Every finding on record at Arden Care Center

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1), reviewed for wandering, the facility failed to ensure adequate supervision for a resident with a known wandering behaviors identified at risk for elopement to ensure the resident was not able to exit the facility without staff knowledge, and failed to ensure hourly rounds were conducted in accordance with facility policy. The facility was notified after the resident was observed in a neighboring town 5.3 miles from the facility, and video surveillance identified Resident #1 was out of the building for approximately two hours. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1 was admitted with diagnoses that included dementia, anxiety, and seizure disorder. An elopement assessment dated [DATE] identified a wander risk with a history of wandering that places the patient at significant risk of getting to a potentially dangerous place, e.g., stairs, outside facility.Record review identified Resident #1 had a court appointed Conservator and resided on a secured unit on the fourth (4th) floor.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 1 had severe cognitive impairment (Brief Interview for Mental Status BIMS of four), had no wandering behavior in the prior seven (7) days, and required supervision transfer and walking up to fifty (50) feet. The Resident Care Plan (RCP) dated 5/28/2026 identified Resident #1 was at risk for elopement, falls, was on anticoagulant therapy and had impaired thought processes. Interventions directed to keep the environment free of hazards maintaining a safe environment. Psychiatric APRN #1 note dated 7/15/2026 identified Resident #1 was seen for persistent agitation with wandering, and repeated attempts to leave the unit reporting he/she needed to get out. The note directed to increase Zyprexa (antipsychotic drug, used to treat behaviors in dementia) from 2.5 milligrams to 5 milligrams daily and to continue to monitor.Nursing note written by the DON dated 7/22/2026 at 11:57 AM identified Resident #1 was not on his/her assigned floor. Family called to notify staff that Resident #1 was seen outside facility on a street. Staff went to the location where Resident #1 was and observed. Resident #1 was assessed with no injuries identified. A facility reportable event (RE) dated 7/22/2026 at 11:50 AM identified Resident #1 was self-ambulatory, and the facility was notified Resident #1 was observed by family friend on local street. Additional review failed to identify a specific location.Facility written statement by NA #2, dated 7/22/2026, identified Resident #1 was last observed on 7/22/2026 about 9:30 AM in the dining room.Facility written statement by NA #3, dated 7/22/2026, identified Resident #1 was last observed after breakfast on 7/22/2026 about 9:15 or 9:30 AM in the hallway with his/her coat on.Facility written statement by NA #5, dated 7/22/2026, identified Resident #1 was last observed on 7/22/2026 about 9:30 AM wearing his/her coat walking down the hallway.Interview and review of facility video with the Administrator on 7/27/2026 at 10:40 AM identified Resident #1 was last seen on the fourth-floor secured unit hallway walking towards the nursing station at 9:47 AM on 7/22/2026. The stairwell #4 exit door was located near the nursing station, without direct video surveillance, and the door required a keypad code entry in order to unlock the door. Additional video review from the opposite direction of the nurse's station at the same approximate time (9:47 AM) did not show Resident #1 walking away from the nurse's station. Further review identified the first-floor stairwell #4 exit door video showed Resident #1 exit the facility into the facility back parking lot area at 9:50 AM (two hours before the facility was notified Resident #1 was on the street). The video identified a construction worker at the stairwell #4 door at 9:47 AM; the Administrator stated she had concluded the door was not secured after use by the construction worker, and Resident #1 was able to exit the unit through the door. The Administrator stated the facility had provided the construction workers with door codes for independent door access prior to the incident. The facility was not aware Resident #1 had left the unit, and they were contacted by a family friend who had observed Resident #1 on the street. The Administrator and DON went to the location and observed Resident #1 fully clothed and wearing sneakers with family members and local police in attendance. Interview identified Resident #1 was located at a street bus stop near a store, and she thought it was about 4.3 miles from the facility. After an assessment was completed, Resident #1 was released to the care of the family for transport to a previously scheduled appointment, with the plan to apply a wander guard bracelet when Resident #1 returned to the facility. In addition the interview determined the facility failed to identify hourly rounds were conducted to identify Resident #1's whereabouts, in accordance with facility policy.Interview with the ADON on 7/27/2026 at 11 AM identified she responded to the location when Resident #1 was identified out of the building, and she assessed Resident #1. The ADON provided the street address where Resident #1 was located.On-line map search identified Resident #1 was found in an adjacent town, 5.3 miles from the facility. The street had two lanes of traffic in opposite directions with parking on both sides of the road, and a sidewalk on both sides. Review of on-line weather history identified between 9 AM and noon the temperature was between 76 and 78 degrees Fahrenheit (F), with no rain,Interview and record review with psychiatric APRN #1 on 7/27/2026 at 12:22 PM identified he evaluated Resident #1 on 7/16/2026 for continued behavior of exit seeking and increased agitation reported to him by nursing staff occurring primarily on the evening shift. APRN #1 stated Resident #1 had exit seeking behaviors at baseline but staff reported Resident #1 needed more redirection. APRN #1 directed an increase in Zyprexa and to continue to monitor.Interview with NA #3 on 7/27/2026 at 2:20 PM identified she observed Resident #1 in the hallway after breakfast at around 9:30 AM on 7/22/2026 (2 hours and 20 minutes prior to located on the street). Resident #1 said he/she was cold and NA #3 helped him/her put his/her jacket on - NA #3 stated Resident #1 usually complained of being cold and wore his/her jacket when walking up and down the hallways. NA #3 stated Resident #1 frequently wandered the halls and checked rooms, stating he/she was looking for his/her children and if he/she saw an open door, he/she would likely look inside to see if the children were there.Observation of the 4th floor stairwell exit door on 7/27/2026 at 11:15 AM identified a keypad code lock on the wall next to the door; a code was required to be entered to unlock the door and enter into the stairwell and the door was self-closing. Upon exiting the unit, there were four flights of stairs to the ground level. The exit door on the first (1st) floor where Resident #1 exited was not alarmed and led to the facility's back parking lot. The street immediately behind the facility had a sidewalk and 2-way traffic. The facility policy Elopement Prevention dated 3/2026 directed in part, that its purpose was to prevent elopement and protect the safety of residents who are at risk for elopement and with wandering behaviors. Preventative measures include alarmed doors and for secured units ensure doors are closed and secured when entering or exiting. Facility documentation review identified staff education was initiated on 7/22/2026 and included not providing exit door codes to any contractors, only staff are to have exit door codes, re-education of facility elopement policy, and door codes were changed. Audits were initiated on 7/22/2026, and a QAPI meeting was held on 7/22/2026. Based on review of facility documentation, past non-compliance was identified.The facility policy Elopement Prevention dated 3/2026 directed in part, NAs should complete hourly observation rounds on each resident at risk for elopement.

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for twenty (20) of twenty-six (26) residents who resided on the 3CD unit (Residents #4, #7, #8, #13, #14, #15, #16, #17, #20, #21, #23, #24, #26, #27, #28, #29, #31, #32, #33, #35, and #36), the facility failed to ensure the residents received their scheduled medications during the evening, 3-11PM, shift. The findings include:1.Resident #4's diagnoses included unspecified mood (affect) disorder, depression, seizures, insomnia, rheumatoid arthritis, spinal stenosis and personal history of traumatic brain injury. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #4 had no memory recall deficits. The physician's order dated 3/20/26 directed to administer Levetiracetam (a medication to treat seizures) 1000 milligrams (mg) give one tablet by mouth two times a day; Glycolax powder (a medication to treat constipation) 17 grams by mouth twice a day; Voltaren gel (a medication to treat pain) 1% apply to bilateral knees topically two times a day; Trazodone (a medication to treat insomnia) 50 mg by mouth at bedtime; Gabapentin (a medication to treat seizures) 300 mg twice a day; Melatonin (a medication to treat insomnia) 3 mg at bedtime and Risperidone (an antipsychotic medication) 1 mg give one and a half tablets once a day at bedtime. Review of the March 2026 Medication Administration Record identified Resident #4 did not receive the medications scheduled during the evening shift on 3/22/26. 2. Resident #7's diagnoses included multiple sclerosis, mild neurocognitive disorder, major depressive disorder, paraplegia, hypertension and diabetes. The annual MDS dated [DATE] identified Resident #7 had no memory recall deficits. The physician's order dated 3/1/26 directed to administer Atenolol (a medication to treat hypertension) 50 mg at bedtime; Ferrous Sulfate (iron supplement to treat anemia) 325 mg twice a day; Latanoprost Ophthalmic Solution (an eye drop to treat glaucoma) instill one drop in both eyes at bedtime, Melatonin 3 mg give 2 tablets at bedtime, Metformin (a medication to treat diabetes) 1000 mg twice a day; Sennosides-Docusate Sodium (a medication to treat constipation) 8.6-50 mg give 2 tablets at bedtime; Simvastatin (a medication to treat high cholesterol) 40 mg at bedtime; and Vitamin C (supplement) 500 mg twice a day. Review of the March 2026 MAR identified Resident #7 did not receive the medications scheduled during the evening shift on 3/22/26. 3. Resident #8's diagnoses included acute embolism and thrombosis (blood clot), atrial fibrillation, paraplegia, peripheral vascular disease and adjustment disorder. The quarterly MDS dated [DATE] identified Resident #8 had no memory recall deficits. The physician's order dated 3/17/26 directed to administer Ascorbic Acid (Vitamin C) 500 mg twice a day; Eliquis (a medication to prevent blood clots) 5 mg twice a day; Senna (a medication to prevent constipation) 8.6 mg give 2 tablets once a day at 9:00 PM; Gabapentin (used to treat neuropathic pain) 300 mg every 8 hours; Baclofen (a muscle relaxant) 10 mg every 8 hours; and Lipitor (a medication to treat high cholesterol) 40 mg once a day at 7:00 PM. Review of the March 2026 MAR identified Resident #8 did not receive the medications scheduled during the evening shift on 3/22/26. 4. Resident #13's diagnoses included chronic obstructive pulmonary disease (COPD), venous insufficiency, congestive heart failure (CHF) chronic pain, neuromuscular dysfunction of bladder, anemia, diabetes mellitus (DM) and acquired absence of other specified parts of the digestive tract. The annual MDS dated [DATE] identified Resident #13 had no memory recall deficits. The physician's order dated 3/1/26 directed to administer Apixaban (a medication to prevent blood clots) 5 mg every 12 hours; Atorvastatin (a medication to treat high cholesterol) 40 mg once a day; Calcium Carbonate (supplement) 500 mg every 8 hours; (Vitamin B-12) 1000 mcg once a day; Gabapentin 600 mg once a day; Lantus Solostar (an insulin used to treat DM) 50 units subcutaneously at bedtime; Ciprofloxacin (an antibiotic used to treat infection) 500 mg every 12 hours; Oxybutrin (a medication used to treat muscle spasms) 5 mg twice a day; Protonix (a medication used to treat esophageal reflux) 40 mg twice a day; and Oxycodone (a narcotic medication to treat pain) 5 mg three times a day. Review of the March 2026 MAR identified Resident #13 did not receive the medications scheduled during the evening shift on 3/22/26. 5. Resident #15's diagnoses included liver disease, alcohol cirrhosis of the liver with ascites (swelling of the abdomen) hepatic encephalopathy, unspecified mood (affect) disorder, and gastroesophageal reflux disease (GERD). The significant change in status MDS dated [DATE] identified Resident #15 had some memory recall deficits. The physician's order dated 3/1/26 directed to administer Baclofen 10 mg tablet give 5 mg (1/2 tablet) at bedtime; Protonix 40 mg twice a day; Quetiapine Fumarate (a medication used to treat delusional disorder) 50 mg tablet give 2 tablets (100 mg) at bedtime; Senna 8.6 mg tablet give 2 tablets twice a day; and Sertraline (a medication used to treat depression) 50 mg tablet once a day at 9:00 PM. Review of the March 2026 MAR identified Resident #15 did not receive the medications scheduled during the evening shift on 3/22/26. 6. Resident #16 had diagnoses that included cardiomyopathy (disease of the heart muscle) dementia, malnutrition, obstructive and reflux uropathy, osteoarthritis, paranoid schizophrenia, depression, anxiety and mild cognitive impairment of unknown etiology. The annual MDS dated [DATE] identified Resident #16 had no memory recall deficits. The physician's order dated 3/1/26 directed to administer Jevity (an artificial nutrition supplement given via a gastric tube (g-tube)) 1.5 give a 420 cubic centimeters (cc) bolus four times a day; Ascorbic Acid 500 mg tablet twice a day, Benztropine Mesylate tablet (a medication used to treat tremors and stiffness of the muscles); Miralax oral packet (a medication used to prevent constipation) 17 grams (gm) one packet via g-tube twice a day; Olanzapine (a medication used to treat bipolar disorder) 20 mg tablet via g-tube at bedtime; Risperidone (a medication used to treat paranoid schizophrenia) 1 mg tablet via g-tube once a day in the evening; Trazodone 100 mg give 150 mg (one and a half tablets) via g-tube at bedtime; Clonazepam (a medication used to treat anxiety) give one tablet twice a day; Famotidine (a medication to treat GERD) 20 mg tablet via g-tube twice a day; Ferrous Sulfate 7.5 milliliters (ml) twice a day; and Methenamine Hippurate (a medication used to prevent urinary tract infection) 1 gram (gm) via g-tube twice a day. Review of the March 2026 MAR identified Resident #16 did not receive the medications scheduled during the evening shift on 3/22/26. 7. Resident #17 had diagnoses that included anoxic brain damage, adjustment disorder with anxiety, epilepsy, anemia, unspecified convulsions, and acute embolism and thrombosis of right iliac vein. The quarterly MDS dated [DATE] identified Resident #17 had severely impaired cognition. The physician's order dated 3/1/26 directed to administer Jevity 1.5 give 100 ml per hour (ml/hr) for 8 hours (10:00 PM to 6:00 AM via g-tube; Amlodipine Besylate(a medication used to treat high blood pressure) 10 mg via g-tube once a day; Apixaban 2.5 mg via g-tube twice a day; Baclofen 5 mg via g-tube three times a day; Clonidine (a medication used to treat high blood pressure) 0.3 mg via g-tube every 8 hours; Gabapentin 300 mg via g-tube every 8 hours; Propranolol (a medication used to treat high blood pressure) 20 mg via g-tube twice a day; Scopolamine Transdermal Patch 1 mg/3 days apply transdermal (on top of the skin) every 72 hours; Senna 8.6 mg 2 tablets via g-tube twice a day; and Zyrtec Allergy (a medication used to treat allergies) via g-tube once a day. Review of the March 2026 MAR identified Resident #17 did not receive the medications scheduled during the evening shift on 3/22/26. 8. Resident #20 had diagnoses that included DM, major depressive disorder, peripheral vascular disease (PVD), chronic pain, cerebrovascular disease and lymphedema. The quarterly MDS dated [DATE] identified Resident #20 had no memory recall deficits. The physician's order dated 3/1/26 directed to administer Carboxymethylcellulose Sod PF Ophthalmic Solution (a medication used to treat dry eyes) 0.5% instill 1 drop into both eyes twice a day and Famotidine (a medication used to treat GERD) 20 mg twice a day. Review of the March 2026 MAR identified Resident #20 did not receive the medications scheduled during the evening shift on 3/22/26. 9. Resident #21 had diagnoses that included atrial fibrillation (an irregular heartbeat), COPD, vascular dementia, hypertension, hyperlipidemia (high cholesterol), anxiety and adjustment disorder with disturbance of conduct. The quarterly MDS dated [DATE] identified Resident #21 had moderately impaired cognition. The physician's order dated 3/1/26 directed to administer Atorvastatin 40 mg tablet at bedtime; Metoprolol Tartrate (a medication used to treat high blood pressure) 25 mg tablet give a half a tablet (12.5 mg) twice a day, Senna 8.6 mg tablet give 2 tablets at bedtime; and Seroquel (a medication used to treat vascular dementia) 100 mg tablet one time a day in the evening. Review of the March 2026 MAR identified Resident #21 did not receive the medications scheduled during the evening shift on 3/22/26. 10. Resident #23 had diagnoses that included major depressive disorder, insomnia, chronic pain syndrome, mild neurocognitive disorder, anxiety, and GERD. The annual MDS dated [DATE] identified Resident #23 had moderately impaired cognition. The physician order dated 3/8/26 directed to administer Melatonin 5 mg tablet at bedtime; Lyrica (a medication used to treat nerve pain) 50 mg tablet three times a day; Trazodone 100 mg tablet at bedtime; Senna Plus 8.6-50 mg give 2 tablets twice a day; Quetiapine Fumarate 25 mg tablet (a medication used to treat anxiety/delusional disorder) three times a day; Omeprazole (a medication used to treat GERD) 20 mg tablet twice a day; and Eliquis 2.5 mg tablet twice a day. Review of the March 2026 MAR identified Resident #23 did not receive the medications scheduled during the evening shift on 3/22/26. 11. Resident #24 had diagnoses that included immunodeficiency, hyperlipidemia, insomnia, and hypertensive heart disease with heart failure. The quarterly MDS dated [DATE] identified Resident #24 had no memory recall deficits. The physician's order dated 3/20/26 directed to administer Tizanidine HCL (a muscle relaxant) 2 mg tablet three times a day; Trazodone 25 mg tablet at bedtime; Melatonin 5 mg tablet at bedtime; and Rosuvastatin Calcium (a medication for high cholesterol) 20 mg tablet at bedtime. Review of the March 2026 MAR identified Resident #24 did not receive the medications scheduled during the evening shift on 3/22/26. 12. Resident #26 had diagnoses that included epilepsy, insomnia, blindness and depression. The quarterly MDS dated [DATE] identified Resident #26 had no memory recall deficits. The physician's order dated 3/8/26 directed to administer Trazodone HCL 50 mg tablet at bedtime; Melatonin 3 mg tablet at bedtime; Depakote (a medication to treat seizures) Delayed Release 250 mg tablet give 4 tablets (1000 mg) twice a day; Lacosamide (a medication used to treat seizures) 150 mg tablet twice a day; and Atorvastatin Calcium 20 mg tablet once a day. Review of the March 2026 MAR identified Resident #26 did not receive the medications scheduled during the evening shift on 3/22/26. 13. Resident #27 had diagnoses that included spinal stenosis, osteoarthritis, insomnia, DM and major depressive disorder. The annual MDS dated [DATE] identified Resident #27 had no memory recall deficits. The physician's orders dated 3/17/26 directed to administer Trazodone 100 mg tablet at bedtime; Carboxymethylcellulose Sodium Ophthalmic Solution 0.5% instill 1 drop into both eyes four times a day; Atorvastatin 10 mg tablet at bedtime; Melatonin 3 mg tablet at bedtime, Lyrica 200 mg capsule three times a day; and Tramadol 50 mg tablet three times a day. Review of the March 2026 MAR identified Resident #27 did not receive the medications scheduled during the evening shift on 3/22/26. 14. Resident #28 had diagnoses that included paranoid schizophrenia, hyperlipidemia, heart failure, anxiety, moderate protein-calorie malnutrition, and hypertension. The quarterly MDS dated [DATE] identified Resident #28 had no memory recall deficits. The physician's order dated 3/8/26 directed to administer Depakote Sprinkles Delayed Release 125 mg capsule give 250 mg (2 capsules) twice a day (used to treat paranoid schizophrenia); Senna Plus 8.6-50 mg tablet at bedtime; Buspirone HCL (a medication to treat anxiety) 10 mg tablet twice a day; Hydralazine HCL (a medication to treat high blood pressure) 25 mg tablet give 75 mg (3 tablets) three times a day; Trazodone HCL 50 mg tablet twice a day, Ziprasidone HCL Capsule (a medication for paranoid schizophrenia) 50 mg capsule twice a day; and Lipitor 10 mg tablet at bedtime. Review of the March 2026 MAR identified Resident #28 did not receive the medications scheduled during the evening shift on 3/22/26. 15. Resident #29 had diagnoses that included schizoaffective disorder, bipolar type, pure hyperglyceridemia, chronic kidney disease, depression, DM, hyperlipidemia, benign prostatic hyperplasia (BPH), constipation and hypertension. The quarterly MDS dated [DATE] identified Resident #29 had no memory recall deficits. The physician's order dated 3/17/26 directed to administer Melatonin 3 mg tablet at bedtime; Clozapine (a medication used to treat schizophrenia) 100 mg tablet give 3 tablets (300 mg) once a day; Sennosides-Docusate Sodium 8.6-50 mg tablet give 3 tablets at bedtime; Atorvastatin Calcium 20 mg tablet once a day; Fenofibrate (a medication used to treat high triglycerides) 145 mg tablet at bedtime; Tamsulosin HCL capsule (a medication to treat BPH) 0.4 mg capsule once a day; and Lantus 100 unit/ml inject 30 units subcutaneously at bedtime. Review of the March 2026 MAR identified Resident #29 did not receive the medications scheduled during the evening shift on 3/22/26. 16. Resident #31 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, insomnia, anemia, chronic kidney disease, depression, and DM. The quarterly MDS dated [DATE] identified Resident #31 had no memory recall deficits. The physician's order dated 3/8/26 directed to administer Carvedilol (a medication used to treat high blood pressure) 12.5 mg tablet twice a day and Mirtazapine (a medication used as an appetite stimulant) 7.5 mg tablet at bedtime. Review of the March 2026 MAR identified Resident #31 did not receive the medications scheduled during the evening shift on 3/22/26. 17. Resident #32 had diagnoses that included atherosclerotic heart disease (narrowing of the artery), CHF, vascular dementia, hyperlipidemia, COPD, insomnia and depression. The annual MDS dated [DATE] identified Resident #32 had no memory recall deficits. The physician's orders dated 3/20/26 directed to administer Atorvastatin 40 mg tablet in the evening; Melatonin 3 mg tablet at bedtime; Entresto (a medication used to treat heart failure) 24-26 mg tablet twice a day, Eliquis 5 mg tablet twice a day; and Ranolazine Extended Relief (a medication used to treat chest pain) 500 mg tablet twice a day. Review of the March 2026 MAR identified Resident #32 did not receive the medications scheduled during the evening shift on 3/22/26. 18. Resident #33 had diagnoses that included multiple sclerosis, DM, paraplegia, and depression. The quarterly MDS dated [DATE] identified Resident #33 had no memory recall deficits. The physician's order dated 3/1/26 directed to administer Rosuvastatin Calcium 10 mg tablet at bedtime and Sennosides-Docusate Sodium 8.6-50 mg tablet at bedtime. Review of the March 2026 MAR identified Resident #33 did not receive the medications scheduled during the evening shift on 3/22/26. 19. Resident #35 had diagnoses that included hypertension, chronic kidney disease, protein-calorie malnutrition, hyperlipidemia, dementia, depression, insomnia, atrial fibrillation, constipation, COPD and chronic embolism and thrombosis of inferior vena cava. The MDS dated [DATE] identified Resident #35 has severely impaired cognition. The physician's orders dated 3/1/26 directed to administer Apixaban 2.5 mg tablet twice a day; Calcium Citrate-Vitamin D (supplement) 315-5 mg-microgram (mcg) tablet give 2 tablets twice a day; Melatonin 3 mg tablet at bedtime; Mirtazapine 15 mg tablet at bedtime; Pravastatin Sodium 20 mg tablet once a day; Sennosides 8.6 mg tablet give 2 tablets twice a day; and Tamsulosin HCl 0.4 mg capsule once a day. Review of the March 2026 MAR identified Resident #35 did not receive the medications scheduled during the evening shift on 3/22/26. 20. Resident #36 had diagnoses that included depression, iron deficiency anemia, constipation, paraplegia, chronic pain, muscle spasm and neuromuscular dysfunction of bladder. The quarterly MDS dated [DATE] identified Resident #36 had no memory recall deficits. The physician's order dated 3/1/26 directed to administer Acetaminophen (Tylenol) 1000 mg every 8 hours; Eliquis 5 mg tablet every 12 hours; Gabapentin 300 mg tablet every 8 hours; Gabapentin 600 mg tablet every 8 hours; Gabapentin 600 mg tablet three times a day; Lactase Enzyme 3000 unit tablet (a medication used to treat stomach upset) three times a day; Lactulose oral Solution 20 gm/30 ml give 30 ml twice a day; Lexapro (a medication used to treat depression) 20 mg tablet once a day; Lipitor 40 mg tablet at bedtime; Olopatadine HCL Ophthalmic Solution 0.1% (used for eye health) instill 1 drop into both eyes twice a day; and Remeron (a medication used to treat depression) 15 mg tablet at bedtime. Review of the March 2026 MAR identified Resident #36 did not receive the medications scheduled during the evening shift on 3/22/26. Review of the facility Medication error report dated 3/22/26 identified Resident #13 reported he/she had not received their scheduled medications during the evening shift on 3/22/26 andthrough the investigation, the facility found there were potentially twenty-six (26) residents who did not receive their medications during the evening shift on 3/22/26. Interview with the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #8, on 4/15/26 at 10:53 AM identified on 3/22/26 she was scheduled to go over to the 3CD unit after finishing her 3-11PM shift on another unit. LPN #8 indicated when she arrived on the unit an 11PM-7AM nurse aide informed her that five (5) residents had reported they did not get their evening medications. LPN #8 identified she went to find the previous evening nurse, LPN #6, and found LPN #6 had left early, and no one came to cover the unit after LPN #6 left. LPN #8 indicated once she was made aware, she went to speak with the residents who had reported they did not receive their medications and she called the supervisor. LPN #8 identified the nursing supervisor, RN #7, attempted to brush the report off stating maybe they were just not signed off. Interview and clinical record review with the Director of Nursing (DON) on 3/15/26 at 12:04 PM identified it was reported to her on 3/23/26 that residents on the 3CD unit had not received their evening medications on 3/22/26. The DON indicated she initiated an investigation and spoke with RN #7 who could not remember if LPN #6 had reported to her that LPN #6 did not give the medications. The DON identified her conversation with LPN #6 identified LPN #6 reported she had given some medications, but not all and she reported this to the supervisor. The DON identified on 3/22/26 LPN #6 was scheduled to work 3-7PM and then allegedly told the supervisor, RN #7, that she would stay for the entire shift, until 11:00 PM. The DON indicated that when a staff nurse was working only a partial shift, there should be another nurse to take over that unit until the end of the shift and if no nurse was available, the supervisor would cover the unit, and she would expect that nurse would finish the medication pass. The DON identified there was no written policy on medication administration, but the expectation was that medications were given as ordered during the shift and it was the responsibility of the supervisors for ensuring the medication passes are completed prior to the licensed staff member ending their shift. The DON indicated she received conflicting reports on whether LPN #6 reported to RN #7 prior to leaving the facility that she had not completed the medication pass and the medication pass should have been completed on 3/22/26 on the 3CD unit in its entirety for the evening shift. Interview with the LPN #6 on 4/15/26 at 12:58 PM identified on 3/22/26 she was scheduled to end her shift at 7:00 PM. LPN #6 identified RN #7 asked her if she could stay the entire shift and she told RN #7 that she could not stay the entire shift but could stay a little longer. LPN #6 indicated at the time of her departure, she reported to RN #7 that she had not finished her medication pass and asked RN #7 if she wanted her to stay until the oncoming nurse arrived, but RN #7 declined and instructed her to punch out. LPN #6 identified she again informed RN #7 that the medication pass had not been completed, and RN #7 told her it's ok, the oncoming nurse will complete it. LPN #6 identified she left the facility at approximately 8:30-9:00 PM. LPN #6 did indicate it was her understanding that another nurse was scheduled to take over the unit once she left. Although attempted, an interview with RN #7 was unsuccessful. Review of the facility policy titled Medication Administration, last revised 5/1/24, directed, in part, the staff will follow written instructions provided by the MD/Advanced Practice Registered Nurse (APRN), which can include a prescription label or the prescriber's written or electronically recorded order for the prescription and will follow the 5 rights for medication administration (right resident, right medication, right dose, right time and right route).

