident funds that had occurred a year prior, on 2/2/2023. The form included that money was deducted from R5, R6, and R7's resident fund accounts for a preneed burial account and given to a funeral home. However, the money was alleged to have been refunded back to former facility Administrator EE in cash, and the funds were never deposited back into the residents' accounts. In addition to former Administrator EE. Further review of the form revealed that the police department was notified, and auditing of burial preneed accounts and resident fund accounts were initiated. Review of the accompanying investigation information that included clinical record documentation, resident fund account information, funeral home documentation, staff statements, the police report, and the facility's follow-up summary revealed evidence that the allegation of misappropriation of residents' money had occurred. During an interview on 2/8/2024 at 1:30 pm, current Administrator BB stated the concern with R5, R6, and R7's burial accounts was discovered when she and current BOM DD were going over resident accounts. Administrator BB stated that she called the funeral home involved and the funeral home director told her that after he received the money (a $24,053 check) from the facility, former Administrator EE called and asked for a refund of the money in cash. Former Dietary Manager AA went and picked up the cash from the funeral home. Administrator BB stated that an audit was completed, and no other residents were affected. Review of the written statement dated 2/5/2024, from current BOM DD, revealed that on 1/30/2024, she reached out to the funeral home director and asked to schedule a time to go over R5, R6 and R7's burial accounts. The concern was that although withdrawals were made and a check issued, which the funeral home deposited on 2/3/2023, the contracts had no money amount applied to the balance. Further review of the statement revealed that on 2/1/2024, during a meeting with the funeral home director, he initially stated that he was given payment, but it wasn't any good and he never received a second payment from the facility. The statement documented that during a second interaction with the funeral home director on 2/1/2024, he stated that after speaking with another funeral home employee he recalled that former Administrator EE had given them a check for $24,053 on 2/2/2023 and a week later said there was a misprint on the check and she needed a refund. She requested the refund in cash. Current BOM DD further documented in her statement that the funeral home director stated that on 2/12/2023 former Dietary Manager AA arrived at the funeral home and had former Administrator EE on the phone during the exchange, and former Dietary Manager AA collected $24,000 cash as a refund. A receipt was typed up and signed by the former Dietary Manager and funeral home employee on behalf of the funeral home director. During interviews on 2/12/2024 at 3:15 pm and 4:05 pm, the current BOM DD confirmed that R7 already had a burial account set up with a different funeral home that was still valid, prior to the account being set up on 2/1/23, therefore he did not need one. She stated that when she spoke with the funeral home director on 2/1/2024 he told her that former Administrator EE said there was a misprint on the check and wanted the money back in cash because she was concerned with that amount of money clearing from the funeral home. Review of the printed Payment Receipt document, dated 2/12/2023, provided by the funeral home, revealed that the recipient was listed as former Administrator EE in the amount of $24,000 for full refund for funeral contracts at the facility. The typed document also included a written note that mother was on the phone when she (former Dietary Manager AA) came to get payment. The form includes two handwritten signatures and the printed name of former Dietary Manager AA. During an interview on 2/13/2024 at 2:57 pm, former Dietary Manager AA confirmed she was related to former Administrator EE but denied going to the funeral home to pick up money. During an interview on 2/13/2024 at 4:03 pm, former Administrator EE denied asking the funeral home for a refund of the $24,053 check issued for resident burial accounts. She denied sending Dietary Manager AA to the funeral home to pick up the refunded money in cash. 2. The facility had a Resident Trust Fund Account policy, with a revision date of 1/9/2022. The Withdrawal section of the policy included the use of receipts and when writing a check. R8 was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, traumatic brain injury, major depressive disorder and mood disorder. Review of the 12/12/2023 Quarterly MDS assessment revealed that R8 was assessed as being cognitively impaired with a BIMS score of 3 out of 15. Review of resident fund account information revealed that R8 had a resident fund account with the facility. Review of her account activity revealed that $163.24 was deducted from her account for Outfit Valentines on 2/2/2023. Further review of resident fund account information revealed that three other residents had money deducted from their accounts for Outfit Valentines. R5, R6, and R7 each had $214.90 deducted from their accounts on 2/2/2023. During an interview on 2/12/2024 at 3:15 pm, current BOM DD stated that four residents (R5, R6, R7 and R8) were charged for Valentine's Day outfits and a check had been written to an individual. Current BOM DD stated that she did not have a receipt to confirm what the money was for. She stated that she was told by staff that the individual was brought in by former Administrator EE for Valentine's Day outfit rentals. Review of check documentation revealed that a check for Valentine's Day outfits for R5, R6, R7 and R8 was issued to individual KK in the amount $807.94 on 2/3/2023. In addition to there being no receipt for confirmation of the charges that were deducted from R5, R6, R7 and R8's resident accounts, there was no evidence that the residents or their responsible parties were notified or consented to money being deducted from their accounts for the outfits. During interviews on 2/19/2024 at 2:18 pm and 2:41 pm, current Administrator BB stated she had looked in R5, R6, R7 and R8's closets and R5 had a suit in his closet and R8 had a dress in her closet. Administrator BB stated that she had spoken with R6 and R7 (who did not have an outfit or suit in their closet) and both stated that they did not tell anyone to buy a suit for them. She further stated that the facility would be replacing the funds that had been withdrawn from the resident accounts for the Valentine's outfits. During additional interviews on 2/19/2024 at 3:06 pm and 5:33 pm, current Administrator BB stated that she had contacted the responsible parties for R6 and R7 and both stated that they had not given permission to anyone to buy suits.