Based on review of the clinical record, facility documentation, facility policy and interviews for one of four residents reviewed for wound care (Resident #2) the facility failed to ensure the record was complete and accurate to include refusals of wound care, and for five of six residents (Residents #4, #5, #6, #7 and #8) reviewed for neglect, the facility failed to ensure the record was complete and accurate to include care provided during shift rounds. The findings include: Resident #2 was admitted to the facility with diagnoses that included peripheral vascular disease (PVD), paraplegia (loss of voluntary movement and sensation to the lower half of the body) and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 (indicated he/she was alert and oriented) and was dependent for personal hygiene, moderate assist for bed mobility and transfers, and had one (1) venous or arterial ulcer. A resident care plan (RCP) dated 2/11/2026 identified Resident #2 was resistive to care, refused care (including wound care), and was at risk for skin breakdown related to PVD, paraplegia and weakness. Interventions directed to provide wound treatment as ordered, explain all care, including procedures (one step at a time), and the reason for performing the care before initiating and to provide with the opportunity for choice during care/activities to provide a sense of control. A physician order dated 3/14/2026 directed to cleanse a right shin wound with normal saline (NS), followed by calcium alginate (absorbent wound dressing that changes into a gel upon wound contact to promote healing) followed by a dry clean dressing every day shift. A facility reportable event (RE) dated 3/19/2026 at 1:00 PM identified during wound rounds it was noted that Resident #2's dressing was not changed for three (3) days by LPN #3. An investigation was initiated and the MD/APRN (provider) was notified. A facility RE summary dated 4/1/2026 identified on 3/19/2026 Resident #2's wound dressing was noted to be dated 3/15/2026. Resident #2 was self-responsible and had refused the right shin wound treatments, however the nurse failed to notify the physician/APRN. Record review identified wound care was documented on the Treatment Administration Record (TAR) as refusded on 3/16/2026 and documented as completed on 3/17, and 3/18/2026. Additional review failed to identify the refusals of wound care on 3/16, 3/17, and 3/18/2026 was documented in the medical record. Interview and review of facility documents with the DON on 4/14/2026 at 10:15 AM identified upon interview with LPN #3 on 3/20/2026, LPN #3 reported Resident #2 had refused to have the dressing changed on 3/16, 3/17 and 3/18/2026. The DON stated LPN #3 documented the refusal on 3/16/2026, but did not document the refusals on 3/17 and 3/18/2026. The DON stated she expected staff to document any refusals. Although multiple attempts were made to contact LPN #3, an interview was not obtained during survey. 2. Resident #4 was admitted with diagnoses that included polyneuropathy (multiple nerve dysfunction that causes numbness, tingling and muscle weakness), traumatic brain injury and depression. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #4 was alert and oriented with a Brief Mental Interview for Mental Status (BIMS) of fifteen (15), and was dependent for toileting, was frequently incontinent of urine, always incontinent of bowel, and was at risk for pressure ulcers. The Resident Care Plan (RCP) dated 3/11/2026 identified Resident #4 a risk for skin breakdown due to immobility and incontinence. Interventions directed to turn and reposition every two (2) hours and observe skin for any signs of breakdown. Resident #5 was admitted with diagnoses that included dementia, diabetes mellitus and depression. A quarterly MDS dated [DATE] identified Resident #5 was alert and oriented (BIMS score 13), was dependent for toileting, was frequently incontinent of urine, and was at risk for pressure ulcers. The RCP dated 3/18/2026 identified Resident #5 a risk for skin breakdown due to limited mobility and cognitive loss. Interventions directed to turn and reposition every one (1) to two (2) hours while in bed and observe skin for any signs of breakdown. Resident #6 was admitted with diagnoses that included multiple sclerosis and peripheral vascular disease (PVD). The RCP dated 12/28/2025 identified Resident #6 at risk for skin breakdown due to limited mobility and incontinence. Interventions directed incontinent care and to observe skin for any changes. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #6 was alert and oriented. was occasionally incontinent of urine, and was at risk for pressure ulcers. Resident #7 was admitted with diagnoses that included multiple sclerosis, paraplegia. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #7 was alert and oriented and was incontinent of urine. The Resident Care Plan (RCP) dated 3/2/2026 identified Resident #7 wat risk for skin breakdown. Interventions directed incontinent care as indicated, observe skin for any changes, and turn and position four (4) times a shift. Resident #8 was admitted with diagnoses that included PVD and paraplegia. The Resident Care Plan (RCP) dated 1/2/2026 identified Resident #8 had altered mobility, compromised circulation and contractures. Interventions directed to reposition resident every two (2) hours and as needed resident allows. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #8 was alert and oriented, was occasionally incontinent of urine, was incontinent of bowel, and was at risk for pressure ulcers. A facility reportable event (RE) dated 3/27/2026, submitted to the State Agency at 4:30 PM for Resident #8 identified an allegation of neglect several residents didn't receive incontinent care during the 11 PM to 7 AM shift on 3/26/26. The RE further identified a staff member reported that during rounds it was noted that several residents did not receive incontinent care timely. They were soaked and some also had feces on them. Additional review of the RE failed to identify who the additional residents were. Request by the State Agency to the facility on 3/31/2026, with a response received on 4/1/2026 at 3 PM (5 days after the facility was aware of the allegation) identified the affected residents were Residents #4, 5, 6, 7 and 8. A RE summary dated 4/1/2026 identified on 3/27/2026 on morning rounds staff reported that several residents did not receive incontinent care timely. They were soaked and some had feces on them. An investigation was immediately initiated, and residents were interviewed by the social worker and DON. The summary indicated Residents #4, 5, 6, 7 and 8 all reported they had no care issues and care was provided timely. Video surveillance reviewed and Aide in questions did provide care and last rounds was also done timely. Record review for Residents #4, #5, #6, #7 and #8 failed to identify documentation of the first and second rounds care provided for the listed residents. Interview and record review with the DON on 4/15/2026 at 2:17 PM identified NA #1 reported that she had completed first rounds at around 1:15 AM and second rounds by 5:15 AM and did not report any other rounds. The DON stated she expected the staff to document the care they provided in the medical record, and NA #1 did not document the care that she provided. The DON stated video monitoring of the 11:00 PM to 7:00 AM shift on 3/26/2026 into 3/27/2026 had indicated that NA #1 performed the rounds as described and failed to document care provided to the residents. Although multiple attempts were made to contact NA #1 during the survey, an interview was not obtained during the survey. The facility policy Nursing Documentation dated 5/1/2023 directed in part that nursing documentation should accurately reflect the resident's condition and care provided by nursing staff.

Based on a review of clinical records, facility documentation, facility policies, and interviews for one of two residents (Resident #2) reviewed for wound care, the facility failed to ensure the APRN was notified timely of Resident #2's refusal of physician ordered daily wound dressings. The findings include: Resident #2 was admitted to the facility with diagnoses that included peripheral vascular disease (PVD), paraplegia (loss of voluntary movement and sensation to the lower half of the body) and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 (indicated he/she was alert and oriented) and was dependent for personal hygiene, moderate assist for bed mobility and transfers, and had one (1) venous or arterial ulcer. A resident care plan (RCP) dated 2/11/2026 identified Resident #2 was resistive to care, refused care (including wound care), and was at risk for skin breakdown related to PVD, paraplegia and weakness. Interventions directed to provide wound treatment as ordered, explain all care, including procedures (one step at a time), and the reason for performing the care before initiating and to provide with the opportunity for choice during care/activities to provide a sense of control. A physician order dated 3/14/2026 directed to cleanse a right shin wound with normal saline (NS), followed by calcium alginate (absorbent wound dressing that changes into a gel upon wound contact to promote healing) followed by a dry clean dressing every day shift. A facility reportable event (RE) dated 3/19/2026 at 1:00 PM identified during wound rounds it was noted that Resident #2's dressing was not changed for three (3) days by LPN #3. An investigation was initiated and the MD/APRN (provider) was notified. A facility RE summary dated 4/1/2026 identified on 3/19/2026 Resident #2's wound dressing was noted to be dated 3/15/2026. Resident #2 was self-responsible and had refused the right shin wound treatments, however the nurse failed to notify the physician/APRN. Interview and record review with APRN #2 on 4/14/2026 at 1:30 PM identified wound dressings are dated when changed to identify the date the treatment was provided. APRN #2 stated she was completing wound rounds with LPN #7 on 3/19/2026 when they noted that Resident #2's right lower extremity dressing was dated 3/15/2026 (indicating the treatment was not provided for 3 days). Resident #2 frequently refused wound treatments. APRN #2 stated staff were required to notify her or the medical APRN if a treatment was refused, but stated staff did not notify her of any refusals of 3/16, 3/17 and 3/18/2026, and she would want to have been notified. Interview and review of facility documents with the DON on 4/14/2026 at 10:15 AM identified upon interview with LPN #3 on 3/20/2026, LPN #3 reported Resident #2 had refused to have the dressing changed on 3/16, 3/17 and 3/18/2026. The DON stated she expected staff to notify the physician/APRN of any treatment refusals and LPN #3 had indicated she forgot to notify an APRN of the refusals. Attempts to contact LPN #3 were unsuccessful during survey. The facility Skin Integrity and Wound Management Policy dated 2/1/2023 directed in part, to collaborate with the provider to review conditions that may affect healing. The facility Treatment: Refusal Policy dated 3/1/2022 directed in part, if a patient refuses treatment to notify the physician of the refusal of treatment. The facility policy Change in Condition: Notification of dated 6/1/2021 directed in part, to notify the physician of a significant change in condition and a need to alter treatment. Further, the Policy directed to provide timely notification about changes relevant to the patient's condition.

Based on clinical record reviews, reviews of facility documentation, facility policies, and interviews for five (5) of six (6) sampled residents (Residents #4, #5, #6, #7 and #8) reviewed for neglect, the facility failed to ensure staff reported an allegation of neglect and failed to ensure the State Agency was notified of the allegations of neglect and for two sampled residents (Residents #11 and #12) who were reviewed for reporting an allegation of abuse, the facility failed to ensure two (2) incidences where Resident #12 made inappropriate sexual comments to Resident #11 were reported to the state agency. The findings include: A. Resident #4 was admitted with diagnoses that included polyneuropathy (multiple nerve dysfunction that causes numbness, tingling and muscle weakness), traumatic brain injury and depression. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #4 was alert and oriented with a Brief Mental Interview for Mental Status (BIMS) of fifteen (15), and was dependent for toileting, was frequently incontinent of urine, always incontinent of bowel, and was at risk for pressure ulcers. The Resident Care Plan (RCP) dated 3/11/2026 identified Resident #4 a risk for skin breakdown due to immobility and incontinence. Interventions directed to turn and reposition every two (2) hours and observe skin for any signs of breakdown. Resident #5 was admitted with diagnoses that included dementia, diabetes mellitus and depression. A quarterly MDS dated [DATE] identified Resident #5 was alert and oriented (BIMS score 13), was dependent for toileting, was frequently incontinent of urine, and was at risk for pressure ulcers. The RCP dated 3/18/2026 identified Resident #5 a risk for skin breakdown due to limited mobility and cognitive loss. Interventions directed to turn and reposition every one (1) to two (2) hours while in bed and observe skin for any signs of breakdown. Resident #6 was admitted with diagnoses that included multiple sclerosis and peripheral vascular disease (PVD). The RCP dated 12/28/2025 identified Resident #6 at risk for skin breakdown due to limited mobility and incontinence. Interventions directed incontinent care and to observe skin for any changes. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #6 was alert and oriented, was occasionally incontinent of urine, and was at risk for pressure ulcers. Resident #7 was admitted with diagnoses that included multiple sclerosis, paraplegia. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #7 was alert and oriented and was incontinent of urine. The Resident Care Plan (RCP) dated 3/2/2026 identified Resident #7 wat risk for skin breakdown. Interventions directed incontinent care as indicated, observe skin for any changes, and turn and position four (4) times a shift. Resident #8 was admitted with diagnoses that included PVD and paraplegia. The Resident Care Plan (RCP) dated 1/2/2026 identified Resident #8 had altered mobility, compromised circulation and contractures. Interventions directed to reposition resident every two (2) hours and as needed resident allows. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #8 was alert and oriented, was occasionally incontinent of urine, was incontinent of bowel, and was at risk for pressure ulcers. A facility reportable event (RE) dated 3/27/2026, submitted to the State Agency at 4:30 PM for Resident #8 identified an allegation of neglect several residents didn't receive incontinent care on 11-7 3/26/26. The RE further identified a staff member reported that during rounds it was noted that several residents did not receive incontinent care timely. They were soaked and some also had feces on them. Additional review of the RE failed to identify the time the rounds were conducted that identified the lack of incontinent care, and failed to identify who the additional residents were. Review failed to identify why the additional residents were not identified in the report, and why the State Agency was not notified until 9 1/2 hours after the start of the day shift. Request by the State Agency to the facility on 3/31/2026 to identify the additional residents. A response was received on 4/1/2026 at 3 PM (5 days after the facility was aware of the allegation) that identified the affected residents were Residents #3, 4, 5, 6, 7 and 8. A RE summary dated 4/1/2026 identified on 3/27/2026 on morning rounds staff reported that several residents did not receive incontinent care timely. They were soaked and some had feces on them. An investigation was immediately initiated, and residents were interviewed by the social worker and DON. The summary indicated Resident #8 reported he/she had no care issues and care was provided timely. Other residents also interviewed and had no issues. Video surveillance reviewed and Aide in questions did provide care and last rounds was also done timely. The facility was unable to substantiate neglect. Interview with NA #2 on 4/15/2026 at 11:30 AM identified on 3/27/2026 she completed her initial rounds at the start of the 7 AM to 3 PM shift, and identified Residents #3, 4, 5, 6, 7 and 8 had saturated pads (wet with urine), and the briefs, night clothes and top sheets were wet. NA #2 stated she thought the night NA had not provided care on the last rounds prior to their shift ending at 7 AM as she started her rounds of her assigned residents at 7:00 AM. NA #2 stated she then provided breakfast for residents and completed AM care for all her assigned residents. NA #2 further stated she was uncomfortable reporting the allegation to the DON, and she when she went on break from the unit about 9:30 AM, she spoke with another staff member about her concerns. The other staff member then transcribed the concerns and assister her to report them to the DON on 3/27/2026. Further, NA #2 indicated although she included Resident #3 in her initial report, she stated Resident #3 was not found wet on the morning of 3/27/2026. Interview, record review and facility documentation review with the DON on 4/15/2026 at 2:17 PM identified the initial allegation of neglect involved Residents #3, 4, 5, 6, 7, and 8. The DON further stated she was notified of the allegation on 3/27/2026 at approximately 9:15 AM (7 hours and 15 minutes prior to notifying the State Agency). After assessing the six (6) residents involved, and interviewing all the residents, the facility identified there was no neglect and the DON stated she chose to only report the allegation for Resident #8 and not to include any information about Residents #3, 4, 5, 6 and 7. The DON stated she believed there was no harm in not notifying the State Agency of the allegations for Residents #3, 4, 5, 6 and 7. Interview further identified NA #2 should have reported the allegation before providing residents with breakfast and morning care. The facility policy Abuse Prohibition dated 10/24/2022 directed in part, neglect was defined as the failure to provide care and services to a patient that are necessary. The Policy further directed anyone who witnesses an incident of suspected abuse or neglect is to report the incident to his/her supervisor immediately, regardless of the shift. The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. The Policy directed immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, the Administrator or designee will to report allegations involving abuse not later than 2 hours after the allegation is made. 1.Resident #11's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic kidney disease stage, epilepsy, unspecified mood (affect) disorder and unspecified psychosis not due to a substance or known physiological condition. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #11 had moderately impaired cognition, was dependent on staff for all activities of daily living. The Resident Care Plan dated 12/12/25 identified Resident #11 had impaired and a decline in cognitive function or impaired thought processes related to a condition other than delirium; impaired decision making. Interventions directed to observe and evaluate types of changes in cognitive status, allow the resident to make daily decisions, use verbal cues, gestures and demonstration to assist in decision making, and provide consistent, trusted caregiver and structured daily routine. The nurse's note dated 2/25/26 at 10:14 PM identified the charge nurse reported an inappropriate verbal comment requesting for Resident #11 to touch Resident #11 to touch him/herself was made by Resident #11's roommate, Resident #12. The note further identified there was no physical contact observed, both residents were assessed and the privacy curtain was closed to promote privacy and maintain appropriate boundaries. The nurse's note dated 3/1/26 at 11:30 AM identified Resident #11 was moved to a different room to maintain safety, there was no specific documentation of an incident with the roommate after the 2/25/26 event. 2. Resident #12's diagnoses included dementia with agitation, adjustment disorder with anxiety and depression and mild neurocognitive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #12 was cognitively intact, was independent with bed mobility and transfers. The Resident Care Plan dated 1/1/26 identified Resident #12 had impaired and a decline in cognitive function or impaired thought processes related to a condition other than delirium; short/long term memory loss and impaired decision making. Interventions directed to observe and evaluate types of changes in cognitive status, evaluate responses from Brief Interview for Mental Status (BIMS-a tool used to calculate cognitive status), evaluate behavioral symptoms for underlying causes, and evaluate need for psych/behavioral health consult as needed. The nurse's note dated 2/26/26 at 3:42 AM identified the charge nurse reported Resident #12 was making inappropriate comments to his/her roommate Resident #11. The note identified there was no physical contact between the residents. The note identified Resident #12 was provided with education regarding inappropriate behavior and maintaining boundaries and the privacy curtain was pulled between the two (2) residents. The note indicated Resident #12 became upset with the Nursing Supervisor shouted at the supervisor to leave the room, stating it was a private conversation between him/her and the roommate. The note indicated the situation would be closely monitored by nursing to ensure safety and appropriateness of behavior throughout the shift. A revision was made to the care plan on 2/26/26 to include Resident #12 exhibits or potential to demonstrate verbal behaviors related to sexually inappropriate language. Interventions directed to evaluate nature and circumstances of the behaviors with the resident, evaluate the need for psych/behavioral health consultation, and social service visits to provide support as needed. The practitioner's note dated 2/27/26 at 3:01 PM identified Resident #12 was evaluated for inappropriate verbal comments directed toward roommate, nursing documentation reflects Resident #12 asked his/her roommate to touch self and made sexually inappropriate statements. The note indicated Resident #12 was placed in the psych communication book and psychiatry was notified with evaluation pending. The practitioner's note dated 3/6/26 at 8:40 AM identified Resident #12 was seen following documented behavioral concerns within the facility. The note indicated episodes of unusual behavior towards the roommate, including sitting at the end of the roommate's bed and speaking to the roommate during the nighttime hours. Review of the Residents #11and Resident #12's clinical records failed to reflect documentation addressing an incident on 3/1/26 incident, only that Resident #11 was moved to another room for safety. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #4, on 4/14/26 at 1:56 PM identified on 3/1/26 upon arriving for her shift, she observed Resident #12 sitting at the end of Resident #11's bed and heard Resident #12 ask Resident #11 if he/she enjoyed last night. LPN #4 explained she observed Resident #11 with his/her brief down to the right side, which Resident #11 would not be able to do by him/herself. LPN #4 identified she did not observe any semen present on either resident. LPN #4 identified she immediately notified the supervisor and at that time Resident #11 was provided with a room change for safety. Interview with the 3-11PM nursing supervisor, Registered Nurse (RN) #6, on 4/14/26 at 2:31 PM identified on 3/1/26 it was reported to her that Resident #12 was observed fondling his/herself at the end of Resident #11's bed. RN #6 indicated she assessed both residents and provided Resident #11 with a room change for safety. Interview and clinical record review with the DON on 4/15/26 at 11:51 AM identified it was reported to her that on 2/25/26 Resident #12 was overheard making sexual talk in front of Resident #11. The DON identified social services and psych services were provided to Resident #12 and Resident #11 was provided with psych services as well. The DON identified the incident was not reported to the state agency nor an investigation was not initiated on 2/25/26 as the incident was reported as an overheard comment. The DON explained the facility did not report the allegation to the state agency as she did not feel this was verbal or sexual abuse as it was just sexual talk and Resident #12 has the right to talk like this in his/her room. The DON identified she was not made aware Resident #11 had his/her brief down at any time. The DON identified on 3/1/26 she was notified Resident #12 was verbalizing something to the effect of I am playing with myself and do you want to see it towards Resident #11. The DON indicated the facility policy on abuse directed to report abuse immediately and initiate an investigation immediately when there is an allegation. The DON identified she did not report the 3/1/26 incident to the state agency as they did not feel this was abuse. The DON identified it is the responsibility of the DON and/or the administrator to report allegations of abuse to the state agency. Interview with the administrator on 4/15/26 at 2:35 PM identified on 2/25/26 an incident was discussed where Resident #12 was making sexual comments in the room shared with Resident #11. The administrator identified on 3/1/26 an incident was reported that Resident #12 was at the end of Resident #11's bed and touching him/herself, there was no touching of Resident #11. The administrator identified on 3/1/26 it was reported that Resident #12 was at the end of Resident #11's bed and touching him/herself, but there was no touching of Resident #11. The administrator indicated the facility did not initiate an investigation or report the alleged incidences to the state agency because they did not feel these incidences met the definition of abuse, either verbal or sexual. Review of the facility policy title Abuse Prohibition, last revised 10/24/22, directed, in part, the center prohibits abuse, mistreatment, neglect, misappropriate of resident property and exploitation for all residents and this included, but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restrain not required to treat the residents medical symptoms. The policy further directed, in part, the administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, and the facility must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime. Additionally, the policy directed, in part, staff will identify events and trends that may constitute abuse and determine the direction of the investigation, this also includes resident to resident abuse. The policy further directed, in part, anyone who witnesses an incident of suspected abuse must report the incident to his/her supervisor immediately, regardless of shift worked, and the notified supervisor will report the suspected abuse immediately to the administrator or designee and other officials in accordance with state law. .

Based on review of the clinical record, facility documentation, facility policy and interviews for three of six residents (Residents #4, #5 and #8) reviewed for neglect, the facility failed to ensure staff repositioned residents timely, in accordance with the plan of care. The findings include: Based on review of the clinical record, facility documentation, facility policy and interviews for three of six residents (Residents #4, #5 and #8) reviewed for neglect, the facility failed to ensure staff repositioned residents in accordance with the plan of care. The findings include: Resident #4 was admitted with diagnoses that included polyneuropathy (multiple nerve dysfunction that causes numbness, tingling and muscle weakness), traumatic brain injury and depression. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #4 was alert and oriented with a Brief Mental Interview for Mental Status (BIMS) of fifteen (15), and was dependent for toileting and bed mobility, was frequently incontinent of urine, always incontinent of bowel, and was at risk for pressure ulcers. The Resident Care Plan (RCP) dated 3/11/2026 identified Resident #4 a risk for skin breakdown due to immobility and incontinence. Interventions directed to turn and reposition every two (2) hours and observe skin for any signs of breakdown. The NA care card identified Resident #4 required assistance to turn and reposition every two (2) hours, as resident allowed. Resident #5 was admitted with diagnoses that included dementia, diabetes mellitus and depression. A quarterly MDS dated [DATE] identified Resident #5 was alert and oriented (BIMS score 13), was dependent for toileting and bed mobility, was frequently incontinent of urine, and was at risk for pressure ulcers. The RCP dated 3/18/2026 identified Resident #5 a risk for skin breakdown due to limited mobility and cognitive loss. Interventions directed to turn and reposition every one (1) to two (2) hours while in bed and observe skin for any signs of breakdown. The NA care card identified Resident #4 required assistance to turn and reposition every two (2) hours, as resident allowed. Resident #8 was admitted with diagnoses that included PVD and paraplegia. The Resident Care Plan (RCP) dated 1/2/2026 identified Resident #8 had altered mobility, compromised circulation and contractures. Interventions directed to reposition resident every two (2) hours and as needed resident allows. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #8 was alert and oriented, was dependent for bed mobility, was occasionally incontinent of urine, was incontinent of bowel, and was at risk for pressure ulcers. The NA care card identified Resident #8 required assistance to turn and reposition every 2 hours as resident allowed. ` A facility reportable event (RE) dated 3/27/2026, submitted to the State Agency at 4:30 PM for Resident #8 identified an allegation of neglect several residents didn't receive incontinent care on 11-7 3/26/26. The RE further identified a staff member reported that during rounds it was noted that several residents did not receive incontinent care timely. They were soaked and some also had feces on them. Additional review of the RE failed to identify the time the rounds were conducted that identified the lack of incontinent care and failed to identify who the additional residents were. A RE summary dated 4/1/2026 identified on 3/27/2026 on morning rounds staff reported that several residents did not receive incontinent care timely. They were soaked and some had feces on them. An investigation was immediately initiated, and residents were interviewed by the social worker and DON. The summary indicated Resident #8 reported he/she had no care issues and care was provided timely. Other residents also interviewed and had no issues. Video surveillance reviewed and Aide in questions did provide care and last rounds was also done timely. The facility was unable to substantiate neglect. Interview with NA #2 on 4/15/2026 at 11:30 AM identified on 3/27/2026 she completed her initial rounds at the start of the 7 AM to 3 PM shift, and identified Residents #3, 4, 5, 6, 7 and 8 had saturated pads (wet with urine), and the briefs, night clothes and top sheets were wet. NA #2 stated she thought the night NA had not provided care on the last rounds prior to their shift ending at 7 AM as she started her rounds of her assigned residents at 7:00 AM. Interview and review of facility documents with the DON on 4/15/2026 at 2:17 PM identified NA #1 reported that she had completed first rounds at around 1:15 AM and second rounds by 5:15 AM, and did not report completing any other rounds. The DON was aware a few of the residents identified by NA #2 (Residents #4, #5 and #8), had interventions to be repositioned at every one (1) to two (2) hours and stated she expected staff to check on residents in accordance with the care plan. The DON stated review of facility video monitoring during the 11 PM to 7 AM shift ending on 3/27/2026 identified NA #1 was observed to be sleeping on the shift, and record review identified NA #1 failed to document care provided to the residents. Interview with RN #11 identified she was the charge nurse on 3/26/2026 (shift ending at 7 AM on 3/27/2026) and saw that NA #1 had fallen asleep in the hallway after the first rounds was completed at around 1:30 AM. RN #11 stated she woke NA #1 up multiple times during the shift, but only observed NA #1 get up to complete second rounds at around 5:15 AM. RN #11 stated she did not recall if call lights were activated on any of NA #1's assigned residents but identified that the other staff assisted to answer call lights. RN #11 stated that NA #1 had told her she had another job where she had just finished a double shift, and RN #11 did not notify the supervisor that NA #1 was sleeping during the shift. Multiple attempts to contact NA #1 during the survey were unsuccessful. The facility policy Person Centered Care plan dated 10/24/2022 directed in part that the care plan is customized and includes instructions needed to provide effective and person-centered care.

Based on a review of clinical records, facility documentation, facility policies, and interviews for one of four residents (Resident #1) reviewed for medication errors, the facility failed to ensure previous orders were discontinued and new orders written for a resident readmitted to the facility, and failed to ensure the double check system verified physician orders accurately resulting in a medication error. The findings include: Resident #1 was admitted to the facility with diagnoses that included status post kidney transplant. A resident care plan (RCP) dated 3/22/2026 identified Resident #1 was at risk for impaired kidney function and complications related to kidney transplant. Interventions directed to administer medications as ordered and monitor for side effects. A quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) 3/24/3036 identified Resident # 1 had a Brief Interview for Mental Status (BIMS) score of 15 (was alert and oriented). Physician order dated 3/4/2026 directed to administer Envarsus XR (Tacrolimus; immunosuppressant used to prevent organ rejection) 4 milligrams, one tablet daily. Record review identified Resident #1 was transferred to the hospital on 3/24/2026 for evaluation related to abnormal lab values. Additional review identified Resident #1 was readmitted to the facility on [DATE] (six days later). A hospital interagency referral report (W-10) medication order dated 3/30/2026 at 3:40 PM directed Tacrolimus XR 24-hour tablet (Envarsus XR), take six (6) tablets for 6 mg total daily (six 1 mg tablets). An APRN note dated 3/30/2026 at 10:17 PM identified Resident #1was newly admitted (re-admitted ) to the facility. admission orders and hospital discharge summary were reviewed with nursing supervisor and medication reconciliation was initiated. Medications reviewed included Tacrolimus XR (Envarsus XR) 6 mg by mouth daily. Record review identified the physician order dated 3/30/2026 directed to administer Envarsus XR oral tablet 4 mg (Tacrolimus), give 6 tablets by mouth one time a day to prevent rejection. Record review identified the physician order entered on 3/30/2026 conflicted with the Tacrolimus six tablets of one (1) mg for a daily total of 6 mg; instead, the order directed to administer six (6) tablets of 4 mg for a total dose of 24 mg (instead of 6 mg). A facility reportable event (RE) dated 3/31/2026 at 2:30 PM identified Resident #1's medication was transcribed incorrectly, and subsequently a wrong dose was administered to Resident #1. APRN assessment was completed with new orders for laboratory tests, monitor vital signs and mental status and to hold medication until laboratory results were obtained. No overt sign of injury was noted. A facility RE summary dated 4/2/2026 identified Resident #1 was given the incorrect dose of Tacrolimus on 3/31/2026; instead of administering the ordered 6 mg, Resident #1 received a total of 24 mg. The summary indicated the cause of the error was a transcription error. After the medication error, Resident #1 had no mental or medical changes and remained stable. Interview and record review with RN #1 on 4/13/2026 at 11:00 AM identified she was one (1) of two (2) evening supervisors on 3/30/2026. RN #1 stated Resident #1 was readmitted to the facility on [DATE] during her shift and RN #2 (the other supervisor) verified the new orders with the APRN. RN #1 entered Resident #1's medication orders into Resident #1 Electronic Medical Record (EMR). RN #1 stated since Resident #1 was a readmission, she was able to pull up the last medication orders in the EMR to update and she used those to reconcile to the hospital W-10. RN #1 indicated she did not realize she had entered the Tacrolimus dose incorrectly. The previous order was for one (1) tablet of 4 mg and she changed the one (1) tablet to match the new order of six (6) tablets; she did not change the tablet dosage because she did not see they were for different mgs - she only changed the number of tablets to administer. After she entered the orders, RN #2 was expected to verify the entered orders for accuracy, and the Tacrolimus 4 mg was available on the unit to administer to Resident #1 from his/her prior admission. RN #1 stated she must have misread the tablet strength on the hospital W-10 when she transcribed the orders. Interview and record review with LPN #1 on 4/13/2026 at 11:31 PM identified she administered the Tacrolimus dose as it was entered into the EMR on 3/31/2026, Tacrolimus Envarsus XR oral tablet 4 mg (Tacrolimus), give six (6) tablets by mouth one time a day. LPN #1 stated two (2) supervisors had reconciled the medication orders for accuracy, and if the medication was available in the medication cart drawer, then she would not question the dose. Although attempted, an interview with RN #2 was not obtained during the survey. Interview and record review with the DON on 4/13/2026 at 11:00 AM identified the facility process was for a supervisor to review the W-10 with the APRN/MD and enters the orders into the EMR for any new admission or re-admission. Then a second supervisor does a second reconciliation to ensure the orders were entered correctly. The DON stated that when Resident #1's medication error occurred, the facility process was for the shift supervisor to reconcile and enter the orders in the EMR and the next shift supervisor to do a second reconciliation. The DON stated that a review of the record identified RN #2 did not complete the second reconciliation of the medication orders. The error was not identified until the afternoon of 3/31/2026 when the pharmacy completed their medication review, and they notified the facility of the transcription error. Since Resident #1 was a readmission, the Tacrolimus four (4) mg tablets were available in the medication cart for dose due at 6 AM on 3/31/2026 and Resident #1 received a total dose of 24 mgs instead of 6 mgs. The DON stated RN #2 did not complete the second reconciliation because she was busy with other incidents during the shift. the DON stated if a resident was discharged from the facility for five (5) or more days, upon readmission the prior orders should be discontinued and new orders should be entered (Resident #1 was discharged for six days). The facility policy Medication Reconciliation dated 9/1/2022 directed in part, that a resident's medication orders will be reconciled when admitted or readmitted from the hospital. Medication reconciliation was the process of comparing a resident's existing medications and involved obtaining and maintaining a complete and accurate list of current medications. Once reconciliation was completed, medication orders were obtained from the physician or APRN and entered into the EMR. A repeat reconciliation was performed to compare hospital medication listing to current facility medication listing to the medication administration record to ensure accuracy.

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for two of two sampled residents (Residents #11 & #12) who were reviewed for abuse, the facility failed to ensure Resident #11 was free from sexual abuse by Resident #12. The findings include:1.Resident #11's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic kidney disease stage, epilepsy, unspecified mood (affect) disorder and unspecified psychosis not due to a substance or known physiological condition. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #11 had moderately impaired cognition, was dependent on staff for all activities of daily living. The Resident Care Plan dated 12/12/25 identified Resident #11 had impaired and a decline in cognitive function or impaired thought processes related to a condition other than delirium; impaired decision making. Interventions directed to observe and evaluate types of changes in cognitive status, allow the resident to make daily decisions, use verbal cues, gestures and demonstration to assist in decision making, and provide consistent, trusted caregiver and structured daily routine. The nurse's note dated 2/25/26 at 10:14 PM identified the charge nurse reported an inappropriate verbal comment requesting for Resident #11 to touch Resident #11 to touch him/herself was made by Resident #11's roommate, Resident #12. The note further identified there was no physical contact observed, both residents were assessed and the privacy curtain was closed to promote privacy and maintain appropriate boundaries. The nurse's note dated 3/1/26 at 11:30 AM identified Resident #11 was moved to a different room to maintain safety, there was no specific documentation of an incident with the roommate after the 2/25/26 event. 2. Resident #12's diagnoses included dementia with agitation, adjustment disorder with anxiety and depression and mild neurocognitive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #12 was cognitively intact, was independent with bed mobility and transfers. The Resident Care Plan dated 1/1/26 identified Resident #12 had impaired and a decline in cognitive function or impaired thought processes related to a condition other than delirium; short/long term memory loss and impaired decision making. Interventions directed to observe and evaluate types of changes in cognitive status, evaluate responses from Brief Interview for Mental Status (BIMS-a tool used to calculate cognitive status), evaluate behavioral symptoms for underlying causes, and evaluate need for psych/behavioral health consult as needed. The nurse's note dated 2/26/26 at 3:42 AM identified the charge nurse reported Resident #12 was making inappropriate comments to his/her roommate Resident #11. The note identified there was no physical contact between the residents. The note identified Resident #12 was provided with education regarding inappropriate behavior and maintaining boundaries and the privacy curtain was pulled between the two (2) residents. The note indicated Resident #12 became upset with the Nursing Supervisor shouted at the supervisor to leave the room, stating it was a private conversation between him/her and the roommate. The note indicated the situation would be closely monitored by nursing to ensure safety and appropriateness of behavior throughout the shift. A revision was made to the care plan on 2/26/26 to include Resident #12 exhibits or potential to demonstrate verbal behaviors related to sexually inappropriate language. Interventions directed to evaluate nature and circumstances of the behaviors with the resident, evaluate the need for psych/behavioral health consultation, and social service visits to provide support as needed. The practitioner's note dated 2/27/26 at 3:01 PM identified Resident #12 was evaluated for inappropriate verbal comments directed toward roommate, nursing documentation reflects Resident #12 asked his/her roommate to touch self and made sexually inappropriate statements. The note indicated Resident #12 was placed in the psych communication book and psychiatry was notified with evaluation pending. The practitioner's note dated 3/6/26 at 8:40 AM identified Resident #12 was seen following documented behavioral concerns within the facility. The note indicated episodes of unusual behavior towards the roommate, including sitting at the end of the roommate's bed and speaking to the roommate during the nighttime hours. Review of the Residents #11and Resident #12's clinical records failed to reflect documentation addressing an incident on 3/1/26 incident, only that Resident #11 was moved to another room for safety. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #4, on 4/14/26 at 1:56 PM identified on 3/1/26 upon arriving for her shift, she observed Resident #12 sitting at the end of Resident #11's bed and heard Resident #12 ask Resident #11 if he/she enjoyed last night. LPN #4 explained she observed Resident #11 with his/her brief down to the right side, which Resident #11 would not be able to do by him/herself. LPN #4 identified she did not observe any semen present on either resident. LPN #4 identified she immediately notified the supervisor and at that time Resident #11 was provided with a room change for safety. LPN #4 identified she created a nurse's note after the incident, but review of the clinical documentation of both Resident #11 and Resident #12 failed to identify a nurse's note was present in the clinical record. Interview with the 3-11PM nursing supervisor, Registered Nurse (RN) #6, on 4/14/26 at 2:31 PM identified on 3/1/26 it was reported to her that Resident #12 was observed fondling his/herself at the end of Resident #11's bed. RN #6 indicated she assessed both residents and provided Resident #11 with a room change for safety. Interview and clinical record review with the Social Worker (SW) #1, on 4/14/26 at 2:46 PM identified an incident was reported to her that on 3/1/26 Resident #12 had displayed some type of sexual behaviors. SW #1 indicated she was not made aware of the 2/25/26 incident until after the 3/1/26 incident. SW #1 identified she provided follow-up with Resident #12 who declined to discuss anything with her at that time and continued to refuse during attempts to reapproach Resident #12. SW #1 identified that making a sexual statement towards another resident would be considered abuse and it should be reported immediately. Interview with RN #1 on 4/15/26 at 8:46 AM identified on 2/25/26 the charge nurse reported to her Resident #12 asked Resident #11 to touch his/herself. RN #1 indicated she went to both residents to have a conversation with each of them. RN #1 explained although Resident #12 stated he/she was not aware of what she was talking about and Resident #11 reported he/she was not upset, she notified the Director of Nursing (DON). RN #1 identified both residents denied anything happened, the privacy curtain was pulled, and a room change was offered at that time to Resident #11 who declined. Interview and clinical record review with the DON on 4/15/26 at 11:51 AM identified it was reported to her that on 2/25/26 Resident #12 was overheard making sexual talk in front of Resident #11. The DON identified social services and psych services were provided to Resident #12 and Resident #11 was provided with psych services as well. The DON identified an investigation was not initiated on 2/25/26 as the incident was reported as an overheard comment. The DON explained the facility did not report the allegation to the state agency as she did not feel this was verbal or sexual abuse as it was just sexual talk and Resident #12 has the right to talk like this in his/her room. The DON identified on 3/1/26 she was notified Resident #12 was verbalizing something to the effect of I am playing with myself and do you want to see it towards Resident #11. The DON identified at the time of the 3/1/26 incident, Resident #11 was provided with a room change and Resident #12 was noted to be very hypersexual in what he/she says. The DON indicated the facility policy on abuse defines sexual abuse as non-consensual sex or contact with any resident, and she did not believe these incidents fit into that definition. Interview with the administrator on 4/15/26 at 2:35 PM identified on 2/25/26 an incident was discussed where Resident #12 was making sexual comments in the room shared with Resident #11. The administrator identified on 3/1/26 an incident was reported that Resident #12 was at the end of Resident #11's bed and touching him/herself, there was no touching of Resident #11, Resident #11 was provided with a room change, each resident was assessed, appropriate parties were notified and psych consults were requested. The administrator identified the facility policy on abuse stated (read off from actual policy) verbal abuse is any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or their families or within their hearing distance, regardless of their age, ability to comprehend or disability. The administrator identified sexual abuse is a non-consensual sexual contact of any type with a patient, it includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Review of the facility policy title Abuse Prohibition, last revised 10/24/22, directed, in part, the center prohibits abuse, mistreatment, neglect, misappropriate of resident property and exploitation for all residents and this included, but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restrain not required to treat the residents medical symptoms. The policy further defines verbal abuse as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents and their families or within their hearing distance regardless of their age, ability to comprehend, or disability. The policy further defined sexual abuse as any non-consensual sexual contact of any type with a resident and included, but was not limited to sexual harassment, sexual coercion, or sexual assault.

Based on review of the clinical record, facility documentation, facility policy and interviews for three (3) of three (3) sampled residents (Residents #1, #2 and #3) reviewed for allegations of neglect, the facility failed to ensure Resident Care Conferences (RCCs) were completed at least quarterly. The findings include:1. Resident #1's diagnoses included mild cognitive impairment, dysthymic disorder (a continuous, long-term form of depression), left foot drop and moderate protein calorie malnutrition.A Care Plan Meeting note dated 5/5/25 at 12:42 PM identified that an RCC was held with Resident #1 and Resident #1's conservator.Review of the clinical record from 5/6/25 through 1/14/26 failed to identify that a subsequent RCC was scheduled or held for Resident #1.The quarterly MDS assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and was dependent on staff assistance for personal hygiene, bed mobility and transfers.Review of the clinical record from 1/15/26 through Resident #1's discharge date of 2/9/26 failed to identify that an RCC was scheduled or held for Resident #1 following the 1/15/26 MDS.2.Resident #2's diagnoses included Alzheimer's disease with late onset (a brain condition that slowly damages your memory, thinking, learning and organizing skills), age-related macular degeneration (an eye disease that blurs one's central vision and leads to vision loss) and major depressive disorder.A Care Plan Meeting note dated 9/25/25 at 11:08 AM identified that an RCC was held with Resident #2's conservator.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 4) and was dependent on staff for bed mobility and transfers.Review of the clinical record from 9/26/25 through 3/9/26 failed to identify that a subsequent RCC was scheduled or held following the 12/4/25 MDS.Although requested, an RCC signature sheet for Resident #2 was not obtained.3. Resident #3's diagnoses included major depressive disorder, chronic kidney disease and generalized abdominal pain.The quarterly MDS assessment dated [DATE] identified Resident #3 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and was independent with bed mobility, transfers and ambulation.Review of the clinical record from Resident #3's admission date of 5/17/25 through 3/9/26 failed to identify that a 72-hour care plan meeting or RCC were scheduled or held.Although requested, an RCC signature sheet for Resident #3 was not obtained.Interview with the Director of Social Services on 3/9/26 at 1:46 PM identified the facility has had social service staffing challenges and 72-hour new admission RCC's, change in condition RCC's and quarterly RCC's had not been consistently completed. Interview with the DON on 3/9/26 at 12:37 PM identified RCC's should be completed within 72-hours of a resident's admission and then at least quarterly and further identified RCC's should have been completed timely for Residents #1, #2 and #3.Review of the Person-Centered Care Plan policy dated 10/24/22 directed, in part, that the center has the responsibility to assist residents to participate in care plan meetings by extending invitations to residents and resident representatives in advance and facilitating the inclusion of the resident and resident representative(s) to attend. Care Plan meetings will be documented by use of the Care Plan Meeting note.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for allegations of neglect, the facility failed to develop an individualized, comprehensive care plan to address the resident's left foot drop present on admission and podiatry abnormalities identified during admission. The findings include:Resident #1's diagnoses included mild cognitive impairment, dysthymic disorder (a continuous, long-term form of depression), left foot drop and moderate protein calorie malnutrition.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and was dependent on staff for personal hygiene, bed mobility and transfers.The facility Reportable Event (RE) dated 2/9/26 identified they received a complaint alleging neglect due to the appearance of Resident #1's legs. The RE reported Resident #1 was seen by podiatry and wound personnel but refused treatments and Resident #1 had since been discharged .A. Hospital documentation dated 12/10/22 identified a past medical history with a diagnosis of left foot drop.Review of the Resident Care Plan (RCP) from 12/10/22 through 2/9/26 failed to identify that Resident #1 had left-foot drop or that interventions were initiated to treat the left foot drop.Interview with PT #1 on 3/9/26 at 12:15 PM identified Resident #1 was admitted to the facility in 2022 with significant left-foot drop. She reported that although therapy attempted to use Ankle Foot Orthoses (AFO) bracing on the left leg and foot, Resident #1 refused the AFO so it was discontinued. PT #1 identified the AFO and therapy were reattempted several times, but Resident #1 refused to participate or get out of bed. She reported that when Resident #1 was on therapy services, therapy would communicate all functional and Activities of Daily Living statuses and updates to nursing and nursing was responsible for developing the RCP with interventions. PT #1 identified Resident #1 should have had a comprehensive care plan to include left foot drop and the refusal of the AFO since admission to the facility on [DATE]. B. A Podiatry note dated 9/22/25 at 9:13 AM identified Resident #1's toenails were thick, yellow, brittle and contained subungual debris (crusty debris under the nail) with diagnoses of Peripheral Vascular Disease (PVD), neuropathy (nerve damage that causes pain and numbness), onychomycosis (fungal infection of the nail plate/bed) and dermatophytosis (fungal infection that thrives on keratin in the skin, hair and nails). The note identified that aseptic debridement (sterile removal of foreign debris, devitalized, necrotic or infected tissue to promote healing and prevent infection) was performed on all ten (10) of the elongated, thick toenails to viable (active/healthy) tissue and that Resident #1 would be followed up with in 6 to 8 weeks.Review of the Resident Care Plan (RCP) from 9/22/25 through 2/9/26 failed to identify Resident #1 had podiatry abnormalities including nail disorders, infections or foot and nail diagnoses to ensure proper treatment and prevent complications. Interview with the DON on 3/9/26 at 12:37 PM identified the interdisciplinary team (IDT) should have care planned Resident #1 for the left-foot drop that was present on admission, initiated interventions to prevent the foot drop from worsening and documented all treatments that were refused. She identified that licensed nursing staff who observed Resident #1's thick, long toenails or the IDT who first reviewed Resident #1's podiatry notes should have developed a podiatry care plan including interventions to ensure proper treatment to prevent complications.Review of the Person-Centered Care Plan policy dated 10/24/22 directed, in part, a comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment (admission, annual or significant change in status) and review and revise the care plan after each assessment. Care plans must describe the following: services that are to be furnished; any services that would otherwise be required but are not provided due to the patient's exercise of rights, including the right to refuse treatment and must include measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. For newly admitted residents, the comprehensive care plan must be completed within seven days of the completion of the comprehensive assessment and no more than 21 days after admission. The care plan will be prepared by the interdisciplinary team.