Based on observations, interviews, record reviews and review of the policy titled Abuse and Neglect - Clinical Protocol, the facility failed to protect the resident's right to be free from verbal abuse by Certified Nursing Assistant (CNA) JJ for one resident (R) (A) of 10 sampled residents. Findings include: The facility had an Abuse and Neglect - Clinical Protocol, with revision date of March 2018. The protocol included a definition of abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse included the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse was defined as including verbal abuse, sexual abuse, physical abuse, and mental abuse. Review of RA's clinical record revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Friedreich ataxia, cerebral palsy, seizures, and scoliosis. Review of the 2/2/2024 Quarterly Minimum Data Set (MDS) assessment revealed that RA was assessed as being cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15. She was also assessed on the MDS assessment as being dependent on staff for Activities of Daily Living (ADL) care. RA was also assessed as being incontinent of bowel and bladder. A review of facility reported incidents revealed a Facility Incident Report Form, dated 2/11/2024, that documented an allegation of staff-to-resident abuse that had occurred on 2/11/2024 at 4:15 pm. The form included that Certified Nursing Assistant (CNA) JJ verbalized she was not going to change RA again. Further review of the form revealed that CNA JJ was suspended. The police department, physician and responsible party were notified. Abuse inservice education would be initiated and emotional support provided to RA. Review of the accompanying investigation information that included clinical record information, personnel file information, a video recording of the incident and a follow-up summary revealed evidence that the allegation had occurred. The investigation revealed that CNA JJ verbally abused RA on 2/11/2024, while in her room to provide ADL care. CNA JJ was terminated from employment. Review of RA's clinical record revealed a 2/11/2024 incident note, made by Licensed Practical Nurse (LPN) II, that documented she was contacted by RA's family member concerning a video the family member had received containing verbal abuse by the CNA. LPN II documented that she received a copy of the video from RA's family member, and it was forwarded to the Director of Nursing (DON). Further review of the incident note revealed that the DON, Administrator, Assistant Director of Nursing (ADON), police, and physician were notified, and the CNA was sent home pending further investigation. During an interview on 2/12/2024 at 11:10 am, Administrator BB confirmed that she had received video of CNA JJ's interaction with RA from 2/11/2024. The video recording was viewed on 2/13/2024 at 3:46 pm. In the video, CNA JJ can be seen in RA's room holding an adult brief and talking to RA, who is in bed. CNA JJ tells RA that she is not coming to work tomorrow because the resident wants to be changed. CNA JJ complains of not being able to rest because the resident is on the call light. CNA JJ tells RA that she can ring (the call light) again because after she (CNA JJ) changes RA this time, she is not coming back. During an interview on 2/13/2024 at 3:50 pm, Administrator BB stated that when she spoke with RA about the incident, RA told her that CNA JJ was always mean to her. The Administrator also stated that during interviews, RA's roommate also said CNA JJ was mean. During an interview on 2/15/2024 at 4:10 pm, RA stated that CNA JJ had been mean to her every day. Review of the facility's five-day follow up summary, dated 2/14/2024, revealed that CNA JJ was terminated from employment as of 2/13/2024. Review of the Separation Notice, dated 2/11/2024, revealed that CNA JJ's employment period ended on 2/11/2024. The reason for separation was listed as a violation of abuse policy.