Based on review of the clinical record, facility documentation/policy, and staff interviews for one (1) of three (3) residents (Resident #1) reviewed for allegations of neglect, the facility failed to notify the physician and resident representative of a change in condition and refusal of care. The findings include:Cross-reference F687 and F656.Resident #1's diagnoses included mild cognitive impairment, dysthymic disorder (a continuous, long-term form of depression), left foot drop and moderate protein calorie malnutrition.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and was dependent on staff for personal hygiene, bed mobility and transfers.A Podiatry note dated 9/22/25 at 9:13 AM identified Resident #1's toenails were thick, yellow, brittle and contained subungual debris (crusty debris under the nail) with diagnoses of Peripheral Vascular Disease (PVD), neuropathy (nerve damage that causes pain and numbness), onychomycosis (fungal infection of the nail plate/bed) and dermatophytosis (fungal infection that thrives on keratin in the skin, hair and nails). The note identified that aseptic debridement (sterile removal of foreign debris, devitalized, necrotic or infected tissue to promote healing and prevent infection) was performed on all ten (10) of the elongated, thick toenails to viable (active/healthy) tissue and that Resident #1 would be followed up with in 6 to 8 weeks. Review of the clinical record from 9/22/25 to 2/9/26 failed to identify the provider or Resident #1's conservator had been notified of the condition of Resident #1's toenails following the 9/22/25 podiatry visit or the need for follow-up.The Podiatry Service Lists dated 11/10/25, 12/22/25 and 1/6/26 identified Resident #1 was due for follow up for tinea unguium (otherwise known as onychomycosis) but the visit was rescheduled and Resident #1 was not seen. The reason for the rescheduling was not identified.The Podiatry Service List dated 2/3/25 identified Resident #1 was due for follow up for tinea unguium but Resident #1 refused the visit.Nurse's notes dated 2/3/26 through 2/9/26 failed to identify documentation regarding Resident #1's refusal to see podiatry or that the provider or Resident #1's conservator had been notified of the refusal.The facility Reportable Event (RE) dated 2/9/26 identified they received a complaint alleging neglect due to the appearance of Resident #1's legs. The RE reported Resident #1 was seen by podiatry and wound personnel but refused treatments and Resident #1 had since been discharged .Interview with Person #1 (Resident #1's conservator) on 3/9/26 at 11:50 AM identified Resident #1 was transferred to another facility on 2/9/26 and he/she was present when a licensed nurse performed the admission assessment at the receiving facility. Person #1 identified Resident #1's toenails were so thick and long they started curling and reported he/she was shocked by the condition and appearance of the toenails. Person #1 identified the facility never notified him/her of podiatry issues or that Resident #1 refused treatment. Person #1 reported that had he/she known, he/she would have advocated for Resident #1, ensured Resident #1 received podiatry care and would have been present when the podiatrist visited to the facility.Interview with the DON on 3/9/26 at 12:37 PM identified although she was not employed by the facility in 9/2025, licensed nursing staff should have ensured after Resident #1 was seen by podiatry on 9/22/25 that they followed up with either the podiatrist or ensured the note was obtained and reviewed for procedures, orders and recommendations and that the provider and Resident #1's conservator were made aware of the condition of Resident #1's toenails. She identified Person #1 sent the facility pictures of Resident #1's legs and feet the same day Resident #1 was discharged on 2/9/26 and reported she (the DON) was unaware of the condition of Resident #1's toenails. She reported that her staff should have documented on the toenails and notified the unit manager or herself so they could have followed up with podiatry regarding Resident #1 and they should have notified both the provider and Resident #1's conservator when Resident #1 refused podiatry care on 2/3/26.Interview with APRN #1 on 3/9/26 at 1:22 PM identified she was never notified of the condition of Resident #1's toenails on 9/22/25 or that Resident #1 refused podiatry care on 2/3/26. She identified that nursing should have documented and notified her of the podiatrist's 9/22/25 visit and note indicating the condition of the toenails, as well as the continued growth and refusal of podiatry care. APRN #1 identified Resident #1 had multiple comorbidities and had she been notified of the 9/22/25 podiatry visit and associated note, she would have ensured Resident #1's feet and toenails were monitored and that podiatry followed up timely. She reported Resident #1 did not easily trust new faces and identified that if herself, other nursing staff, or Resident #1's conservator had been involved in the podiatry care, refusals of care may have been prevented. Review of the Notification of Change in Condition policy dated 6/1/21 directed, in part, the purpose of the policy is to provide appropriate and timely information about changes relevant to the resident's condition and the center must immediately inform the resident, consult with the resident's physician and notify the resident's healthcare decision maker when there is a need to alter treatment significantly or a change in the resident's physical status.Review of the Refusal of Treatment policy dated 3/1/22 directed, in part, if the resident is refusing treatment, staff will determine what the resident is refusing and why. Staff will try to address the residents' concern(s) and consult his/her supervisor. If the resident continues to refuse treatment, determine decision making capacity and inform the healthcare decision maker of the resident's refusal after discussion with the resident. Notify the physician of the refusal of treatment. Staff will determine and document what the resident is refusing, assess the reasons for refusal, advise the resident and healthcare decision maker of consequences of the refusal and offer alternative treatments.Review of the Foot Care policy dated 8/7/23 directed, in part, the purpose of the policy is to ensure residents receive proper treatment and care to maintain mobility and good foot health. The center will provide foot care and treatment in accordance with professional standards of practice and state scope of practice, including to prevent complications from the resident's medical condition(s) such as diabetes, peripheral vascular disease or immobility and ensure residents receive proper treatment and care to maintain mobility and good foot health. Residents who have complicating disease processes requiring foot care including, but not limited to, infections/fungus, ingrown nails, diabetes mellitus, neurological disorders, renal failure and peripheral vascular disease must be referred to qualified professionals such as podiatrists or other qualified providers.

Based on review of the clinical record, facility documentation, and facility policy for one (1) of three (3) sampled residents (Resident #1) reviewed for allegations of neglect, the facility failed to ensure Resident #1 received ongoing podiatry care and timely follow-up after abnormalities were identified requiring follow-up within six (6) to eight (8) weeks. The findings include:Cross-reference F656. Resident #1's diagnoses included mild cognitive impairment, dysthymic disorder (a continuous, long-term form of depression), left foot drop and moderate protein calorie malnutrition.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and was dependent on staff for personal hygiene, bed mobility and transfers.A Podiatry note dated 9/22/25 at 9:13 AM identified Resident #1's toenails were thick, yellow, brittle and contained subungual debris (crusty debris under the nail) with diagnoses of Peripheral Vascular Disease (PVD), neuropathy (nerve damage that causes pain and numbness), onychomycosis (fungal infection of the nail plate/bed) and dermatophytosis (fungal infection that thrives on keratin in the skin, hair and nails). The note identified that aseptic debridement (sterile removal of foreign debris, devitalized, necrotic or infected tissue to promote healing and prevent infection) was performed on all ten (10) of the elongated, thick toenails to viable (active/healthy) tissue and that Resident #1 would be followed up with in 6 to 8 weeks.Review of the Resident Care Plan (RCP) from 9/22/25 through 2/9/26 failed to identify Resident #1 had podiatry abnormalities including nail disorders, infections or foot and nail diagnoses to ensure proper treatment and prevent complications.Review of the clinical record from 9/22/25 to 2/9/26 failed to identify further podiatry treatment for Resident #1 or refusal of podiatry treatment.Review of Nurse's notes from 9/22/25 through 2/9/26 failed to identify documentation regarding Resident #1's feet or toenails or refusal of podiatry treatment.The Treatment Administration Records (TARs) for September 2025 through February 2026 failed to identify treatments or monitoring were in place for Resident #1's feet or toenails.The Podiatry Service Lists dated 11/10/25, 12/22/25 and 1/6/26 identified Resident #1 was due for follow up for tinea unguium (otherwise known as onychomycosis) but the visit was rescheduled and Resident #1 was not seen. The reason for the rescheduling was not identified.The Podiatry Service List dated 2/3/25 identified Resident #1 was due for follow up for tinea unguium but Resident #1 refused the visit.Nurse's notes dated 2/3/26 through 2/9/26 failed to identify a note regarding Resident #1's refusal to see podiatry.The facility Reportable Event (RE) dated 2/9/26 identified they received a complaint alleging neglect due to the appearance of Resident #1's legs. The RE reported Resident #1 was seen by podiatry and wound personnel but refused treatments and Resident #1 had since been discharged .Interview with Person #1 (Resident #1's conservator) on 3/9/26 at 11:50 AM identified Resident #1 was transferred to another facility on 2/9/26 and he/she was present when a licensed nurse performed the admission assessment at the receiving facility. Person #1 identified Resident #1's toenails were so thick and long they started curling and reported he/she was shocked by the condition and appearance of the toenails. Person #1 identified the facility never notified him/her of podiatry issues or that Resident #1 refused treatment. Person #1 reported that had he/she known, he/she would have advocated for Resident #1, ensured Resident #1 received podiatry care and would have been present when the podiatrist visited to the facility.Interview with the Administrator on 3/9/26 at 12:35 PM identified she was unaware of the 9/22/25 podiatry note for Resident #1 and that podiatry notes are all sent to Medical Records and Medical Records staff communicates with the podiatry group by email. The Administrator identified licensed nursing staff should be aware if there are recommendations from podiatry but was unsure of how that occurred.Interview with the Director of Nursing (DON) on 3/9/26 at 12:37 PM identified licensed nursing staff should have followed up with the podiatrist and/or obtained and reviewed the podiatry visit note for orders and recommendations following the 9/22/25 visit. The DON stated she was unaware of the condition of Resident #1's toenails until 2/9/26, when Person #1 provided photographs of the resident's legs and feet after discharge. She indicated staff should have assessed and documented the condition of the toenails and notified the unit manager or DON to facilitate timely podiatry follow-up. The DON further identified there was no designated nursing staff responsible for coordinating or assisting with podiatry visits, and at the time of the 2/9/26 allegation, the facility did not have a process to ensure specialty providers communicated findings and recommendations to nursing staff prior to leaving the facility. Additionally, the DON reported that during her investigation, she misinterpreted the Podiatry Service Lists dated 11/10/25, 12/22/25, and 1/6/26 as refusals and was unable to determine why the resident was not seen by podiatry on those dates.Interview with APRN #1 on 3/9/26 at 1:22 PM identified she was never notified of the condition of Resident #1's toenails on 9/22/25 or that Resident #1 refused podiatry care on 2/3/26. She identified that nursing should have documented and notified her of the podiatrist's 9/22/25 visit and note indicating the condition of the toenails, as well as the continued growth and refusal of podiatry care. APRN #1 identified Resident #1 had multiple comorbidities and had she been notified of the 9/22/25 podiatry visit and associated note, she would have ensured Resident #1's feet and toenails were monitored and that podiatry followed up timely. She reported Resident #1 did not easily trust new faces and identified that if herself, other nursing staff, or Resident #1's conservator had been involved in the podiatry care, refusals of care may have been prevented.Although attempted, an interview with Person #2 (facility podiatry representative) was not obtained.Review of the Foot Care policy dated 8/7/23 directed, in part, the center will provide foot care and treatment in accordance with professional standards of practice and state scope of practice, including to prevent complications from the resident's medical condition(s) such as diabetes, peripheral vascular disease or immobility and ensure residents receive proper treatment and care to maintain mobility and good foot health. Residents who have complicating disease processes requiring foot care including, but not limited to, infections/fungus, ingrown nails, diabetes mellitus, neurological disorders, renal failure and peripheral vascular disease must be referred to qualified professionals such as podiatrists or other qualified providers.Review of the Consultant Agreements and Responsibilities policy dated 3/1/22 directed, in part, the outside resource will apprise the Administrator in writing of recommendations, plans for implementation and continuing assessment through dated and signed reports which will document the length of the visit. Consultant reports will be retained for follow-up action and evaluation of performance. The Administrator will provide evidence of review of the recommendations.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for behavioral concerns, the facility failed to develop and implement a comprehensive care plan with person-centered interventions to address intrusive behaviors. The findings include: Resident #1's diagnoses included severe dementia with psychotic disturbances (abnormal thinking and perceptions of reality), adjustment disorder with mixed anxiety and depressed mood.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 4) and required supervision assistance for transfers and ambulation.The Resident Care Plan (RCP) dated 1/21/26 identified Resident #1 exhibited or was at risk for distressed/fluctuating mood symptoms, had impaired cognitive function related to dementia and impaired communication as evidenced by impaired hearing. Interventions included providing consistent, trusted caregivers and structured daily routines when possible, using short phrases that require yes or no answers, allowing time to express feelings and reassurance and referring to a Behavioral Health Specialist as needed. A nurse's note by LPN #1 dated 1/15/26 at 2:43 PM identified Resident #1 was observed being intrusive (unwanted or uninvited) in another resident's room (Resident #2) and was noted to be following the resident down the hallway. The note reported Resident #1 was immediately redirected away from the other resident, escorted away from the room, separation was maintained and Resident #1 was placed on every fifteen (15) minute safety checks. The note identified the provider was notified, social services was notified, the conservator was notified and Resident #1 was subsequently moved to a new unit.A nurse's note by RN #3 dated 2/1/26 at 5:52 PM identified Resident #1 was observed by staff in the common area tugging the front collar area of another resident's (Resident #4) shirt. The behavior was brief, non-aggressive and non-threatening. The note reported no injuries were reported from either resident and Resident #1 was easily redirected, was educated to not touch others and every 15-minute checks would remain in place.Interviews with LPN #1, LPN #2, LPN #5, NA #2, NA #4 and NA #7 on 2/17/26 identified Resident #1 enjoyed staying busy and thought he/she was at work at the facility. Resident #1 often tried to help other residents by obtaining plastic cups from the nurse's carts and passing out drinks, pushing residents down the hallway in their wheelchairs, and at times, following other residents.Review of the RCP failed to identify intrusive behaviors toward other residents or include person-centered interventions to address and redirect intrusive behaviors. Interview with the Director of Nursing (DON) on 2/17/26 at 3:10 PM identified she was aware Resident #1 frequently handed out cups of water to other residents and pushed residents down the hallway in their wheelchairs. The DON reported Resident #1 appeared to believe he/she was helping other residents and enjoyed staying busy. The DON identified a behavioral care plan should have been developed with interventions to address the behaviors and prevent further incidents. She identified potential interventions could have included asking Resident #1 to assist the recreation department with passing out materials during structured activities or assigning Resident #1 a task related to his/her past occupation to provide a sense of purpose. The DON reported the interdisciplinary team discussed the behaviors during morning report following the 1/15/26 incident and identified Resident #1 required a behavioral care plan to address the behaviors; however, did not follow up to ensure the care plan was developed. Review of the Person-Centered Care Plan policy dated 10/22/24 directed, in part, that Person-Centered Care Plans are developed to promote positive communication between resident, resident representative, and team to obtain the resident's and resident representative input into the plan of care, ensure effective communication, and optimize clinical outcomes. The care plan must be customized to each individual resident's preferences and needs. Care plans will be communicated to appropriate staff, resident, resident representatives and family members and will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and as needed to reflect the response to care and changing needs and goals.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for a room change, the facility failed to ensure ongoing social services monitoring for a resident with severe cognitive impairment and psychiatric diagnoses during the seventy-two (72) hour adjustment period after relocation. The findings include:Resident #1's diagnoses included severe dementia with psychotic disturbances (abnormal thinking and perceptions of reality), adjustment disorder with mixed anxiety and depressed mood. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 4) and required supervision assistance for transfers and ambulation. The Resident Care Plan (RCP) dated 1/15/26 identified Resident #1 was adjusting to a new memory care environment. Interventions included encouraging reminiscence by discussing meaningful family relationships and providing opportunities for quiet and one-to-one visits. A nurse's note by LPN #1 dated 1/15/26 at 2:43 PM identified Resident #1 was observed being intrusive (unwanted or uninvited) in another resident's room (Resident #2) and was noted to be following the resident down the hallway. The note reported Resident #1 was immediately redirected away from the other resident, escorted away from the room, separation was maintained and Resident #1 was placed on every fifteen (15) minute safety checks. The note identified both the medical and psychiatric APRN's were notified for evaluation, social service staff were notified, the conservator was notified and Resident #1 was subsequently moved to a new unit. A social service note by Social Worker #3 dated 1/15/26 at 3:27 PM identified she met with Resident #1 to show him/her the new room prior to the room change, and that following the change to an adjacent unit, Resident #1 was noted to be confused with the change but was not agitated or behavioral. A social service note by Social Worker #2 dated 1/16/26 at 3:34 PM identified she assessed Resident #1 for the adjustment period following a new room change. Resident #1 was adjusting well with no signs of anxiety or distress over the room change. The note identified that she would follow up with Resident #1 two (2) more times per protocol. Review of the clinical record from 1/17/26 through 1/21/26 failed to identify any further social service follow ups for Resident #1. Interview with the Administrator on 2/17/26 at 3:40 PM identified following a resident room change, social service staff were required to follow up with the resident for 72 hours to ensure a smooth transition and that the resident was adjusting well. He/she identified that social services failed to follow up with Resident #1 after the initial visit on 1/16/26. The Administrator reported that Social Worker #2 was reassigned following the 1/16/26 visit and identified that the follow-up was missed in transition to the new social worker. Review of the Room Change policy dated 5/1/24 directed, in part, that the resident's physical, social, emotional and cognitive needs as well as preferences are assessed by the interdisciplinary team and considered prior to relocating the resident to a different room. Social Services will follow up with the resident to see how they are adjusting and will address and document any issues.