Based on interviews, record reviews, and review of the Abuse and Neglect - Clinical Protocol and Abuse Investigation and Reporting policies, the facility failed to ensure that allegations of abuse were reported to the State Survey Agency in a timely manner for one resident (R) (A), from a total sample of 10 residents. Findings include: The facility had an Abuse and Neglect - Clinical Protocol, with revision date of March 2018. The protocol included a definition of abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse was defined as including verbal abuse, sexual abuse, physical abuse, and mental abuse. The facility had an Abuse Investigation and Reporting policy, with a revision date of July 2017. The policy statement documented that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies. The Reporting section of the policy included the State licensing/certification agency responsible for surveying/licensing the facility as one of the agencies the facility would report alleged violations to. The Reporting section also specified that an alleged violation of abuse, neglect, exploitation, or mistreatment would be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. 1. Review of RA's clinical record revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Friedreich ataxia, cerebral palsy, seizures, and scoliosis. Review of the 2/2/2024 Quarterly Minimum Data Set (MDS) assessment revealed that RA was assessed as being cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15. She was also assessed on the MDS assessment as being dependent on staff for Activities of Daily Living (ADL) care. Review of R10's clinical record revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, schizoaffective disorder and bipolar disorder. Review of the 2/1/2024 annual MDS assessment revealed that R10 was assessed as having some cognitive impairment with a BIMS score of 11 out of 15. He was also assessed as having no functional limitations in range of motion and as using a wheelchair. Further review of RA's clinical record revealed an 8/21/2023 incident note, made by Licensed Practical Nurse (LPN) FF, that documented RA was placed outside in the hallway to enjoy the weather and to interact with other residents. A male resident approached her and proceeded to grab the upper and lower parts of her body. The supervisor, Director of Nursing (DON), and Administrator were made aware of the situation. Further review of the incident note revealed that RA was moved to the nursing station for monitoring and to protect her from unwanted contact. Review of an 8/21/2023 health status note, made by the Assistant Director of Nursing (ADON), documented that the ADON, DON, and Administrator spoke with RA about the male resident touching her. The note included that RA said that the male resident grabbed her hand and kissed it, and he was rubbing on her arms and touched her chest. She pushed his hands away and asked him to stop. During an interview on 2/12/2024 at 4:45 pm, Administrator BB clarified that she was not at the facility on 8/21/2023, but a member of the facility's corporate staff was at the facility. During an interview on 2/12/2024 at 5:00 pm, corporate staff person HH confirmed that she was made aware of the incident involving RA when she came to the facility on [DATE], and she talked to RA about it. She stated that the male resident who touched RA was R10. Further review of R10's clinical record revealed an 8/21/2023 incident note, documented by LPN FF, that R10 was observed by a staff member touching a female resident in the upper and lower parts of the body and proceeding to smell his hand. The incident note further documented that R10 was asked not to do that again and was placed on safety checks. Review of Resident Safety Check forms, dated 8/21/2023, revealed that R10 was placed on safety checks every 15 minutes for sexual behaviors from 8/21/2023 11:15 am through 8/22/2023 11:15 am. Review of census information for R10 revealed that he was also moved to a room on a different hall, on 8/22/2023, further away from RA. However, there was no evidence that the sexual abuse incident that involved RA and R10 that occurred on 8/21/2023 was reported to the State Survey Agency. During the interview on 2/12/24 at 5:00 pm with corporate staff person HH, she would have been responsible for reporting the incident (to the State Survey Agency) but that she did not. During an interview on 2/15/2024 at 4:10 pm, RA confirmed that R10 had touched her and stated that he touched her breasts. 2. Review of R1's clinical record revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, paraplegia, neuromuscular dysfunction of the bladder, and hypertension. Review of the 12/4/2023 Quarterly MDS assessment revealed that R1 was assessed as being cognitively intact with a BIMS score of 15 out of 15. He was also assessed as having bilateral limitations in the upper and lower extremities and as using an (electric) wheelchair. Further review of R1's clinical record revealed a 12/31/2023 behavior note, made by LPN II, that a Certified Nursing Assistant (CNA) reported to her that RA said that R1 had made a sexual advance towards her. R1 is documented as telling RA he wanted her to slide her pants down so he could see her private area. The note included that staff would monitor the resident and notify the Administrator and Director of Nursing. Review of RA's clinical record revealed a 12/31/2023 health status note, made by LPN II, that R1 made a sexual advance towards RA and wanted her pants slid down so he could see her private area. The health status note further documents that RA told R1 no and that she did not want him in her room. Review of One on One Documentation for Resident Supervision/24 hours forms, dated 12/31/2023, revealed that RA was monitored for her safety from 12/31/2023 at 2:00 pm through 1/1/2024 at 6:00 pm. During an interview on 2/12/24 at 2:30 pm, LPN