Based on clinical record reviews, facility documentation, facility policy, and interviews for three (3) sampled residents (Residents #2, #3, and #4) reviewed for medication administration, the facility failed to administer anxiolytic medications in accordance with the provider's order to prevent the administration of an incorrect, higher dose of a controlled medication and omitting doses of controlled medications. The findings include: 1. Resident #2's diagnoses included vascular dementia with mood disturbances, anxiety disorder and depressive episodes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #2 was alert and oriented and received anti-anxiety, antidepressant and anticonvulsant medications. The Resident Care Plan dated 10/18/25 identified Resident #2 exhibited or was at risk forDistressed or fluctuating mood symptoms related to sadness/depression caused by depressive episodes and/or bipolar disorder. Interventions included administering medications as ordered and referring the resident to the behavioral health specialist as needed. A physician's order dated 12/10/25 directed to administer Ativan 0.5 milligrams (mg), give 0.5 (1/2) tablet by mouth three (3) times daily for anxiety. The Facility Reported Incident form dated 12/24/25 at 9:10 AM identified an incorrect dose of Ativan 0.5 mg was administered instead of 0.25 mg to Resident #2from 12/10/25 through 12/23/25. The Situation Background Assessment, Recommendation (SBAR) dated 12/24/25 at 2:22 PM identified Resident #2 had been taking the wrong dosage of Ativan, reporting Ativan 0.5 mg instead of 0.25 mg (double the prescribed dose) was administered. The note identified there were no signs or symptoms of distress, pain or discomfort and the Advanced Practice Registered Nurse (APRN) and Resident #2's representative were notified and the Ativan order was updated and corrected. Review of the December 2025 Medication Administration Record identified Resident #2 had been administered Ativan 0.5 mg by mouth three times daily from 12/10/25 through 12/24/25. The Controlled Substance Disposition Record (a form used by facilities to track every dose of a controlled medication from the time it is received until administered to a resident or properly discarded, documents who administered the medication when given, how much was used, and how much was remaining, helping to prevent misuse and medication errors) identified on 12/1/25 the facility received a supply of thirty (30) (1/2) tablets of Ativan. Review of the order on the Controlled Substance Disposition Record read Ativan 0.5 mg tablet, 1/2 tab (0.25 mg) by mouth three (3) times daily. The sign out records identified two (2) half (1/2) tablets of Ativan 0.25 mg (equaling 0.5 mg) were administered in error seventeen (17) times. On 12/10/25 at 9:00 AM, 1:00 PM, and 8:00 PM, on 12/11/25 at 9:00 AM and 1:00 PM, on 12/13/25 at 9:00 AM and 1:00 PM, 12/18/25 at 8:00 PM, on 12/19/25 at 9:00 AM and 1:00 PM, on 12/21/25 at 9:00 AM, 1:00 PM, and 8:00 PM, 12/22/25 at 9:00 AM and 1:00 PM and on 12/23/25 at 9:00 AM and 1:00 PM. A physician's order dated 12/24/25 identified the Ativan order was increased and now directed to administer Ativan 0.5 milligrams (mg), give 0.5 mg (1 tablet) by mouth three (3) times daily for anxiety and/or agitation. Review of the December 2025 Medication Administration Record identified Resident #2 had been administered Ativan 0.5 mg by mouth three (3) times daily and all doses were signed off as administered from 12/24/25 through 12/31/25. Review of the Controlled Substance Disposition Record dated 12/1/25 identified Resident #2 was administered one (1) half (1/2) tab (0.25 mg) on 12/24/25 at 9:00 PM, 12/25/25 at 9:20 and 9:45 PM and on 12/26/25 at 9:00 PM. The record indicated there were four (4) errors of administering half the dose (0.25 mg) of what the 12/24/25 physician's order directed (0.5 mg). Interviews with the charge nurses Licensed Practical Nurse (LPN) and Registered Nurse (RN), LPN #1, RN #1, LPN #3, LPN #4 and LPN #5, on 1/14/26 identified they misread the 11/27/25 and/or 12/10/25 physician's order for the Ativan, explaining they thought the order read to give 0.5 mg. They identified they should always be following the five (5) rights of medication administration (right drug, right patient, right dose, right route and right time) and failed to compare both the electronic Medication Administration Record order to the order on the blister pack of the Ativan resulting in administering double the ordered dose. 2. Resident #3's diagnoses included dementia with agitation, schizophrenia (mental health condition that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others), anxiety, major depressive disorder and epilepsy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a staff assessment for mental status indicating short-term and long-term memory problems. The Resident Care Plan dated 11/18/25 identified that Resident #3 exhibited or was at risk for distressed and/or fluctuating mood symptoms related to major depressive disorder, anxiety and Schizophrenia. Interventions included administering medications as ordered and documenting the effectiveness, side effects and referring the resident to a behavioral health specialist as needed. A physician's order dated 12/8/25 directed to administer lorazepam 0.5 mg, give one (1)tablet by mouth every eight (8) hours for anxiety and agitation. Review of the January 2026 Medication Administration Record identified Resident #3 had been administered lorazepam 0.5 mg by mouth every eight (8) hours daily as ordered. The Medication Administration Record indicated the lorazepam was scheduled daily at 5:00 AM, 1:00 PM and 9:00 PM. Review of the Controlled Substance Disposition Record dated 10/1/25 failed to identify the lorazepam 0.5 mg was administered to Resident #3 on 1/3/26 at 5:00 AM although the medication had been signed off on the Medication Administration Record as administered. 3. Resident #4's diagnoses included dementia with behavioral disturbances, paranoid personality disorder, generalized anxiety disorder and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of two (2) out of fifteen (15) indicating Resident #4 had short-term and long-term memory problems. The Resident Care Plan dated 12/26/25 identified that Resident #4 exhibited or was at risk fordistressed and/or fluctuating mood symptoms related to psychiatric disorders including paranoidpersonality disorder, anxiety disorder and alcohol use disorder. Interventions included observing for signs of delirium, including delusions and hallucinations; observing for signs and symptoms of worsening sadness, depression, anxiety, fear, anger and agitation; observing for worsening signs and symptoms of existing psychiatric disorders and notifying the provider of any changes as needed. A physician's order dated 12/16/25 directed to administer Xanax 0.5 mg, give 0.5 mg by mouth three (3) times a day for anxiety/agitation. Review of the January 2026 Medication Administration Record identified Resident #4 had been administered Xanax 0.5 mg by mouth three (3) times daily as ordered. The Medication Administration Record indicated the Xanax was scheduled daily at 9:00 AM, 1:00 PM and 5:00 PM. Review of the Controlled Substance Disposition Record dated 12/17/25 failed to indicate the Xanax 0.5 mg was administered to Resident #4 on 1/5/26 at 5:00 PM, 1/7/26 at 9:00 AM and 1:00 PM, 1/10/26 at 5:00 PM and 1/13/26 at 9:00 AM and 1:00 PM although all six (6) scheduled doses were signed off on the Medication Administration Record as administered. Interview with the psychiatric Advanced Practice Registered Nurse (APRN) on 1/14/26 at 5:04 PM identified licensed nurses are to fully read orders, follow the five (5) rights of medication administration to include the right dose, to administer the medications per the provider's order and clarify the orders with a provider if they are unsure. The APRN indicated no one had called him to clarify or question either the 11/26/25 or the 12/10/25 Ativan orders for Resident #2 until 12/24/25 and reported he was never made aware Residents #2, #3 or #4 had omitted doses of anxiolytic medications between December 2025 and January 2026. The APRN identified although Residents #2, #3 or #4 had no documented negative effects from the medication errors, they were all diagnosed with dementia and were at risk for increased anxiety, agitation and impaired comfort when scheduled anxiolytic medications were omitted. Interview with the Director of Nursing (DON) on 1/14/26 at 12:52 PM identified licensed nurses are expected to fully read the physician's order and compare the order to the label on the blister pack of medication before each medication was administered and if there were any questions they are to clarify the order with the provider, which they did not do and Resident #2 subsequently received double the dose of Ativan intended per physician's order. The DON indicated if the licensed nurses had followed the physician's orders and ensured the five (5) rights of medication administration were followed to include the right dose, the errors could have been prevented with Resident #2. The DON identified medications are expected to be signed off as administered in the Medication Administration Record at the time they are given, the Medication Administration Records for Residents #2, #3 and #4 should have matched with the corresponding Controlled Substance Disposition Record. Review of the Medication Administration policy dated 5/1/24 directed, in part, that staff would follow the written instructions provided by the physician/advanced practice registered nurse, and that nurses were responsible for documenting whenever a medication was given at the time the medication was administered, and not any time before or after that. The Medication Administration policy further directed staff to check the dose on the patient's chart with the dose being dispensed. Review of the Medication Errors policy dated 6/1/21 directed, in part, that a medication error is defined as a discrepancy between what the physician/advanced practice provider ordered and what the resident received. Types of errors include medication omissions, wrong resident dose, route, rate or time, incorrect preparation and/or incorrect administration technique.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for allegations of abuse and/or neglect, the facility failed to provide documentation the allegations of abuse and/or neglect were thoroughly investigated. The findings include: Resident #1's diagnoses included epilepsy (a chronic disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), multiple sclerosis (disorder where the body's immune system attacks the protective covering of the nerve cells, disrupting the flow of information within the brain and between the brain and the body and causing muscle weakness, vision changes, numbness and memory issues), repeated falls and adjustment disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicating Resident #1 rarely or never made decision regarding tasks of daily living. The Situation Background Assessment Recommendation (SBAR) note dated 11/10/25 at 8:33 AM identified Resident #1 had a seizure, the provider was notified and new orders were obtained to administer Ativan (fast-acting benzodiazepine used as a rescue medication to stop acute, prolonged or cluster seizures) one (1) milligram (mg) intramuscularly and transfer Resident #1 to the Emergency Department (ED) for further evaluation. The nurse's note dated 11/19/25 at 11:00 AM written by the former Director of Nursing (DON) identified per Resident #1's hospital record, Resident #1's family reported to the hospital staff concerns of the facility withholding Resident #1's anti-seizure medications. The note indicated the October and November 2025 Medication Administration Records (MAR) were reviewed. Review of the facility's Grievance Book failed to identify a grievance or documentation related to the allegation the facility withheld seizure medications from Resident #1 as documented in the 11/19/25 nurse's note. Although requested, a facility Accident and Investigation (A & I) related to the allegation of neglect was not available. Review of the State Agency Reportable Events website failed to reflect documentation the State Agency was notified of the allegation of neglect on or around 11/19/25. Interview with the former DON on 1/15/26 at 1:25 PM identified although she wrote the 11/19/25 at 11:00 AM nurse's note identifying she was aware of Resident #1's family alleging Resident #1 did not receive the anti-seizure medications prior to the 11/10/25 seizure incident, she did not report the allegation to the State Agency or fully investigate it aside from reviewing the Medication Administration Records because the family did not report the allegation to the facility itself, only the hospital staff, and looking back she should have. Interview with the Administrator on 1/21/26 at 1:49 PM identified the former DON had casually reported to her around 11/19/25 there was a medication issue related to Resident #1 but never mentioned the incident again or reported to her it was an allegation of neglect. The Administrator identified she was unaware of the 11/19/25 nurse's note written by the former DON and stated had she seen the note or if the former DON had reported to her the extent of the medication issue she would have ensured the allegation was reported to the State Agency within two (2) hours and the allegation fully investigated by the facility. Review of the Abuse Prohibition policy dated 10/24/22 directed, in part, that immediately upon receiving information concerning report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following: Enter allegations into the PCC Risk Management Portal, reporting allegations to the appropriate state and local authorities involving neglect, exploitation or mistreatment not later than two (2) hours after the allegation is made if the event results in serious bodily injury and within 24 hours if it does not result in serious bodily injury, notify local law enforcement, Licensing Boards and Registries and other agencies as required, initiate an investigation within 24 hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent, causative factors and interventions to prevent further injury. The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews is included. Failure to report in the required time frames may result in disciplinary action, up to and including termination.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three sampled residents (Resident #2) who received medications that required laboratory monitoring, the facility failed to ensure bloodwork was obtained per the physician's order. The findings include:Resident #2's diagnoses included vascular dementia with mood disturbances, anxiety disorder and depressive episodes. A physician's order dated 8/21/25 directed to administer Depakote sprinkles delayed release oral capsule 125 milligrams (mg), give six (6) capsules by mouth at bedtime for bipolar disorder (chronic mental health disorder causing extreme mood swings ranging from extreme highs to sever lows). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #2 was alert and oriented and received anti-anxiety, antidepressant and anticonvulsant medications. The Resident Care Plan dated 10/18/25 identified that Resident #2 was at risk for complications related to the use of psychotropic medications. Interventions included monitoring for side effects and consulting the physician and/or pharmacist as needed and monitoring for the continued need of the medication. A physician's order dated 12/24/25 directed to obtain a Complete Blood Count (CBC), Complete Metabolic Panel (CMP) and a Depakote level on the next laboratory draw day. Review of the clinical record from 12/24/25 through 1/15/25 failed to reflect documentation the lab work had been obtained as per the physician's order. Interview with the Director of Nursing (DON) on 1/15/26 at 2:47 PM identified the normal facility laboratory days are on Monday, Wednesday, Friday and as needed. The DON explained Resident #2's bloodwork should have been obtained on 12/26/25 but she was unable to find documentation the lab draw had occurred. The DON indicated when laboratory orders are entered into the electronic health record, the same shift was responsible for confirming the order, writing the order in the laboratory book and the 11PM-7AM shift was responsible to ensure the order matched what was written in the laboratory book. The DON was unable to provide documentation the 12/24/25 laboratory orders were noted in the laboratory book and explain why the labs were not obtained. Although requested, facility policies for physician orders, transcription of orders and obtaining bloodwork were not provided.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of abuse and/or neglect, the facility failed to ensure an allegation of neglect was reported to the State Agency when identified. The findings include:Resident #1's diagnoses included epilepsy (a chronic disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), multiple sclerosis (disorder where the body's immune system attacks the protective covering of the nerve cells, disrupting the flow of information within the brain and between the brain and the body and causing muscle weakness, vision changes, numbness and memory issues), repeated falls and adjustment disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicating Resident #1 rarely or never made decision regarding tasks of daily living. The Situation Background Assessment Recommendation (SBAR) note dated 11/10/25 at 8:33 AM identified Resident #1 had a seizure, the provider was notified and new orders were obtained to administer Ativan (fast-acting benzodiazepine used as a rescue medication to stop acute, prolonged or cluster seizures) one (1) milligram (mg) intramuscularly and transfer Resident #1 to the Emergency Department (ED) for further evaluation. The nurse's note dated 11/19/25 at 11:00 AM written by the former Director of Nursing (DON) identified per Resident #1's hospital record, Resident #1's family reported to the hospital staff concerns of the facility withholding Resident #1's anti-seizure medications. Review of the facility's Grievance Book failed to identify a grievance or documentation related to the allegation the facility withheld seizure medications from Resident #1 as documented in the 11/19/25 nurse's note. Although requested, a facility Accident and Investigation (A & I) related to the allegation of neglect was not available. Review of the State Agency Reportable Events website failed to reflect documentation the State Agency was notified of the allegation of neglect on or around 11/19/25. Interview with the former DON on 1/15/26 at 1:25 PM identified although she wrote the 11/19/25 at 11:00 AM nurse's note identifying she was aware of Resident #1's family alleging Resident #1 did not receive the anti-seizure medications prior to the 11/10/25 seizure incident, she did not report the allegation to the State Agency or fully investigate it aside from reviewing the Medication Administration Records, stating looking back she should have. Interview with the Administrator on 1/21/26 at 1:49 PM identified the former DON had casually reported to her around 11/19/25 there was a medication issue related to Resident #1 but never mentioned the incident again or reported to her it was an allegation of neglect. The Administrator identified she was unaware of the 11/19/25 nurse's note written by the former DON and stated had she seen the note or if the former DON had reported to her the extent of the medication issue she would have ensured the allegation was reported to the State Agency within two (2) hours and the allegation fully investigated by the facility. Review of the Abuse Prohibition policy dated 10/24/22 directed, in part, that immediately upon receiving information concerning report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following: Enter allegations into the PCC Risk Management Portal, reporting allegations to the appropriate state and local authorities involving neglect, exploitation or mistreatment not later than two (2) hours after the allegation is made if the event results in serious bodily injury and within 24 hours if it does not result in serious bodily injury, notify local law enforcement, Licensing Boards and Registries and other agencies as required, initiate an investigation within 24 hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent, causative factors and interventions to prevent further injury. The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews is included. Failure to report in the required time frames may result in disciplinary action, up to and including termination.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure anti-seizure medications were refilled prior to not having a supply available and not borrowing from another resident's supply. The findings include:Resident #1's diagnoses included epilepsy (a chronic disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), multiple sclerosis (disorder where the body's immune system attacks the protective covering of the nerve cells, disrupting the flow of information within the brain and between the brain and the body and causing muscle weakness, vision changes, numbness and memory issues), repeated falls and adjustment disorder. A physician's order dated 5/18/25 directed to administer levetiracetam tablet 1000 milligrams (mg), give one (1) tablet by mouth twice daily for seizures and oxcarbazepine tablet 300 mg, give one (1) tablet by mouth twice daily for seizures. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicating Resident #1 rarely or never made decision regarding tasks of daily living. The Resident Care Plan dated 9/17/25 identified Resident #1 exhibited and/or was at risk for seizure activity. Interventions included medicating the resident as ordered and monitoring for effectiveness as well as side effects and report to the physician as needed, monitoring blood levels for therapeutic dose of medication as ordered and report abnormal levels to the physician and monitoring for sign and symptoms of impending seizures. The Situation Background Assessment Recommendation (SBAR) note dated 11/10/25 at 8:33 AM identified Resident #1 had a seizure, the provider was notified and new orders were obtained to administer Ativan (fast-acting benzodiazepine used as a rescue medication to stop acute, prolonged or cluster seizures) one (1) milligram (mg) intramuscularly and transfer Resident #1 to the Emergency Department (ED) for further evaluation. The nurse's note dated 11/19/25 at 11:00 AM written by the former Director of Nursing (DON) identified the October and November 2025 Medication Administration Records were reviewed and there were no missed doses of either anti-seizure medication, the levetiracetam and oxcarbazepine, noted. Review of the October and November 2025 Medication Administration Records identified both the levetiracetam and oxcarbazepine were scheduled at 9:00 AM and 9:00 PM and all doses were signed off as administered. Interview with the Pharmacist on 1/15/25 at 1:41 PM identified all deliveries of both the oxcarbazepine and levetiracetam were sent in fourteen (14) day supplies (twenty-eight (28) tablets of each medication) and the facility had not requested any STAT (immediate) deliveries of either the levetiracetam or oxcarbazepine from 5/18/25 through 11/10/25. The Pharmacist indicated the levetiracetam was stocked in the automated medication dispensing system used to store an emergency supply of medications (Pyxis) but that the oxcarbazepine was not. Review of the facility Order Audit Report for the oxcarbazepine identified:The 5/18/25 delivery was not requested for refill until 6/10/25 (9 days late).The 6/22/25 delivery was not requested for refill until 7/7/25 (1 day late).The 7/7/25 delivery was not requested for refill until 7/23/25 (2 days late).The 8/6/25 delivery was not requested for refill until 9/3/25 (14 days late).The 9/16/25 delivery was not requested for refill until 10/2/25 (2 days late). Review of the facility Order Audit Report for the levetiracetam identified:The 5/18/25 delivery was not requested for refill until 6/10/25 (9 days late).The 6/21/25 delivery was not requested for refill until 7/7/25 (2 days late).The 7/7/25 delivery was not requested for refill until 7/23/25 (2 days late).The 7/23/25 delivery was not requested for refill until 8/10/25 (4 days late).The 10/6/25 delivery was not requested for refill until 10/22/25 (2 days late).The 10/22/25 delivery was not requested for refill until 11/7/25 (2 days late). Review of the Pyxis report dated 5/18/25 through 11/10/25 failed to identify the levetiracetam had been pulled from emergency supply. Interview with the 3-11PM Registered Nurse (RN) #3 on 1/20/26 at 3:01 PM identified she worked full-time on Resident #1's unit and consistently when she returned to work after being off for a few days, would have to refill Resident #1's anti-seizure medications, as she would not be able to locate the levetiracetam or oxcarbazepine and it appeared as if other nurse's had not attempted to refill them. RN #3 indicated although she always administered both the oxcarbazepine and levetiracetam to Resident #1, if the levetiracetam or oxcarbazepine were not available she would find other residents who were on the same medications and use their supply. RN #3 identified she should not have taken the medications from other residents' supply and should have notified the nursing supervisor, pulled the medication from the Pyxis if available and called the pharmacy to request the medications STAT. Interviews with Licensed Practical Nurse (LPN) #2, LPN #11 and LPN #12 identified they could not recall ever exhausting the supply of oxcarbazepine or levetiracetam but reported they were not able to locate the medications on several occasions so instead of notifying the nursing supervisor, pulling the medication from the Pyxis and calling the pharmacy to inquire about the medications whereabouts as they should have done, they took the medications from other residents who were on anti-seizure medications. LPN #2, LPN #11 and LPN #12 stated they should not have taken the medications from other residents because it then put those residents at risk for running out of their medications too early. LPN #2, LPN #11 and LPN #12 identified they were unable to identify why the medications were not refilled through either the electronic Medication Administration Record or by calling the pharmacy to refill and the medications should have been refilled at least two (2) days prior to the medication blister pack being exhausted. Interview with the Director of Nursing (DON) on 1/15/25 at 2:01 PM and on 1/21/25 at 11:17 AM identified the levetiracetam had not been pulled from emergency stock since Resident #1's admission and the oxcarbazepine was not stocked in the facility's emergency supply. The DON explained she reviewed the Order Audit Reports which identified the oxcarbazepine and levetiracetam were not being reordered timely, the charge nurses were responsible for requesting refills on medications when the supply was down two (2) to three (3) days and each shift thereafter should be calling the pharmacy to check on the status of the medication refill. The DON identified if a licensed nurse was unable to locate a medication for a resident, they should be notifying the nursing supervisor immediately, obtaining the medication from the Pyxis stock if available and calling the pharmacy to inquire about the whereabouts and requesting the medication STAT. The DON identified the nurses should not be utilizing other residents' medications at any time, as it then puts those residents at risk for running out of their medications. Review of the Reordering, Changing and Discontinued Medication Orders policy (undated) directed, in part, that the facility will communicate any medication reorders, changes or discontinuations to the pharmacy in accordance with pharmacy guidelines and state/federal regulations thus ensuring standardized process of communication. Communication may be transmitted through verbal, written or electronic orders. Review of the Medication Administration policy dated 05/01/24 directed, in part, that staff will follow written instructions provided by the provider to include the seven (7) rights of medication administration to include the: Right Individual, Right Medication, Right Dose, Right Time, Right Route, Right Documentation and the Right Response.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #4), reviewed for medication administration, the facility failed to inform the resident of a new diagnosis, discuss available treatment options, and provide education regarding the risks of refusing treatment, thereby failing to support the resident's right to make an informed decision regarding care and treatment. The findings included:Resident #4 was admitted to the facility in March of 2023 and had diagnoses that included type 2 diabetes mellitus, chronic diastolic (congestive) heart failure, and end stage renal disease. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was dependent for bathing, personal hygiene, and oral hygiene.The Resident Care Plan (RCP) dated 2/7/24 identified Resident #4 required total assistance of one with activity of living care for bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting, and was refusing medications. Interventions directed to provide a two staff approach with care if the resident had behaviors and to update the interdisciplinary team with deviations in the plan of care.A nursing note dated 3/14/24 at 7:01 PM identified Resident #4 was admitted to hospice services.A note by APRN #1 dated 3/15/24 at 12:00 AM identified Resident #4 reported nausea and watery diarrhea, and a stool sample was to be collected and tested for Clostridium Difficile, if watery.Lab results dated 3/18/24 at 2:54 PM identified Resident #4 tested positive for Clostridium Difficile.A note by APRN #1 dated 3/18/24 at 12:00 AM identified Resident #4 tested positive for Clostridium Difficile, was placed on contact precautions, and had his/her loperamide (antidiarrheal medication) discontinued. The note further noted that oral vancomycin was not started due to Resident #4's history of consistently refusing medication and due to his mentation. Further review of APRN #1's note failed to indicate Resident #4 was updated with the change of condition or that he/she was offered antibiotic treatment. A note by APRN #1 dated 3/20/24 at 12:00 AM identified Resident #4 refused antibiotic treatment for Clostridium Difficile and that vancomycin would be ordered stat (immediately) from the pharmacy as soon as the resident agreed to take it.A note by APRN #1 dated 3/22/24 at 12:00 AM identified Resident #4 agreed to start antibiotic treatment for Clostridium Difficile.Review of physician's orders dated 3/22/24 directed Vancocin (Vancomycin HCL, an antibiotic), 125 milligrams capsule, be administered every six (6) hours for ten (10) days for treatment of Clostridium Difficile.Interview with APRN #1 on 12/17/24 at 10:37 AM identified his/her standard of practice was to speak with a resident regarding a new diagnosis, update the nursing staff with refusals to start treatment, and order antibiotic treatment in the event the resident decided to accept treatment. APRN #1 further indicated he/she would have discussed Resident #4's change of condition with the resident representative if there were mentation concerns. APRN #1 identified if there was no documentation on 3/18/24 of offering the antibiotic treatment or educating the resident on the rationale for the antibiotic treatment, then the discussion did not occur.Interview with MD #1 on 12/18/25 at 9:59 AM identified that although Resident #4 was on hospice and had a history of refusing medications, the standard of practice would be for the attending provider to inform the resident of the new diagnosis, offer treatment, and if refused, educate the resident on the risks of refusing treatment. Review of the clinical record failed to identify that Resident #4 was informed of the Clostridium Difficile diagnosis, offered antibiotic treatment, or educated on the rationale for treatment on 3/18/24.The facility Medication Administration policy included, in part, that the staff will explain negative affects of refusing medications to residents and medication refusals will be documented in a progress note.

Based on clinical record review, facility documentation review, policy review, and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure medications were administered in accordance with physician orders, resulting in a significant medication error and hospital admission. The failures resulted in a finding of Immediate Jeopardy. The finding includes: Resident #1's diagnoses included epilepsy, cerebral palsy, and a history of aspiration pneumonia. The admission nursing assessment dated [DATE] identified Resident #1 had a gastrostomy tube (G-tube for feeding feeding), was alert, responsive, incoherent, able to answer yes/no questions, and the medication list was reviewed with the provider. Review of the admission orders from APRN #1 dated 2/29/2024, directed nothing by mouth (NPO), and to administer the following medications via gastrostomy tube: Dilantin (used to prevent seizures) 100 milligrams (mg) daily (at 9 AM), Dilantin 150 mg daily (at 9 PM), Clobazam (used to prevent seizures) 15 mg daily (1.5 tabs) every evening (at 8 PM), Lamotrigine (used to prevent seizures) 400 mg twice a day (at 9 AM and 9 PM) and Zonisamide (used to prevent seizures) 50 mg (3 capsules) daily (at 9 AM). Review of facility documentation dated 2/29/2024 identified that RN#2 activated admission orders which notifies the Pharmacy to deliver the medications to the facility. Review of the medication administration record (MAR) dated 2/29/2024 identified the 9 PM medications were coded as HD to indicate hold, and to see nursing notes. Review of the MAR dated 3/1/2024 identified the medications were coded as HD and NN for the 9 AM medications, to indicate see nursing notes for the scheduled medications. Review of the facility incident report dated 3/1/2024 identified Resident #1 did not receive Dilantin 150 mg, Clobazam 15 mg, and Lamotrigine 400 mg on 2/29/2024 at 9 PM and did not receive Dilantin 100 mg, Lamotrigine 400 mg, and Zonisamide on 3/1/2024 at 9 AM, and Clobazam 15 mg on 3/1/2024 at 9 PM in accordance with physician orders (seven doses of anti-seizure medication were not administered). Nursing note (authored by RN #4) dated 3/1/2024 at 10:36 AM identified APRN #1 was notified of the missed evening medications (2/29/2024). Review of APRN #1's note dated 3/1/2024 identified Resident #1 was seen after admission from the hospital and had a history of Epilepsy. Per nursing report, resident missed some medications last night due to the timing of his/her arrival, and all scheduled medications were given in the morning. A nursing note (authored by LPN #2) dated 3/1/2024 at 10:39 PM identified Clobazam was not received from the pharmacy and the APRN was notified to send another script (prescription). Record review failed to identify Resident #1 received Clobazam on 2/29/2024 and 3/1/2024 as prescribed. A nursing note dated 3/2/2024 at 3:01 AM identified the resident had a change in condition with nausea, vomiting, and seizure activity of less than one (1) minute. New orders were obtained for Zofran (treat vomiting). Review of the physician's order dated 3/2/2024 directed Zofran 4 mg tablet via G-tube every six (6) hours as needed for nausea and vomiting. A nursing note (authored by RN #5) dated 3/2/2024 at 6:21 AM identified Resident #1 had two (2) seizure occurrences last night, one about midnight and another about 5:45 AM, first less than two (2) minutes, second with vigorous body shaking and tilting head, vomited twice and Zofran was given. Resident #1 sustained a slight cut to the right forehead above the nose, the APRN was notified, and a call was placed to the pharmacy to deliver Clobazam STAT (immediately). A nursing note (authored by RN #6) dated 3/2/2024 at 8 AM identified at 7:40 AM, Resident #1 was observed on his/her knees on the floor, upper body leaning on the bed, and staff reported a seizure. Resident was noted unresponsive, left eye fixed, bilateral upper extremities elbows bent with arms folded up toward chest and fists clenched. APRN was notified, new order to transfer to hospital, and when the ambulance arrived Resident #1 had another seizure that lasted approximately one (1) minute. Review of Emergency Medical Services (EMS) run sheet dated 3/2/2024 at 7:52 AM identified Resident #1 was observed on the ground in a fetal position with contractures to the upper extremities and was on oxygen at three (3) liters per minute via a nasal cannula. Staff reported a history of seizure disorder, resident was unresponsive to verbal and painful stimuli, pulse was 121, blood pressure recorded at 104/systolic not recorded, breathing adequately with a blood oxygen level of 97% (normal 90% and above). Skin was warm, sweaty, and Resident #1 was observed to begin having a full tonic clonic seizures (stiffening and jerking movements) that lasted approximately one (1) minute. While enroute to the hospital Resident #1's blood oxygen level decreased to 79%, was placed on a non-rebreather mask at 15 liters oxygen and arrived at the hospital at 8:31 AM. Review of the Hospital record dated 3/2/2024 identified Resident #1 had a history of aspiration pneumonia, cerebral palsy and seizures, and presented after being found at the facility curled in a fetal position. The resident was unresponsive, intubated and admitted to the ICU. Hospital lab results dated 3/2/2024 identified the resident's Clobazam level collected at 6:37 PM was under 10 nanograms/millilter (ng/ml) (normal 30 to 300). The hospital note dated 3/7/2024 identified Resident #1 was admitted to the hospital for seizures due to missed anti-epilepsy drugs at the facility. Resident #1 remained in the hospital at the time of this survey. Review of the facility Admission Check list identified the physician orders were completed by the next shift nurse (not the admitting nurse). The form had a space for the admitting nurse to check to identify the orders were reviewed and completed, a space for the next shift nurse to double check the orders, and a clinical meeting review to be checked off. Review of the form identified the only medication review/orders was completed by the next shift nurse; the review was not completed by the admitting nurse or during the clinical meeting review. Interview, clinical record review and facility documentation review with the DON and Regional RN #3 on 3/7/2024 at 1:04 PM identified Resident #1 did not receive the medications as listed in the incident report (seven doses of anti-seizure medications were omitted) because the medications were ordered from the pharmacy on 2/29/2024 at 9:22 PM for routine delivery (due to be delivered the next day after 2 PM) and they should have been ordered for STAT delivery. The DON and Regional RN #3 stated although the facility did not have a policy that directed new admission medications to be ordered STAT, the facility process was to order all new admission medications as STAT by calling the pharmacy. The DON indicated the Clobazam was additionally delayed because it needed to be reordered in liquid form. The DON identified staff should have completed the medication order review upon admission, completed a second check and then should have completed a third review during the clinical meeting the next day. The DON identified if the second and third checks were completed, the errors could have been identified sooner and the medications could have been ordered for faster delivery. Interview, clinical record review and facility documentation review with Pharmacist #2 on 3/7/2024 at 2:26 PM identified the medications were ordered as a routine delivery on 2/29/2024 after 9 PM and were scheduled for delivery on 3/1/2024 after 2 PM. Pharmacist #2 indicated the medications were delivered to the facility at 2:27 PM, with the exception of the Clobazam because they were waiting for a script for a liquid medication which was delivered on 3/2/24, following the resident discharge to the hospital. Interview, clinical record review and facility documentation review with RN #2 on 3/7/2024 at 2:05 PM identified although she activated Resident #1's orders in the electronic record on 2/29/24 to order them from the pharmacy, she did not order the medications STAT. RN #2 indicated new admission orders should be placed STAT, and she was unable to explain why they were not ordered STAT. Interview, clinical record review and facility documentation review with APRN #1 on 3/7/2024 at 3:10 PM identified he documented in his note dated 3/1/2024 that last antiseizure medications were not administered on 2/29/2024 and was informed the medications were given the morning of 3/1/2024, he subsequently was notified that the medications were never given, and Resident #1 was admitted to the hospital due to seizure activity related to the omitted medications as listed above. Interview and clinical record review with the Medical Director on 3/11/2024 at 9:26 AM identified he reviewed the clinical record and believed the hospital should have administered the doses that were due on 2/29/2024, however the facility failed to order the medications from the pharmacy for timely receipt. Further, the Medical Director indicated the missed medications could contribute to the cause of the seizures and hospital admission. Facility documentation review identified staff education was initiated on 3/4/2024 that all new admission medication orders are to be ordered STAT from the pharmacy by placing a call to the pharmacy, and when a medication is not available for administration, the provider must be notified. Audits were initiated on 3/4/2024, and a QAPI meeting was held on 3/4/2024. Based on review of facility documentation, past non-compliance was identified. Review of facility Medication: Administration: General Policy directed in part, if a medication is not available the nurse will coordinate with the pharmacy to procure the medications as soon as possible and discuss possible substitutions options with the pharmacist, to notify the physician of the unavailability of the medications and discuss substitution options if applicable. The Policy further directed if unable to provide the medication or substitutions within one hour of the prescribed time, refer to Medication Error Policy.

Based on record review, facility documentation review, and interviews for one of eight residents (Resident #7) reviewed for accidents, the facility failed to provide the necessary supervision to a resident who required assistance with toileting resulting in a fall with injury. The finding includes: a. Resident #7's diagnoses included vascular dementia, muscle weakness, chronic pain syndrome, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had moderate cognitive impairment and required extensive with two staff assistance for transfers, and required one staff assistance for ambulation and toilet use. The Resident Care Plan (RCP) dated 9/30/2023 identified Resident #7 had dementia and required assistance with ADLs. Interventions directed to provide moderate assistance for toileting needs and transfers, and to provide cueing for safety and sequencing to maximize current level of function. A nursing note dated 10/21/2023 at 10:37 AM identified the resident reported he/she fell during the 3-11 shift on 10/20/2023 and the responsible party was contacted. The responsible party indicated the resident had notified them on 10/20/2023 of the fall and Resident #7 indicated he/she had a bruise. The provider was contacted to obtain an order for a left hip x-ray. The Physician's order dated 10/21/2023 directed a left hip x-ray. The nursing note dated 10/22/2023 at 6:29 AM indicated x-ray would be done this morning and as needed Oxycodone was administered for pain with good results. Review of nursing notes dated 10/22/2023 at 2:54 PM and 3:41 PM identified the resident was transferred to the hospital related to a left hip fracture. Clinical record review identified after the fall, in addition to the scheduled Oxycodone (15 milligrams 7.5 mg, two times a day, for chronic pain), Resident #7 received Oxycodone 5 mg PRN for complaints of pain on 10/21/2023 at 1:17 AM, 11:45 AM and 4:15 PM. Further, Resident #7 received Oxycodone 5 mg PRN for complaints of pain on 10/22/2023 at 3:45 AM and 2:20 PM, prior to transfer to the hospital on 10/22/2023 (2 days after the fall). Review of the Hospital Diagnostic Studies radiology report (x-ray report) dated 10/22/2023 identified Resident #7 had a left-sided transcervical femur fracture with slight superior displacement of the proximal femur was visualized. Resident #7 was admitted to the hospital on 10/22/2023 and had a left hip hemiarthroplasty (half of a hip joint replacement) on 10/23/2023. Interview with NA #7 on 11/6/2023 at 3:40 PM identified on 10/20/2023 she was assigned to Resident #7 and after dinner time NA #6 assisted Resident #7 to the bathroom and notified her that Resident #7 would call when ready. When Resident #7 activated the call light, NA #7 went to assist the resident and upon entry to the room, observed Resident #7 was coming out of the bathroom doorway with his/her walker and was noted to be shaking. NA #7 indicated she immediately attempted to retrieve Resident #7's wheelchair, but before she could get the wheelchair Resident #7 fell to the ground and she immediately notified LPN #2. Interview with LPN #2 on 11/6/2023 at 11:10 AM identified on 10/20/2023, she was walking by Resident #7's room, and observed the resident on the floor between the edge of the bed and the wall with his/her walker nearby and NA #7 was with the resident. Resident #7 indicated he/she was tired after using the bathroom, and NA #7 indicated Resident #7 had just sat down. Interview with NA #6 on 11/6/2023 at 3:25 PM identified on 10/20/2023, after dinner time, she assisted Resident #7 to the bathroom and directed Resident #7 to ring the bell when finished. NA #6 indicated she then left the room and continued to provide care for other residents. A few minutes later she went back to check on the resident who stated they needed more time. NA #6 then left the room and notified NA #7 that the resident was in the bathroom. NA #6 indicated that Resident #7 required supervision with transfers and ambulation and she should have stayed with Resident #7 while the resident was in the bathroom to ensure the resident was safely assisted back to bed/chair. Interview with the Director of Therapy (DOT) on 11/6/2023 at 2:20 PM identified Resident #7 was discharged from physical therapy services on 10/21/2023 and required supervision for ambulation with a walker. The DOT indicated Resident #7 would not be safe to be left alone in the bathroom due to the resident's cognitive status and limited physical ability. Interview with the DON on 11/6/2023 at 2:30 PM identified during the facility investigation, it was identified NA #6 should have stayed with Resident #7 while in the bathroom for safety.

Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision and failed to ensure interventions were implemented for the safety of Resident #1 when Resident #1, known to have severe cognitive impairment, eloped from the facility. Resident #1 left the facility without staff knowledge, unescorted, unsupervised and was not located for more than 2 hours and was located approximately 6 miles from the facility. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included vascular dementia, cerebral infarction with hemiplegia and hemiparesis affecting the right dominant side, aphasia, adjustment disorder, and anxiety disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition, required supervision with assistive devices for locomotion, and had no wandering behaviors in the prior seven (7) days. The Resident Care Plan dated 2/9/2023 identified Resident #1 had decreased ability to perform ADLs related to paralysis/weakness affecting the right arm and leg. Interventions directed to assist with transfers and Resident #1 was independent with wheelchair propulsion using his/her left arm/leg. Clinical record review identified Resident #1 had a court appointed Conservator of Person. Review of Psychiatry Evaluation and Consultation dated 5/7/2023 identified the Resident #1 was seen for behavior review. Resident #1 was alert, had vascular dementia with unspecified severity of agitation, anxiety disorder, adjustment disorder with depressed mood, and insomnia, and verbalized wanting to go home. Review of the Psychological Services Supportive Care Progress Notes identified the following: 1. On 5/16/2023, Resident #1 indicated he/she had a hard time adjusting to the facility and wanted to leave. 2. On 6/6/2023, Resident #1 was observed sitting outside, did not want to take his/her medications and reported he/she wanted to go home. 3. On 6/16/2023, Resident #1 reported he/she goes outside often and wanted to go home. 4. On 7/21/2023, Resident #1 indicated he/she wanted to go home, asked often about leaving the facility and indicated he/she is not going to comply with facility staff requests because he/she doesn't want to be there. 5. On 8/25/2023, Resident #1 was upset that he/she isn't home, indicated he/she isn't going to comply with anything until he/she gets home. Resident #1 reported he/she coped by going outside as much as possible, but Resident #1 indicated he/she wanted to leave the facility. 6. On 9/1/2023, Resident #1 questioned why he/she had not been discharged yet and indicated he/she sits outside in front of the facility. 7. On 9/16/2023, Resident #1 was irritable and angry and refused medications and care at times. Resident #1 indicated he/she had intermittent anxiety due to being in the facility. 8. On 9/26/2023, Resident #1 has been noncompliant with medications and recommendations by staff and indicated he/she just wants to go home. Review of the Recreation Quarterly Evaluations identified the following: 1. On 2/9/2023, Resident #1 wheels self about the facility, becomes angry and verbalized he/she wanted to go home. 2. On 5/10/2023, Resident #1 was independent with wheelchair mobility and sits outside the facility. 3. On 8/5/2023, Resident #1 preferred to sit looking out a window. Review of the Care Plan Meeting Progress Note dated 8/18/2023 at 12:40 PM identified Resident #1 refused weights and food, self-propelled in his/her wheelchair and goes to the front entrance. The note further identified Resident #1 lacked motivation due to wanting to go home. The facility Elopement of a Patient Policy dated 10/24/2022 directed to assess a patient's elopement risk upon admission, re-admission, quarterly, or with a significant change in condition. For patients identified at risk, an interdisciplinary elopement prevention care plan will be developed. Additionally, facility staff are to complete the Elopement Risk Identification form for all patients at risk of elopement and place it in a binder that is easily accessible to staff in designated area(s). Review of the clinical record for Resident #1 indicated an elopement risk assessment was not conducted, as indicated in the facility's Elopement of a Patient Policy, for Resident #1. Facility Policy indicates: A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement. This situation represents a risk to the resident's health and safety and places the resident at risk of potential injury related to the weather and traffic in the area. The Facility Incident and Summary Form dated 10/2/2023 at 4:23 PM identified Kitchen Aid (KA) #1 observed Resident #1 getting on a city bus in his/her wheelchair. Facility staff were notified, a facility search was initiated, the local police were notified, and the bus company was notified. Facility staff also drove the bus route to search for Resident #1 and located Resident #1 at 6:40 PM (2 hours and 17 minutes after identified missing) in the downtown area of a large nearby city, approximately six (6) miles from the facility. Resident #1 was transferred to the hospital for evaluation and returned to the facility on [DATE] with no injuries identified. Subsequent to the incident, an elopement assessment was completed for Resident #1, a wander guard was applied due to risk for elopement, a psych consult was ordered, and the care plan was updated. Interview with KA #1 on 10/10/2023 at 10:15 AM identified as she was getting off the bus on 10/2/2023, she observed the bus driver was assisting Resident #1 on the wheelchair lift, and identified the bus ride did not require any payment on that day. KA #1 attempted to talk to Resident #1, but Resident #1 repeatedly verbalized hurry up, hurry up to the bus driver. KA #1 identified she panicked at the situation, and immediately went into the facility to report what was occurring, although acknowledging that Resident #1 and the bus would most likely have left for the next destination stop before staff could intervene. Interview with the DON on 10/10/2023 at 10:45 AM identified a resident elopement risk assessment should be completed by the charge nurse upon admission/readmission, quarterly, and upon a change of condition. The DON identified that although Resident #1 verbalized wanting to go home, that was Resident #1's baseline behavior and she did not think an elopement assessment was required. Although it was the facility's policy to assess residents elopement risk upon admission, and quarterly, and Resident #1 repeatedly verbalized he/she wanted to leave the facility, the DON indicated no elopement risk assessments were completed for Resident #1 and she was unable to explain why an elopement risk assessment was not completed since 2/2022 for Resident #1. Interview with Receptionist #1 on 10/10/2023 at 11:00 AM identified she utilizes the elopement book to determine which residents have a wander guard to ensure those residents are closely monitored and do not exit the facility. Receptionist #1 indicated Resident #1 would frequently come down to the main lobby area and go in the front door vestibule or outside. Receptionist #1 indicated Resident #1 was self-mobile in his/her wheelchair, and since Resident #1 was not listed in the elopement book as an elopement risk, there was no indication for additional safety measures that she was aware of. Observation on 10/11/2023 of the environment outside the facility identified the facility was on a slight hill and had an intact sidewalk located along the side of the street. Resident #1 would have had to traveled approximately 350 feet up the hill, and then at the top of the hill there was a slight downhill approximately 350 feet to get to the bus stop. Interview with Director of Social Work (DSW) on 10/11/2023 at 11:20 AM identified although Social Services does not complete the wander risk assessment, and she was aware Resident #1 would go to the main lobby area, if a resident verbalizes I want to go home, it would be considered as verbal exit seeking. The facility failed to follow their policy to assess a resident's risk of elopement and conduct elopement risk assessments and implement appropriate interventions upon a resident's known verbal exit seeking behaviors in a timely manner prior to Resident #1 leaving the facility without staff knowledge on 10/2/2023 and was found approximately 2 hours and 17 minutes after identified missing. As a result, Immediate Jeopardy was identified. Review of facility documentation dated 10/6/2023 identified the facility conducted a Quality Assurance Performance Improvement (QAPI), which included the following: the elopement book was updated to include Resident #1, elopement education for all staff, elopement drills were completed on every shift, door audits were to be completed, audits of equipment to ensure functioning, charts of all residents were reviewed to ensure compliance if a resident is observed outside unsupervised, and the charts of all residents with wander guards were reviewed to ensure compliance with the appropriate assessments, orders, and care plans. Review of facility documentation dated 10/10/2023 identified the facility provided staff education on the frequency of completing elopement risk assessments per the facility policy, and all in-house residents had been reassessed for elopement risk as of 10/6/2023 and will be reassessed quarterly or with a change of condition, per facility policy.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of two sampled residents (Resident # 2) who were reviewed for accidents, the facility failed to ensure adequate supervision was provided to a resident with a swallowing disorder and known to impulsively reach for other residents' food items who subsequently experienced a significant choking episode after acquiring access to a food item that was left unattended which resulted in a finding of Immediate Jeopardy. The findings include: Resident # 2's diagnoses included dementia and dysphagia (a swallowing disorder with difficulty swallowing). The Speech Therapy Discharge Summary dated 3/3/22 identified Resident #2 with dysphagia with skilled interventions that addressed assessment trials of diet textures. Recommendations identified Resident #2 was to remain on a puree diet with thin liquids. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had severe cognitive impairment with poor decision making and required supervision, required one (1) person assistance with movement on the unit, was self-sufficient when in the wheelchair and required extensive assistance of one (1) with eating. The Resident Care Plan dated 6/15/23 identified Resident #2 had impaired cognitive decline related to dementia and was at nutritional risk related to receiving modified textures and dependence on nursing for intake. Interventions directed to observe and evaluate changes in cognitive status including impulsivity, notify the physician of changes, provide diet/consistency as ordered, and provide extensive assistance with meals. A physician's order dated 7/1/23 directed a dysphagia puree texture diet. The nurse's note dated 7/5/23 at 2:00 PM identified Resident #2 was in the dining room, noted to be vomiting with food coming out his/her mouth and unable to exchange breaths, the Heimlich (a lifesaving maneuver to dislodge an obstructed airway) was performed, Resident #2 was still unable to expel the food keeping his/her teeth clenched tight. The note indicated Resident #2's was not alert, his/her lips were blue, Resident #2 was laid on the floor and abdominal thrusts were administered, Resident #2 began to take breaths, and oxygen was applied via a nonrebreather (higher oxygen delivery system) mask. The note indicated a tuna fish sandwich was noted on the floor by Resident #2's wheelchair. The Reportable Event summary dated 7/10/23 identified on 7/5/23 at 2:00 PM Resident #2 was observed by staff coughing and choking on food in the dining room and a sandwich was observed on the floor next to Resident #2's wheelchair. The summary identified staff performed the Heimlich maneuver until Resident #2 lost consciousness, abdominal thrusts and cardiopulmonary resuscitation were initiated, residual food was suctioned from Resident #2's mouth and Resident #2 regained consciousness. The summary indicated Resident #2 had taken a tuna fish sandwich off the nurse's medication cart that was intended as an afternoon nourishment for another resident. The summary identified Resident #2 could self-propel his/her wheelchair and was able to reach for items that are on surfaces greater than the height of his/her wheelchair. Resident #2 was evaluated by Speech Therapy on 7/5/23 and scheduled to be seen four (4) times a week, vital signs were monitored, Intravenous (IV) fluids and IV antibiotics were administered prophylactically, and a chest x-ray was obtained to rule out aspiration pneumonia which was negative. An interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 7/18/23 at 12:01 PM identified she was the primary aide assigned to Resident #2. NA #1 identified on 7/5/23 after lunch had finished, she provided incontinent care to Resident #2, transferred him/her back into the wheelchair, and observed Resident #2 self-propel him/herself back to the dining room as she continued checking and changing other residents. NA #1 indicated a short time later, as she was walking past the dining room, she observed Resident #2 in his/her wheelchair in the dining area slumped to the side, not making any sounds, appeared to be in distress, and Resident #2's mouth was full of food. NA #1 identified she alerted the charge nurse, Licensed Practical Nurse (LPN) #1, who was just a few feet away and LPN #1 began the Heimlich maneuver. NA #1 identified it was later discovered Resident #2 took a sandwich from LPN #1's medication cart which was located in the dining room. NA #1 indicated Resident #2 had to be watched as he/she would attempt to grab food items from other resident's meal trays. NA #1 stated approximately one (1) week ago Resident #2 was in the dining room and was observed to have eaten a roll, she held out her hand and Resident #2 spit out the bolus of partially eaten roll. NA #1 identified she reported the incident to LPN #1 who stated staff need to keep an eye on Resident #2 when serving meal trays. Interview with the Speech Therapist, ST #1 on 7/18/23 at 12:29 PM identified she had previously assessed Resident #2 for modified food textures and determined a puree diet with thin liquids to be a safe consistency and Resident #2 needed to be fed by staff. ST #1 indicated that although she was not aware Resident #2 would reach for food items prior to the choking episode, Resident #2 was observed to reach at his/her meal tray when evaluating food textures after the incident. An interview with NA #2 on 7/19/23 8:35 AM identified Resident #2 was known to reach for other residents' food items while in the dining room. NA #2 stated when Resident #2 exhibited the behavior, she reported the event to LPN #1. Interview with NA #3 on 7/19/23 at 8:40 AM identified she regularly monitors residents in the dining room during mealtime and has observed Resident #2 reaching for other residents' meal trays and the behavior was reported to nursing when observation. An interview with LPN #1 on 7/20/23 at 8:13 AM identified Resident #2 was known to her. LPN #1 identified on 7/5/23 after lunch, she was in the dining room with the medication cart. LPN #1 stated she left the area momentarily, about a minute or two (2) to provide care to another resident. LPN #1 identified while returning to the dining area, she was alerted by NA #1 that Resident #2 was choking, she immediately responded and observed Resident #2 had vomited but was not coughing. LPN #1 indicated she observed food in Resident #2's mouth but was unable to grasp the food as his/her teeth were clenched tight, so the Heimlich maneuver was initiated. LPN #1 explained Resident #2 deteriorated, losing consciousness, and was subsequently placed on the floor with continued efforts to clear the airway until Resident #2 began to take breaths spontaneously. LPN #1 identified she observed a half eaten tuna fish sandwich that was intended for another resident that was left on top of the medication cart was found next to Resident #2's wheelchair. LPN #1 identified about one (1) week prior to the incident, NA #1 alerted her during a meal that Resident #2 had something in his/her mouth, possibly a roll, she observed Resident #2 chewing and swallowing without difficulty, and she was informed by NA #1 that Resident #2 reaches for food not meant for him/her. Interview with the Director of Nursing (DON) on 7/19/23 at 10:18 AM identified no food items should have been left on top of the medication cart when unattended. An interview with NA #5 on 7/20/23 at 10:48 AM identified she floated at times to the unit where Resident #2 resided. NA #5 identified she was in the dining room documenting at the time of the choking incident, it was after lunch and there were two (2) to three (3) residents in the dining room as well. NA #5 indicated she did not observe Resident #2 remove anything off the top of the medication cart. NA #5 identified she heard LPN #1 yelling for help, observed Resident #2 receiving the Heimlich maneuver, and assisted in lowering Resident #2 to the floor where LPN #1 continued with life saving measures. NA #5 stated prior to the incident, she had been informed by staff to make sure food items were secured because Resident #2 would reach for food. Interview with the Medical Director on 7/20/23 at 1:58 PM identified he was made aware of Resident #2's choking episode who was treated and had no lasting effects. The Medical Director indicated he would expect staff to ensure food items were secured from a resident with a swallowing disorder who opportunistically attempted to access food. Although a policy for accident prevention was requested, one was not provided. A review of the facility policy for Snacks, Nourishments and Supplements, and Pantry stock directed snacks were to be passed within fifteen (15) minutes of delivery to the unit or properly stored and offered at a later time.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #4), reviewed for wandering, the facility failed to ensure staff verified that the wander guard bracelet was functioning and that the generator room door was secured, and as a result the resident eloped from the facility, was located 0.3 miles away, and staff were unaware he/she was not in the facility from 4:15 AM until notified by a caller from the apartment complex at approximately 6:50 AM (2 hours and 33 minutes). The failures resulted in a finding of Immediate Jeopardy, past non-compliance. The finding includes: Resident #4 was admitted with diagnoses that included dementia with psychotic disturbance, orthostatic hypotension, and hallucinations. A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderately impaired cognition, had no wandering behavior in the prior seven (7) days, and required extensive assistance with one (1) staff for locomotion on unit and dressing. Review of the Resident Care Plan (RCP) dated 3/11/2023 identified Resident #4 was at risk for elopement related to cognitive loss and a family member requested placement of the wander guard device. Interventions directed use of wander guard security bracelet, redirect Resident #4 if near exits or doorways, ambulate with rolling walker and one (1) staff assistance. A physician's order dated 2/25/2023 directed to check function of wander guard every night shift. Review of the Treatment Administration Record (TAR) for April 2023, identified the wander guard function was initialed to identify the function was checked nightly on 4/23, 4/24 and 4/25/2023. The TAR failed to identify that staff verified wander guard placement every shift. A facility reportable event form dated 4/25/2023 at 7:30 AM identified Resident #4 had wandered away from the facility to the building across the street and stated he/she was going to church. Resident #4 was returned to the facility by police and a wander guard bracelet was placed on his/her right ankle. Resident #4 had no complaints of pain, and no injuries were identified. A nursing note dated 4/25/2023 at 7:30 AM identified Resident #4 returned to the facility, a body assessment was performed, and Resident #4 had no injuries. A review of the Emergency Medical Service (EMS) report dated 4/25/2023 at 6:56 AM identified EMS was called at 6:50 AM and evaluated Resident #4 at 6:56 AM. RN #1/supervisor arrived on scene and indicated to EMS Resident #4 had dementia and must have gotten out of the facility somehow. Observations identified the apartment building where Resident #4 was found, was located across a State road (route) with three (3) lanes of traffic in one direction and two (2) lanes of traffic in the opposite direction, 0.3 miles from the facility. Interview and observations with the Maintenance Supervisor on 5/10/2023 at 1:11 PM identified the elevators on Resident #4's unit had wander guard alarms, and required a code to be entered to de-activate the alarm for use of the elevator if a wander guard bracelet was nearby. Further, Resident #4's room was located near the nurse's station and close to the elevators. The Maintenance Supervisor indicated he reviewed the facility video surveillance tape which was recorded on 4/25/2023, and the tape revealed Resident #4 had accessed the wander guard alarmed dietary elevator on the second floor and was recorded exiting that elevator on the first floor at 4:15 AM. The next video recorded Resident #4 walking to a door to the generator room/main water supply room. Resident #4 was able to open the door (the door was unsecured) and was viewed to then exit the facility through an unsecured door to the outside at 4:17 AM. The Maintenance Supervisor indicated the generator room door should always be secured (locked) and indicated the type of lock on the door did not always lock securely. The Maintenance Supervisor further identified, subsequent to Resident #4's elopement on 4/25/2023, the door lock style was changed to a lock that required a key to unlock the door. Interview with Person #1 on 5/10/2023 at 10:20 AM identified on 4/23/2023 as he/she was exiting the facility with Resident #4's laundry and the wander guard alarm sounded at the elevator. Person #1 notified the charge nurse (LPN #2) the wander guard bracelet may be in the laundry, and staff verified Resident #4 did not have the wander guard bracelet on. Interview with LPN #2 on 5/10/2023 at 11:16 AM identified that on 4/23/2023 Person #1 notified her that the wander guard bracelet may be in the laundry as the alarm had sounded when entering the elevator. LPN #2 verified Resident #4 did not have a wander guard bracelet on, and she did not replace the bracelet because she did not see an order to check the wander guard bracelet placement every shift. Further, LPN #2 indicated because she did not see a physician's order and there was no unit list/resource of residents at risk for wandering for staff reference, she did not notify the nursing supervisor. Interview with RN #1 on 5/10/2023 at 2:30 PM identified that she was the evening nurse on 4/23/2023 (took over after LPN #4 left at the start of the shift) and was not aware Resident #4 required a wander guard bracelet to be applied. Further, RN #1 indicated the TAR did not direct her to check placement of a wander guard device for Resident #4; there was no physician order that directed her to verify placement of the wander guard bracelet during her shift. RN #1 indicated that if there was an order, it would have shown up on the TAR, and then she would have reapplied the bracelet. Interview with LPN #1 on 5/10/20203 at 10:30 AM identified that she was Resident #4's nurse during the 11 PM to 7 AM shifts on 4/24 and 4/25/2023. LPN #1 indicated although she had documented that she had checked the wander guard function during both shifts, LPN #1 indicated she had only checked the placement. LPN #1 indicated the wander guard bracelet was on during both shifts, but she did not verify the function of the device. LPN #1 indicated she received re-education to ensure she verifies the placement and the function of the device. Interview with RN #3/supervisor on 5/12/2023 at 8:30 AM identified on 4/25/2023 at approximately 6:40 AM she received a call from someone at the apartment complex across the street asking her if they were missing a resident, and she replied no. The person informed her that Resident #4 was in the lobby. RN #3 went to the apartment complex and observed Resident #4 with the police and EMS. RN #3 indicated Resident #4 must have left the facility without staff knowledge while staff were busy. RN #3 indicated when Resident #4 returned to the facility, he/she was not wearing a wander guard bracelet, and a bracelet was reapplied. Interview with the DNS on 5/10/2023 at 10:48 AM identified Resident #4 should not have been able to exit the facility without staff knowledge. The DNS indicated staff are expected to check residents at least four (4) times a shift and the staff should have identified that Resident #4 was not on the unit prior to receiving notification from the police at approximately 6:58 AM. She identified there should have been physician orders that directed staff to check placement of the wander guard device and it should have been replaced when it was identified as missing on 4/23/2023, and the generator room door should have been locked. The facility policy, Patient Security Bracelet, dated 11/30/2020 directed in part, a Resident/Patient security bracelet (e.g., Wander guard) will be at a minimum of every shift for placement and daily for function to ensure patient's safety. The facility policy, Elopement of Patient, dated 10/24/2022, directed in part, that the process for managing patients at risk of elopement would include a elopement risk identification form and to place the form in a binder accessible to staff. Subsequent to the 4/25/2023 incident, the facility implemented an immediate plan of correction that included immediate staff education regarding accurately entering wander guard orders into the clinical record, checking placement of wander guard bracelets every shift and replacing timely, checking function of wander guard bracelets daily, performing rounds to monitor resident's whereabouts, and to lock the generator room door. Audits were conducted and are ongoing, and results reviewed in quality assurance meetings. This plan was verified as fully implemented on 4/29/2023, resulting in Immediate Jeopardy past non-compliance.