FF clarified that staff were not one on one with RA, but that she was monitored frequently. During an interview on 2/13/2024 at 10:05 am Administrator BB stated that she was not made aware of the 12/31/2023 incident involving RA and R1 until 1/1/2024. Review of the Facility Incident Report Form submitted to the State Survey Agency revealed that it was not submitted until 1/1/2024. During an interview on 2/15/2024 at 11:02 am, LPN II clarified that when RA reported the incident involving R1 on 12/31/2023, RA said that it had happened the day prior, on 12/30/2023, but that the resident did not say anything until 12/31/2023. LPN II stated that when RA told her what R1 said to her, the LPN put RA on frequent checks and never saw R1 back in her room. When questioned if she reported the allegation of the sexual advance to the Administrator or DON on 12/31/2023, LPN II stated that she thought she had called them that day, but she could not remember.

Based on resident and staff interviews, record review and review of the facility policy titled, Abuse Prevention Policy and Procedure the facility failed to ensure that one of three sampled residents (R)(RAA) was free from abuse by a Temporary Nurse Aide (TNA). Findings include: Review of the facility policy titled Abuse Prevention Policy and Procedure with a revision date of 2/26/2019 revealed the following policy statement, This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Though it cannot guarantee that such occurrences will not occur at this facility, preventative steps will be taken to reduce the potential for such occurrences Definitions: . Abuse- A basic definition describes abuse as the harmful treatment of people, ranging from rough handling to the use of insulting or coarse language. A more substantive definition of abuse is as follows: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or goods and mental anguish, or deprivation by an individual, including caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, even those in coma, cause physical harm, or pain and mental anguish. Physical abuse- the infliction of physical pain or injury, includes but is not limited to : slapping, pinching, hitting, kicking, or shoving. It also includes behavior through corporal punishment. A review of the Facility Incident Report Form dated 3/23/23 documented staff to resident abuse involving R AA and Temporary Nurse Aide (TNA) A. Further review of the form revealed RAA called the charge nurse to his room and reported TNA A hit him on his stump (resident is an amputee). Assessment revealed no injuries, the police were notified, and the resident was sent to the emergency room (ER) for assessment. A review of the accompanying investigation that included staff witness statements and a statement from Resident AA and the five-day summary conclusion revealed that the allegation of abuse occurred, and TNA A was terminated on 3/23/23. Review of the TNA A personnel file revealed an employment date of 1/11/23 and was terminated on 3/23/23 for abuse policy violation. Further review of the personnel file revealed the TNA had attended an in-service January 2023 for Abuse/Abuse Prevention. R AA was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: orthopedic aftercare following surgical amputation, abnormal posture, weakness, right above the knee amputation, left above the knee amputation, muscle weakness, lack of coordination, insomnia, atrial fibrillation, morbid obesity, bipolar disorder, hypertension, manic episode severe with psychotic symptoms, pyogenic arthritis, and post-traumatic stress disorder. Review of the Minimum Data Set (MDS) with an assessment date of 2/3/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition with no behaviors, required extensive assistance of two staff person for bed mobility and hygiene, required total dependence from staff for toilet use, and was incontinent of bladder and bowel. Review of the 3/23/23 ER Clinical Report - Physicians/Mid level report had a clinical impression of acute traumatic pain in right lower extremity (thigh, about the knee amputation stump) and physical assault by bodily force. Morphine 2 milligrams (mg) intramuscular (IM) was administered while in ER. During an interview with R AA on 4/10/23 at 1:30 p.m., he stated the incident occurred on 3/23/23 around 7:48 p.m. He called for assistance to use the bathroom and after about 30 minutes TNA A came in his room and said, What do you want? He told the TNA he needed to use the bedpan and requested for his fan to be turned off before she removed his blanket because he was cold. He stated she went ahead and removed his blanket before turning his fan off as requested. He told her No, don't move that but she continued to remove the blanket. He stated they exchanged some words and when she turned him to his right side, she hit his right stump with an open hand. He stated it was a deliberate act and after she hit him, he said Are you crazy, you just hit me! The TNA then told him he could just shit on himself and wipe it off with his hand and left the room. The nurse then came in the room and helped on the bedpan. He stated after the TNA hit his stump it felt like electrical shocks going through his leg. The facility sent him to the emergency room and while he was there, he received an injection of Morphine and was finally able to relax. During an interview with the resident's roommate RBB on 3/29/23 at 1:35 p.m., he stated although he did not see anything, he did hear a smack sound and stated the TNA hit his roommate. He stated she didn't do his roommate right and she abused him. After he heard the smacking sound, his roommate and the TNA had an exchange of words but could not remember what was said. During an interview with the Administrator on 4/11/23 at 1:30 p.m., she confirmed that through their investigation it was determined the TNA had hit RAA on his stump and was terminated on 3/23/23.