Based on clinical record reviews, observations, review of facility documentation and policies, and interviews for one of three sampled residents (Resident #4) who was dependent on staff for transfers in and out of the bed and chair, the facility failed to safely transfer the resident via a mechanical lift to prevent a fall with injury and for one of two sampled residents (Resident #7) who had difficulty swallowing and required a mechanically altered diet, the facility failed to provide supervision during dining to protect the resident from obtaining foods that were not part of the resident's dietary consistency which lead to a choking episode. The findings include: 1. Resident #4's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had no cognitive impairments, required total two (2) person assistance with transfers in and out of the bed and chair, utilized a wheelchair for mobility, the resident's balance during surface to surface transfer (transfer between bed and chair or wheelchair) was not steady, the resident was only able to stabilize with staff assistance, and had functional limitation in range of motion in both lower extremities. The Resident Care Plan dated 6/19/19 identified Resident #4 was at risk for falls due to [MEDICAL CONDITION]. Interventions directed to transfer Resident #4 via a mechanical lift with the assistance of two (2) to the wheelchair. The Reportable Event Form dated 7/9/19 at 3:30 PM identified that Resident #4 was being transferred via the mechanical lift and two (2) staff when the resident fell to the floor. The report indicated Resident #4 sustained two (2) small pinhole lacerations to the back of the head. The nurse's note dated 7/9/19 at 5:43 PM identified upon entering the room the Registered Nurse noted Resident #4 was lying supine on the floor in his/her room and a physical therapist was at the bedside applying pressure to the back of Resident #4's head. The note indicated a moderate amount of bleeding was noted, the resident was able to converse with staff, denied having a headache, and a cold compress was applied to the back of the head. The note identified Resident #4 complained of right hip and back pain, the resident was seen by the Advanced Practice Registered Nurse (APRN) and an x-ray was ordered. The APRN progress note dated 7/9/19 at 9:05 PM identified that Resident #4 fell to floor while being transferred with the mechanical (Hoyer) lift. The note indicated there was no neurological deficits but Resident #4 complained of severe right leg and back pain and the resident sustained [REDACTED]. The plan was to send Resident #4 to the Emergency Department for further evaluation and an orthopedic evaluation for acute management of the fracture. The nurse's note dated 7/10/19 at 7:16 AM (a late entry note for 7/9/19) identified when the charge nurse entered the room Resident #4 was lying supine on the floor with the therapist holding a cold compress to the back of the resident's head. The note indicated Resident #4 was alert, both lower extremities were outstretched, the resident verbalized pain to his/her head, the back and right hip and there was a moderate amount of blood on the floor next to Resident #4's head. The nurse's note dated 7/10/19 at 5:27 AM identified that Resident #4 returned from the hospital on [DATE] at 3:00 AM, with one (1) staple to [MEDICAL CONDITION] noted and an x-ray of the right femur showed no fracture or dislocation. Interview with a 3-11PM nurse aide, Nurse Aide (NA) #2 on 7/18/19 at 3:35 PM identified that she and another nurse aide, NA #1, were transferring Resident #4 from the wheelchair into the bed and she was operating the mechanical lift while NA #1 was behind Resident #4's wheelchair. NA #2 stated Resident #4 was up in the air at the bed level and while she tried to position the mechanical lift legs under the bed, NA #1 moved the wheelchair away. NA #2 identified that when she was moving Resident #4 in the mechanical lift sling, NA #1 did not have his hands on Resident #4 to steady the resident during the transfer because he just turned to push the wheelchair away. NA #2 indicated that as she was moving the mechanical lift Resident #4 pitched forward and fell out of the mechanical lift sling onto the floor. NA #2 stated when Resident #4 fell out of the mechanical lift, the sling was still attached to the mechanical lift and she removed the sling off of the mechanical lift. Interview with NA #1 on 7/18/19 at 4:00 PM identified that NA #2 and he were transferring Resident #4 from the wheelchair into the bed and NA #2 was operating the mechanical lift. NA #1 stated although NA #2 identified that he had just turned to push the wheelchair away, NA #1 stated that he stepped out of the room for a second to push the wheelchair out while NA #2 turned the mechanical lift. NA #1 identified that when he returned to the room Resident #4 was on the floor and mechanical lift sling was still attached to the mechanical lift. Interview and clinical record review with the Director of Nursing (DON) on 11/19/19 at 2:29 PM identified that a one (1) person assistance was an improper way of transferring the resident via a mechanical lift. The DON stated one (1) nurse aide should be operating the mechanical lift while the second nurse aide should have had their hands on the resident while the resident was up in the air during the transfer. The facility's policy Safe Resident Handling/Transfer Equipment identified the total lift will be used as the primary intervention to manual lifting, transferring, and repositioning and requires a minimum of two (2) persons to perform the lift. The total lift is used for those patients who are dependent non-weight bearing or have inconsistent weight bearing. 2. Resident #7's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 had short and long term memory deficits, difficulty focusing attention, disorganized thinking, was independent with eating after set-up, and required a mechanically altered diet. The Resident Care Plan dated 9/7/18 identified the resident was at risk for impaired swallowing related to dysphagia and had a behavior of being intrusive in other resident rooms, eating other residents' personal snack items, hiding behind a curtain while eating restricted consistency of foods and taking items from other residents dinners. Interventions directed to alert staff to monitor resident's food seeking behavior, to redirect the resident away from other resident's food, and offer food within the resident's dietary restriction, pureed consistency when observed seeking out other resident's food. A physician's orders [REDACTED]. The nurse's note dated 11/2/18 at 2:04 PM identified a nurse aide reported to the charge nurse that Resident #7 had taken someone's food and would not remove the food item from his/ her mouth. The note indicated the charge nurse immediately went to check Resident #7 and asked the resident to remove the food from his/her mouth, the resident refused and was unable to clear the food from the his/her throat. The note identified a code was initiated and the [MEDICATION NAME] maneuver was successful. The note indicated the physician was on hand, assessed the resident, oxygen was applied, Resident #7 became responsive and expelled another piece of food. The note identified Resident #7 was transferred to the hospital for further evaluation per the physician. The nurse's note dated 11/2/18 at 8:45 PM identified Resident #7 returned to the facility with no ill effects from the choking incident. In an interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #5, on 11/18/19 at 12:35 PM, she stated that on 11/2/18 during lunch in the dining room she was feeding another resident when she witnessed Resident #7 shoveling 'regular food' into his/her mouth. NA #5 indicated that she asked the resident to remove the food from his/her mouth but the resident refused so she called the charge nurse for assistance. NA #5 stated Resident #7 had the habit of stealing food belonging to other residents that was brought in by family members and food from the break room. NA #5 identified that prior to this incident, she had witnessed Resident #7 taking other residents' food in the dining room but that Resident #7 was not successful in eating the food until the 11/21/8 incident. NA #5 indicated that she had reported Resident #7's behavior to the charge nurse and that staff were aware of the resident's behavior of taking food that was not on his/her diet. NA #5 was unable to recall the number of staff that were present in the dining room when the 11/2/18 incident occurred. An observation of residents during lunch in the dining room on the 3CD unit on 11/18/19 at 12:50 PM identified residents who required a pureed diet were seated at the same table with residents having a regular diet. In an interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #5, on 11/18/19 at 1:30 PM, she stated that she was called to the dining room by NA #5 and observed Resident #7 struggling to breathe and having color change. LPN #5 indicated that she performed the [MEDICATION NAME] maneuver on Resident #7 and solid food was expelled from the resident's mouth. LPN #5 stated although Resident #7 was always observed by staff, someone was not always at his/her table in the dining room. In an interview and clinical record review with the Director of Rehabilitation services on 11/18/19 at 2:30 PM she identified that there was no documentation Resident #7 was seen by the speech therapist in 2018 however a Speech Therapy initial evaluation note dated 1/23/17 recommended Resident #7 have pureed foods with thin liquids. The 1/23/17 evaluation identified Resident #7 had demonstrated safe tolerance of pureed foods by teaspoons but required maximum cuing to reduce shoveling and impulsivity. Review of the 'Meal Service in Dining Room' policy directed to provide assistance/supervision based on the resident's current level of self-performance in eating.

Based on clinical record reviews, review of facility documentation and interviews for two of three sampled residents (Resident #2 and #6) who were reviewed for allegation of sexual abuse, the facility failed to supervise two (2) residents with known sexual behaviors to ensure residents were free from sexual abuse. The findings included: 1. Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record identified Resident #2 had a Conservator of Person (COP). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had short and long term memory recall deficits, was not oriented to the month, year, and/or day, was independent with transfers in and/or out of the bed and chair, repositioning while in the bed and ambulated independently on the unit. The nurse's note dated 10/5/19 at 10:36 PM identified Resident #2 was lying in bed with the clothing to the lower body off and a resident was seen quickly getting off the bed. Resident demonstrated no signs of fear, distress, and/or pain and Resident #2 refused a body check and to be transferred to the hospital. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record identified Resident #1 had a Conservator of Person (COP). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had short and long term memory recall deficits, was not oriented to the month, year, and/or day, had difficulty focusing attention, was independent with transfers in and/or out of the bed and chair, and ambulated independently on and off the unit. The Reportable Event Form dated 10/5/18 at 8:00 PM indicated that upon entering Resident #2's room a staff member observed Resident #1 quickly jumping off Resident #2's bed and Resident #1 was observed to be naked from the waist down. The report identified that Resident #2 was observed in a supine position, was also undressed from the waist down and Resident #2 quickly pulled the covers up. The investigation identified when questioned by the Nursing Supervisor, Resident #2 would not answer questions regarding the incident, the resident was seated in bed with the blanket held close to his/her body and Resident #2 would not allow the charge nurse and/or supervisor to check him/her for any injuries and the resident declined three (3) times when asked if he/she would like to be transferred to the hospital for an evaluation. In an interview with the 3-11PM nurse aide, Nurse Aide (NA) #3, on 9/9/19 at 3:00 PM she indicated that on the evening of 10/5/18 Resident #2's room door was closed and upon entering the room she observed Resident #1 on top of Resident #2, Resident #1 quickly got off Resident #2 and went into the bathroom. NA #3 stated that both residents were naked from the waist down. In an interview with the charge nurse, Licensed Practical Nurse (LPN) #5, on 9/10/19 at 11:00 AM she indicated that Resident #1 was intrusive and would often go into other resident rooms. In an interview with the Assistant Director of Nursing (ADON) on 9/10/19 at 1:15 PM she identified that Resident #2 was confused, conserved and unable to make a decision regarding intimate contact. 2. Resident #6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record identified Resident #6 had a Conservator of Person (COP). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 had short and long term memory recall deficits, was not oriented to the month, year, and/or day, required extensive assistance of one person for bed mobility, transfers and personal hygiene. The change in condition nurse's note dated 8/8/19 at 11:30 AM identified Resident #5 had an alleged non-staff sexual abuse. Resident #5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 had short and long term memory recall deficits, was not oriented to the month, year, and/or day, difficulty focusing attention, exhibited no behavioral symptoms in the past seven (7) days, required supervision when ambulating in the corridor and/or on the unit and received an antidepressant medication. Resident #5's care plan dated 5/12/19 identified the resident exhibited sexually inappropriate behavior which included masturbation in room/hallway, attempt to kiss female residents, flirtatious behaviors towards females, inappropriately fondling females, inappropriately touching female staff, grabbing staff on buttocks when backs are turn. Interventions directed to monitor for inappropriate flirtatious behaviors, redirect/distract as needed, staff to redirect when attempting to kiss female residents and two staff members when providing care. The Reportable Event Form dated 8/8/19 at 10:00 AM indicated that Resident #6 was observed in another resident's room, lying supine on the resident's bed and unclothed from the waist down. The report identified the other resident (Resident #5) was noted to be kneeling on the floor performing an inappropriate sexual gesture to Resident #6. The report identified the residents were immediately separated, neither resident had ill effects from the incident and Resident #5 was transferred to another unit and floor. In an interview with NA #1 on 9/9/19 at 1:35 PM she indicated that upon entering Resident #5's room she observed the bed was in the low position, Resident #6 was naked from the waist down lying on the bed and Resident #5's face was noted to be close to Resident #6's lower legs. NA #1 stated that Resident #5 frequently made sexual gestures towards the staff and residents of the opposite sex. In an interview with the ADON on 9/10/19 at 1:15 PM identified that Resident #6 was confused and was unable to make a decision regarding intimate contact. Review of the facility abuse prohibition policy identify sexual abuse as a non-consensual sexual contact of any type with a resident and includes but is not limited to sexual harassment, coercion or sexual assault.