Based on record review and staff interview, the facility failed to routinely assess one resident's ((R) R#6) skin to identify a stasis ulcer. This failure resulted in actual harm that resulted in a sock embedded in the skin of the left foot and hospitalization of R#6. The facility also failed to follow physician's orders to irrigate a surgical wound for R#7 from a sample of eight residents. Findings include: 1. R#6 was admitted to the facility on [DATE] with the following diagnoses: chronic peripheral vascular disease (PVD), unspecified dementia without behavioral disturbance, major depressive disorder, bipolar disorder and hypertension. The resident had a quarterly Minimum Data Set (MDS) assessment completed on 6/17/22 which indicated the resident had a Brief Interview for mental Status (BIMS) score of 14 indicating the resident had intact cognition, no behaviors, required supervision with setup help for dressing and personal hygiene and was independent with setup help only for bathing. The resident had a care plan for activities of daily living (ADL) self-care performance deficit with interventions to assist with ADL's as needed, staff to assist resident as needed to ensure that resident has a neat clean appearance. The resident also had a care plan for being resistive to care with an intervention if resident resists with ADL's, reassure resident, leave and return five to ten minutes later and try again. A care plan for the resident having peripheral vascular disease with interventions to observe the extremities for signs and symptoms of injury, infection or ulcers, observe, document, report as needed any signs and symptoms of skin problems related to PVD: redness, edema, blistering, itching, burning, bruises, cuts, or other lesions. Review of the record revealed the resident had been treated for stasis ulcers to the left and right lower legs from 12/14/21 to 7/1/22. Further review of the record revealed resident had a history of refusing staff to complete skin assessments. Review of the 7/25/22 Nursing Progress Notes indicated the Certified Nursing Assistant (CNA) reported the resident's foot was swollen that morning. The treatment nurse entered the resident's room and resident had his left shoe off with his sock showing. The treatment nurse attempted to remove the sock but was unsuccessful as the sock seemed to be embedded into his foot. The treatment nurse then soaked the resident's foot in a basin pan and was able to cut majority of the sock off. The sock continued to be embedded into the resident's foot under his toes. The physician was notified and agreed to send the resident to the emergency room (ER) for an evaluation. Review of the 7/25/22 emergency room physician's note revealed the resident presented with a swollen, infected left foot with offensive odor. The ER physician noted the clinical impression of infected left foot and was admitted to the hospital. Review of the Radiology Report dated 7/25/2022 revealed irregularity of the soft tissues of the distal 4th digit possibly due to overlying material. The 7/26/22 hospital physician's progress noted the resident was admitted with swelling of lower extremity pain in lower extremity and was found to have an adherent sock to his skin which peeled on removal and thus diagnosed with cellulitis of the foot. It further stated that resident was to continue on current antibiotics. The 7/27/22 hospital physician's progress notes documented the resident appears to have mental illness. He lives in a group home with possible neglect due to observed ulcer on his left foot which was not adequately taken care of. Patient did complain that he does not have sensation in his legs, so he did not complain about it. Review of the July 2022 Documentation Survey Report form revealed the resident was scheduled to receive a bath/shower on Tuesday, Thursday and Saturday. However, there was no documentation the resident either received, refused or was offered a shower from 7/1/22 through 7/25/22. During an interview with CNA CC on 10/31/22 at 2:30 p.m., he stated that the resident was scheduled to receive a shower on nightshift. He stated although the resident was able to dress himself and shower himself, staff are supposed to stay in the shower with the resident for safety and assistance. He stated staff also help the residents change clothes and make sure they put on clean socks and clothes. He stated apparently the nightshift was not bathing the resident. He stated if a resident refuses a shower, you leave and come back later with a different approach. You don't just say OK and give up. He stated the resident was never violent and was cooperative with him. On 7/25/22 he noticed the resident was walking slower and his leg was swollen. He also noticed there was an odor from the resident's leg and foot and reported it to the nurse. During an interview with Licensed Practical Nurse BB on 10/31/22 at 2:00 p.m., she stated that on 7/25/22 the CNA came and got her to look at the resident's foot. Stated the toes of the resident's sock and been cut off and the sock was embedded in the foot on the side of the left foot. She stated she thought the resident got his showers on the nightshift. During an interview with the Administrator on 11/3/22 at 12:20 p.m., she stated that if the resident continuously refused showers, she would expect the staff to do something because the resident would need a bath. They could also call the family and ask them to come and talk to the resident. Review of the facility policy titled Bath, Shower/Tub dated February 2018 indicated staff were to document if the resident refused the shower/tub bath, the reason(s), notify the supervisor if the resident refuses the shower/tub bath and notify the physician of any skin areas that may need to be treated. The policy also indicated staff were to document the date and time the shower/tub bath was performed, the name and title of the individual(s) who assisted the resident with the shower/tub bath, document all assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 2. R#7 was admitted to the facility on [DATE] with the following but not limited to diagnoses: hemiplegia and hemiparesis following cerebral infarct, diabetes mellitus, pressure ulcer sacral region stage 4, hypertensive chronic kidney disease, cognitive communication deficit. Review of the 8/31/22 hospital Endoscopy Report documented the resident developed an abscess of the back which started at her sacral decubitus ulcer. Description of the procedure noted that additional debridement was performed, and two new Jackson-[NAME] drains were inserted. The 8/31/22 Discharge Instructions noted to change the dressing daily with wet/dry using sterile normal saline. Irrigate each drain with 20 milliters hydrogen peroxide twice a day for one week. Then discontinue hydrogen peroxide and start using saline twice a day. There were further instructions to call the Physician's office for any questions. Review of the nursing progress notes dated 9/1/22 at 1:39 p.m., writer received a call back the Physician's office regarding clarification of orders received from the hospital. The order is to irrigate the drain two times a day with hydrogen peroxide for one week then discontinue hydrogen peroxide and start using saline two times a day. When asking for clarification on where to irrigate as there is only one port, she was unable to clarify. Director of Nursing (DON) aware. Review of notes revealed on 9/1/22 at 2:13 p.m. the writer and the DON went to resident's room to assess drainage sites after phone call from doctor's office. Writer along with DON assessed drain and drain unable to be irrigated. Placed a phone call to doctor's office and left two messages for return call. Also placed a called to the hospital surgical department for further instruction. Review of notes revealed on 9/2/22 at 9:45 a.m., writer spoke with nurse at doctor's office this morning regarding clarification orders for irrigation and reported to nurse that one of the drains is not holding suction. Nurse stated that the doctor would be out of the office until Wednesday, but she would get in touch with him and give call back. Writer gave nurse personal cell phone number for return call and requested call back ASAP. Review of notes dated 9/2/22 at 12:02 p.m., revealed the resident continues to cry with pain, resident to be sent to the ER for evaluation of surgical site from 8/31/22. MD onsite and aware, 911 contacted and report called to ER. The resident returned to the facility on [DATE] at 4:31 p.m. Review of notes dated 9/2/22 ER physician documentation noted the JP drains are under pressure and the bulb appears to be completely compressed appears as if the JP drain is very functional, will send patient back to the nursing home for follow-up with surgery on an outpatient basis. The discharge instructions indicated Jackson-[NAME] drain care. The nursing progress note dated 9/9/22 at 12:19 p.m., documented that on 9/2/22 spoke at length with the Physician who explained in detail the procedure for flushing JP drain. Procedure performed as instructed without complication. Review of the September 2022 Treatment Record revealed there was no documentation the JP drains were flushed as ordered until 9/9/22. During an interview with the Administrator on 11/3/22 at 12:25 p.m., she stated she would expect the staff to contact the Medical Director for further instructions if they were not able to get intact with the surgeon. She stated that is why she terminated the previous DON.