Based on clinical record reviews, review of facility documentation, interviews, and policies review for two of three sampled residents (Resident #1 and #5) who were reviewed for an allegation of sexual abuse, the facility failed to adequately supervise two (2) residents with known sexual behaviors to prevent inappropriate sexual contact with other residents. The findings included: Resident #1's diagnoses included Alzheimer's disease, depression, and dementia. The Admission Record identified Resident #1 had a Conservator of Person (COP). The nurse practitioner's note dated 8/3/18 identified Resident #1 was seen for agitation. The assessment indicated Resident #1 had increased behavioral symptoms that included agitation, restlessness, refusing care, intrusive with peers and delusions. The recommendation plan was to continue the current medications to manage targeted behavioral symptoms and to continue to observe the resident for changes in mood and behavior. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had short and long term memory recall deficits, was not oriented to the month, year, and/or day, had difficulty focusing attention, was independent with transfers in and/or out of the bed and chair, and ambulated independently on and off the unit. The Resident Care Plan dated 9/12/18 identified Resident #1 had a history of and was at risk for sexually inappropriate behavior and/or inappropriate touching. Interventions directed to when sexually inappropriate behaviors occur approach the resident in a calm, unhurried manner and reassure as necessary, remove the resident from the environment, monitor conditions that may contribute to inappropriate sexual behavior, redirect residents of the opposite gender from the resident's room if he/she exhibits any sexually inappropriate behavior, to redirect the resident if the resident was inappropriate with dressing, and psych consult. The nurse's note dated 9/17/18 at 10:01 PM identified Resident #1 had increased confusion and intrusiveness with peers, the resident was looking for a family member, was going into other resident rooms and interfering with the care of another resident who he/she believed to be a family member and was redirected throughout the shift. The nurse's note dated 9/28/18 at 9:00 PM identified that Resident#1 was observed sitting on the side of another resident's bed with the resident laying in the bed. A nurse aide, upon entering the room, observed that Resident #1 was in the process of exposing him/herself, no physical contact was made and Resident #1 was redirected out of the room. The note indicated Resident #1 had intrusive behaviors throughout the shift, was going to other resident rooms and looking in, was redirected to common areas and to his/her own room throughout the shift. The nurse's note dated 10/4/19 at 3:02 PM identified Resident #1 was alert, confused, pacing, had increased agitation, paranoia, was intrusive with others and redirected all shift. The nurse's note dated 10/5/19 at 2:10 PM identified Resident #1 had increased agitation, paranoia, was intrusive with others and redirected all shift. Resident #2's diagnoses included vascular dementia and major depressive disorder. The Admission Record identified Resident #2 had a Conservator of Person (COP). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had short and long term memory recall deficits, was not oriented to the month, year, and/or day, was independent with transfers in and/or out of the bed and chair, repositioning while in the bed and ambulated independently on the unit. The Reportable Event Form dated 10/5/18 at 8:00 PM indicated that upon entering Resident #2's room a staff member observed Resident #1 quickly jumping off Resident #2's bed and Resident #1 was observed to be naked from the waist down. The report identified that Resident #2 was observed in a supine position, was also undressed from the waist down and Resident #2 quickly pulled the covers up. The investigation identified when questioned by the Nursing Supervisor, Resident #2 would not answer questions regarding the incident, the resident was seated in bed with the blanket held close to his/her body and Resident #2 would not allow the charge nurse and/or supervisor to check him/her for any injuries and the resident declined three (3) times when asked if he/she would like to be transferred to the hospital for an evaluation. A physician's order dated 10/5/18 directed 1:1 from 7:45 PM until Resident #1 was cleared by psych and/or the physician. Review of the clinical record from 9/28/18 through 10/5/18 failed to reflect documentation that the care plan was reviewed and/or revised after the 9/28/18 inappropriate sexual conduct and the increased intrusiveness, agitation and restlessness. In an interview with the 3-11PM nurse aide, Nurse Aide (NA) #3 on 9/9/19 at 3:00 PM she indicated that on the evening of 10/5/18 Resident #2's room door was closed and upon entering the room she observed Resident #1 on top of Resident #2, Resident #1 quickly got off Resident #2 and went into the bathroom. NA #3 stated that both residents were naked from the waist down. In an interview with the charge nurse, Licensed Practical Nurse (LPN) #5, on 9/10/19 at 11:00 AM she indicated that Resident #1 was intrusive and would often go into other resident rooms. In an interview with the Assistant Director of Nursing (ADON) on 9/10/19 at 1:10 PM she indicated that Resident #1 had a history of inappropriate sexual behavior prior to being admitted to the facility. The ADON identified although the care plan addressed Resident #1's inappropriate sexual behavior, no new interventions were put into place after the 9/28/19 incident when Resident #1 was observed in another resident's room. The ADON stated Resident #2 was cognitively impairment therefore would not be able to consent to sexual interactions. 2. Resident #5's diagnoses included [CONDITION(S)] disease and chronic kidney disease. The Admission Record identified Resident #2 had a Power of Attorney representative. The nurse's note dated 3/23/19 at 11:46 AM identified Resident #5 was in the doorway of other residents' room disrobing and asking the resident to come to his/her room. The nurse's note dated 3/25/19 indicated Resident #5 made unwanted sexual advances towards the nurse and resident was transfer to acute care hospital for psychiatric evaluation. Resident #5 returned to the facility with no new orders. The nurse's note dated 3/27/19 at 3:39 PM identified Resident #5 was sexually inappropriate throughout the shift, touching staff on the buttocks, making gestures behind the staff and going into others rooms. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 had short and long term memory recall deficits, was not oriented to the month, year, and/or day, difficulty focusing attention, exhibited no behavioral symptoms in the past seven (7) days, required supervision when ambulating in the corridor and/or on the unit and received an antidepressant medication. The Resident Care Plan dated 5/29/19 identified Resident#5 with tendency to exhibit sexually inappropriate behavior which included masturbation in room/hallway, attempt to kiss female residents, flirtatious behaviors towards females, inappropriately fondling females, inappropriately touching female staff, grabbing staff on buttocks when backs are turn. Interventions directed to monitor for inappropriate flirtatious behaviors, redirect/distract as needed, staff to redirect when attempting to kiss female residents and two staff members when providing care. The nurses' notes dated 5/9/19 at 3:02 PM indicated Resident #5 was inappropriately touching and verbally inappropriate with staff, and followed staff very closely from behind. Resident #5 was found lying on other residents' beds. Review of the clinical record from 5/9/19 through 8/8/19 failed to reflect documentation that Resident #5's behaviors of inappropriate sexual behavior towards females and wondering into other resident rooms were monitored. The change in condition nurse's note dated 8/8/19 at 11:02 AM identified Resident #5 had had an alleged non-staff sexual abuse. The social service note dated 8/8/19 at 11:10 AM Resident #5 was seen secondary being involved in a sexual activity another resident, Resident #6, and Resident #5 was unable to provide consistent details of the incident. The note indicated Resident #5's room was changed due to the incident. Resident #6's diagnoses included [CONDITION(S)], ataxia, major depressive disorder, and [CONDITION(S)]. The Admission Record identified Resident #6 had a Conservator of Person (COP). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 had short and long term memory recall deficits, was not oriented to the month, year, and/or day, required extensive assistance of one person for bed mobility, transfers and personal hygiene. The Reportable Event Form dated 8/8/19 at 10:00 AM indicated that Resident #6 was observed in another resident's room, lying supine on Resident #5's bed and unclothed from the waist down. The report identified Resident #5 was noted to be kneeling on the floor and performing an inappropriate sexual gesture to Resident #6. The report identified the residents were immediately separated, neither resident had ill effects from the incident and Resident #5 was transferred to another unit. In an interview with NA #1 on 9/9/19 at 1:35 PM she indicated that upon entering Resident #5's room she observed the bed was in the low position, Resident #6 was naked from the waist down lying on the bed and Resident #5's face was noted to be close to Resident #6's lower legs. NA #1 stated that Resident #5 frequently made sexual gestures towards the staff and residents of the opposite sex. The ADON on 9/10/19 at 1:15 PM identified that Resident #5 and Resident #6 were both confused, and conserved and/or had a legal guardian and were unable to make a decision regarding intimate contact.

Based on clinical record review and interview, for 1 of 2 residents reviewed for hydration, (Resident #327), the facility failed to ensure hydration status was monitored. The findings include: Resident #327 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified Resident #327 had severely impaired cognition, required extensive assistance for bed mobility and transfers, did not walk, ate independently after set up, had weight loss, and no dehydration. The care plan dated 2/13/17 identified Resident #327 was at nutritional risk related to inadequate intake. Interventions included monitor for changes in nutritional status, including unplanned weight loss or gain, and monitor intake at all meals. Physician's order dated 2/28/17 directed to obtain a chest x ray today stat due to cough, nausea and vomiting and diarrhea. Review of an APRN note dated 3/1/17 identified Resident #327 had recent nausea and vomiting. A laboratory report dated 3/9/17 identified Resident #327's values as follows; Sodium of 152 mmol/L (normal range 133-145 mmol/L) BUN of 14 mg/dL (normal range 10-24 mg/dL) Creatinine of 1.0 mg/dL (normal range 0.7-1.5 mg/dL). APRN note dated 3/9/17 indicated Resident #327 had [MEDICAL CONDITION]. The APRN indicated the plan was to follow the resident's sodium levels, monitor intake, and encourage fluids. Review of Resident #327's meal intake on the ADL record dated 3/9/17 through 3/16/17, 21 possible meals, identified the resident consumed 50% during 7 meals, 25% during 11 meals, 0% during 1 meal, and 2 meals were refused. A social service note dated 3/13/17 indicated Resident #327 was not having very good intake. Nursing note dated 3/16/17 at 2:37 AM identified Resident #327 had a temperature of 95.4 F, (normal 98.6 F) a pulse of 101, a respiratory rate of 22, (normal 12 - 18 breaths per minute) and a blood pressure of 88/35, (normal range 120/80). Additionally, the note identified Resident #327 was sent to the hospital for evaluation. Physician's order dated 3/16/17 directed to send Resident #327 to the hospital for an evaluation. Review of the clinical record 3/9/17 - 3/16/17 failed to reflect that fluid intake and/or output was monitored, and nursing notes failed to reflect Resident #327's issues related to inadequate intake. The hospital discharge summary dated 4/14/17 identified Resident #327 was admitted with twitching, hypothermia, [MEDICAL CONDITION], and septic shock due to multifocal pneumonia due to aspiration. Admission laboratory results included Sodium of 170 mmol/L, Potassium of 5.4 mmol/L, (normal 3.3-5.0 mmol/L), BUN of 58 mg/dL, and Creatinine of 3.1 mg/dL. Review of the clinical record failed to reflect intake and/or output had been monitored and/or that hydration assessments had been completed when Resident #327 had an increased sodium level or decreased intake after 3/9/17. Interview with MD #2 on 9/21/17 at 10:00 AM indicated based on Resident #327's elevated Sodium level of 152 on 3/9/17, the resident was at risk for dehydration and, therefore, per facility policy, intake and outputs should have been monitored. Review of the facility policy for fluid balance indicates the center will provide patients with sufficient amounts of fluids based on individual needs and patient's hydration status will be determined through routine nursing evaluation. The policy further indicated that intake and output will be monitored and documented when the resident is at risk of dehydration.

Based on clinical record reviews, review of facility documentation, and interviews, for one of three sampled residents (Resident #273) who were at risk for falls, the facility failed to follow the plan of care to prevent a fall with a major injury. The findings include: Resident #273 had [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] identified Resident #273 had severe cognitive deficits, required extensive two (2) person assistance with bed mobility, transfers, and toilet use, was not steady with walking, moving from seated position, and/or surface to surface transfers, and had a history of [REDACTED]. The Resident Care Plan dated 4/17/17 identified the resident was at risk for falls related to lack of safety awareness, and impaired mobility. Interventions directed to encourage the resident to be in common areas until bedtime, and to maintain a clutter free environment. The Reportable Event Form dated 5/22/17 at 4:30 PM identified Resident #273 was observed laying on the floor on his right side with the wheelchair in front of him/her at the nurses station, there was a small amount of bleeding from an old laceration on right upper lip with swelling, the area was cleansed and ice was applied. The report identified the resident was placed on continuous nurse aide observation. The nurse's note dated 5/22/17 at 5:04 PM identified that Resident #273 was laying on his right side in front of the nurse's station with his wheelchair next to him/her with a small amount of bleeding and swelling was noted. The nurse's note dated 5/22/17 at 7:40 PM identified Resident #273 was found lying on the right side on the floor, and was attempting to get up to the wheelchair at the time of the fall and was free from injury. The Reportable Event Form dated 5/22/17 at 7:40 PM identified that the resident was found on the floor on his/her right side, with no injuries noted. A new intervention to toilet the resident at times of restlessness was implemented. The Reportable Event Form dated 5/23/17 at 7:25 PM identified the resident had a witnessed fall onto the right side of his face after standing from his/her wheelchair, his/her dental implant was dislodged, a moderate amount of bleeding from the mouth was noted, pressure was applied and the bleeding stopped, the resident was sent to the emergency department for evaluation. Review of the clinical record failed to reflect documentation that Resident #273 was on close observation 5/22/17 at 4:30 PM through transfer to the hospital on [DATE] at 7:25 PM. Interview with the Nursing Supervisor, Registered Nurse (RN) #4 on 9/20/17 at 1:00 PM identified that she was the Nursing Supervisor at the time of the fall on 5/23/17. RN #4 stated she saw the resident stand up, then fall to the ground, and Resident #273 was noted to be bleeding from the mouth and his implanted partial bridge was dislodged. RN #4 stated she applied pressure and ice, called the physician, and the resident was sent to the emergency department. RN #4 identified that she was not aware the resident was on constant observation.

Based on clinical record reviews, review of facility documentation, and interviews for one of three sampled residents (Resident #137) who had a pressure ulcer present on admission, the facility failed to notify the physician and/or Advanced Practice Registered Nurse when a pressure ulcer re-opened and/or declined in appearance and/or for one of three sampled residents (Resident #307) who had a change in neurological status, the facility failed to notify the physician at the time the change occurred. The findings include: 1. Resident #137's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the wound physician's reports identified the resident was seen on 2/3/17 for a sacral stage (2) pressure ulcer, that measured 5 x 4 x 0.1 centimeters (cm), for the next three (3) weeks the wound had improved and was healed on 2/17/17. The consult identified the recommendation was to apply stock moisturizer to the area, discontinue the Vitamins C and Zinc [MEDICATION NAME] (if applicable), to continue present skin care and breakdown prevention and to re-consult as needed. Review of the March 2017 Treatment Administration Record (TAR) identified that the pressure area injury to the coccyx, excoriation to the bilateral buttocks was cleansed with wound cleaner followed by Z-guard every shift was applied. Review of the skin integrity tracking sheet from 2/17/17 through 3/20/17 identified Resident #137 had a stage two (2) pressure ulcer of the sacrum and on 3/20/17 the wound was noted to have declined. On 3/15/17 the appearance of the coccyx area was 100% [MEDICATION NAME] 12 x 12 x 0.1 cm with no drainage and/or odor. On 3/20/17 the appearance was 90% [MEDICATION NAME] and 10% slough. The clinical record failed to reflect documentation the physician had been notified of the initial decline in the wound appearance on 3/20/17. The wound physician report dated 3/24/17 identified an initial assessment of a post-surgical wound of the abdomen, the report failed to reflect documentation the wound physician was notified and updated that Resident #137 had a sacral wound present. Review of the clinical record from 3/20/17 through 3/27/17 failed to reflect documentation that the physician, Advanced Practice Registered Nurse (APRN), wound physician and/or Infection Control Nurse had been notified of the decline in the appearance of the coccyx wound. The nurse's note dated 3/27/17 at 12:54 PM identified a wound to the coccyx. The note written by Infection Control Nurse identified the wound was covered with greater than 50% yellowish slough and the physician and APRN were notified. A physician's orders [REDACTED]. The wound physician consultation report dated 3/31/17 identified a pressure wound of the sacrum that measured 8 x 6 x 0.4 cm with thick adherent devitalized necrotic tissue 40% that required surgical excisional debridement. The recommendations were to continue the Santyl once daily, off-load the wound, reposition per facility protocol, limit sitting to sixty (60) minutes, a group two (2) mattress and gel cushion to chair, follow up in seven (7) days. Interview and clinical record review with the Infection Control Nurse, Registered Nurse (RN) #3, on 9/19/17 at 11:47 AM identified that once a pressure ulcer was identified as healed by the wound physician subsequent area monitoring was the responsibility of the floor nurses. RN #3 stated she had not been notified that Resident #137's sacral wound had reopened until she completed the skin assessment on 3/27/17. The facility Skin Integrity Care Delivery Process Policy and the Change in condition policy indicated the center must consult with the resident's physician when there is a change in condition such as a significant unanticipated decline of a wound and a need to alter treatment. 2. Resident #307 had a [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #307 had severe cognitive impairments, was independent with activities of daily living and ambulating, and had a history of [REDACTED]. of his/her head hurting, and Tylenol was administered. The nurse's note dated 7/21/17 at 11:15 PM identified the resident was observed on the floor with his/her back against the bed with a skin tear above the left eyebrow, the resident stated that he/she was on the way to the bathroom, neurological assessments and vital signs were within normal limits. The nurse's note dated 7/22/17 at 12:28 PM identified there was swelling to the left eye. The note failed to reflect documentation that the physician had been updated. The nurse's note dated 7/22/17 at 8:28 PM identified the bruising persisted. The nurse's note dated 7/22/17 at 10:51 PM identified the charge nurse had reported to the Nursing Supervisor that Resident #307 had slurred speech and weakness in both legs when ambulating. The Nursing Supervisor evaluated the resident and noted the speech was back to baseline, two (2) staff members assisted Resident #307 back to bed, neurological checks were normal and the Nursing Supervisor instructed the charge nurse to keep monitoring the resident and pass the information on in report. Review of the clinical record from 7/22/17 at 12:28 PM through 7/23/17 at 3:04 AM failed to reflect documentation that the physician had been notified of the swelling and/or of the assessment conducted on 7/22/17 at 10:51 PM. The nurse's note dated 7/23/17 at 3:04 AM identified Resident #307 had blood coming from his/her nose and mouth, the physician was called and the resident was transferred to the emergency department. The hospital discharge summary dated 7/29/17 identified that the resident was admitted on [DATE] for a [DIAGNOSES REDACTED]. Interview with the charge nurse, Licensed Practical Nurse (LPN) #3, on 9/18/17 at 3:45 PM identified that she had not been informed in shift report that the resident's left eye was swollen. LPN #3 stated knowing the resident had fallen the night before, she called the Nursing Supervisor, Registered Nurse (RN) #7, to assess the resident, and did not notify the physician because that was the responsibility of the Nursing Supervisor. Interview with the Nursing Supervisor, Registered Nurse (RN) #7, on 9/18/17 at 4:10 PM identified that she did not recall being notified by LPN #3 of increased swelling to Resident #307's left eye, if she had been notified, she would have assessed the area, written a nurses note, and called the physician if necessary. Interview with the attending physician, MD #1, on 9/19/18 at 1:45 PM identified that if there was a new onset of swelling to the left eye after a fall, he would expect to be notified, and would have ordered to ice the area for comfort, and continue to monitor. Review of the change in condition policy identified that the facility must immediately inform the physician is there is a change in the resident's physical condition.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 6 residents, (Resident #129 and 134) who required extensive assistance with care, the facility failed to ensure the residents were free from mistreatment. The findings included: 1. Resident #129's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #129 had moderately impaired cognition, and required extensive assistance for care. The associated care plan identified Resident #129 was at risk for falls. Interventions included to place the call bell in reach while in bed, remind the resident to use the call bell, and use a calm voice or gentle touch to arouse if sleeping. physician's orders [REDACTED]. A reportable event form dated 5/8/17 at 12:05 PM identified that after Resident #129 activated the call bell, which was wrapped around his/her left arm, NA #7 entered the room, and pulled the call bell away from the resident, which caused a 5cm hematoma to the left arm. Following the event, Resident #129 was upset and cried. physician's orders [REDACTED]. Additionally, the physician's orders [REDACTED]. Nurse's note dated 5/8/17 at 3:10 AM (identified as a late entry) identified that a charge nurse asked RN #5 to assess Resident #129. Upon assessment, NA #7 indicated to RN #5 that Resident #129 injured him/herself. A 4cm raised area, with a scab of 0.5cm in the center was observed on the residents left forearm. Resident #129 indicted that he/she did not do that to him/herself. During the assessment, the area on Resident #129's arm grew to approximately 6cm in diameter, with ice in place. The note indicated that the APRN and family were updated. Nurse's note dated 5/8/17 at 7:50 PM identified Resident #129 had slight discomfort of the left arm hematoma, ice was applied, and the resident was weepy. Resident #129 was encouraged not to wrap the call ball around his/her arm. Nurse's note dated 5/8/17 at 10:50 PM identified Resident #129's left forearm hematoma was slightly smaller, had open skin with minor bleeding, and was wrapped loosely with cling. Tylenol was administered for pain at 6:00 PM with good effect. Nurse's note dated 5/9/17 at 6:50 AM identified Resident #129's left forearm hematoma measured 7cm by 4cm. Nurse's note dated 5/9/17 at 2:50 PM identified Resident #129's was noted to be in discomfort at the left forearm site when the area was touched. The area was raised, soft to firm, and bluish in color. Nurse's note dated 5/9/17 at 7:57 PM identified Resident #129 complained of pain to left forearm. Tylenol was administered with good effect. Interview and review of the reportable event with RN #5 on 9/20/17 at 2:06 PM indicated that he/she was called by LPN #7 to assess Resident #129's left arm hematoma. Resident #129 reported to RN #5 that after activating the call bell, due to difficulty breathing, NA #7 came in and pulled the call bell away from him/her, which resulted in a hematoma. Resident #129 was upset, and insisted that he/she was not lying about the incident. Interview and review of the reportable event with LPN #7 on 9/20/17 at 2:16 PM identified that NA #7 asked LPN #7 to see Resident #129 for a self-inflicted injury. LPN #7 indicated that he/she felt uneasy about the situation, because Resident #129 was upset and already had an ice pack on his/her arm before LPN #7 had the opportunity to evaluate it. LPN #7 indicated that he/she immediately notified the supervisor (RN #5), regarding Resident #129's status. Interview and review of the reportable event form with NA #7 on 9/20/17 at 2:45 PM indicated that the hematoma was sustained because Resident #129 was swinging the call bell while the cord was wrapped around his/her arm. Prior to swinging the call bell, NA #7 identified that Resident #129 had utilized it twice. After responding to Resident #129's call bell for the first time, Resident #129 did not respond or open his/her eyes. NA #7 further noted that less than a minute later, Resident #129 activated the call bell a second time, and this time, Resident #129 was noted as being upset, complaining of difficulty breathing and had asked NA #7 to get the nurse (LPN #7). Instead of getting LPN #7, NA #7 indicated that he/she tried to calm Resident #129 down, and that was when Resident #129 began swinging the call bell. It was further noted during the interview that NA #7 was unable to explain how the call bell came in contact with Resident #129 to cause the injury to the left arm. Interview and review of the facility investigation with the Regional Nurse, RN #11 on 9/20/17 at 3:00 PM identified that based on the facility investigation, which included a review of video camera footage of NA #7's activity on the unit at that time, NA #7 was terminated. Review of the abuse policy, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, injury or mental anguish. 2. Resident #134's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #134 was cognitively intact with no behaviors, and required extensive assistance with care. The associated care plan identified Resident #134 required assistance for care in bathing, grooming, dressing, transfers, locomotion and toileting. Interventions included to provide extensive assistance with lower body care, set up for upper body care, and ensure Resident #134's comfort and privacy. Review of a reportable event form dated 10/18/16 identified that Resident #134 reported that on 10/16/16, 2 days prior, NA #9 threw a pair of shorts in Resident #134's face, used profanity toward the resident, and left the room. Resident #134 identified he/she was upset at the time it happened. Review of NA #9's statement dated 10/20/16 identified he/she denied the allegation involving Resident #134, and indicated he/she was professional at all times. Review of the follow up report dated 10/21/16 identified although Resident #134 indicated no pain or discomfort when the shorts were thrown in his/her face, he/she felt insulted. Additionally, the follow up report indicated that Resident #134's roommate confirmed the allegation. Interview with the Administrator on 9/21/17 at 12:00 PM identified that the facility investigation substantiated the allegation against Resident #134, and NA #9 was terminated. Review of the facility's abuse prohibition policy identified that the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all residents. Additionally, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, injury or mental anguish.

Based on clinical record reviews, review of facility documentation, and interviews for one of three sampled residents (Resident #137) who had a pressure ulcer present on admission, the facility failed to provide treatment to promote wound healing and/or to prevent a wound from reoccurring. The findings include: Resident #137's [DIAGNOSES REDACTED]. The Resident Care Plan dated 2/2/17 indicated the resident was at risk for skin breakdown related to a history of pressure ulcers. A physician's order dated 2/2/17 identified pressure area to coccyx, excoriation to bilateral buttocks with directions to cleanse with wound cleanser followed by Z-guard every shift and as needed. The clinical record identified wound care physician consultation report dated 2/3/17 identified on initial assessment of a sacral wound, the wound was classified as a stage (2) pressure ulcer that measured 5 x 4 x 0.1 centimeters (cm). The admission Minimum Data Set assessment dated [DATE] identified Resident #137 had no memory or cognitive impairments, required two person total assistance with turning and repositioning, transfers in and/or out of the bed or chair, extensive one person assistance with eating, was at risk for developing pressure ulcers and had two (2) Stage II pressure ulcers. Review of the wound physician's reports identified the resident was seen for the next three weeks, the wound had improved and was healed on 2/17/17. The consult identified the recommendation was to apply stock moisturizer to the area, discontinue the Vitamins C and Zinc [MEDICATION NAME] (if applicable), to continue present skin care and breakdown prevention and to re-consult as needed. Review of the March 2017 Treatment Administration Record (TAR) identified that the pressure area injury to the coccyx, excoriation to the bilateral buttocks was cleansed with wound cleaner followed by Z-guard every shift was applied. Review of the skin integrity tracking sheet from 2/17/17 through 3/20/17 identified Resident #137 had a stage two (2) pressure ulcer of the sacrum and on 3/20/17 the wound was noted to have declined. On 3/15/17 the appearance of the coccyx area was 100% [MEDICATION NAME] 12 x 12 x 0.1 cm with no drainage and/or odor. On 3/20/17 the appearance was 90% [MEDICATION NAME] and 10% slough. The clinical record failed to reflect documentation the physician had been notified of the initial decline in the wound appearance. The wound physician report dated 3/24/17 identified an initial assessment of a post-surgical wound of the abdomen, the report failed to reflect documentation the wound physician was notified and updated that Resident #137 had a sacral wound present. The nurse's note dated 3/27/17 at 12:54 PM identified the Infection Control Nurse assessed Resident #137 and identified a wound to the coccyx that was covered with greater than 50% yellowish slough. The skin integrity report identified a stage two with 75% slough and 25% [MEDICATION NAME] that measured 12 x 11 x 0.1 with moderate amount of serous drainage and the surrounding tissue was macerated. A physician's orders dated 3/27/17 directed to cleanse the sacral wound with wound wash followed by Santyl ointment to the wound bed and cover with dry clean dressing every shift. The wound physician consultation report dated 3/31/17 identified a pressure wound of the sacrum that measured 8 x 6 x 0.4 cm with thick adherent devitalized necrotic tissue 40% that required surgical excisional debridement. The recommendations were to continue the Santyl once daily, off-load the wound, reposition per facility protocol, limit sitting to sixty (60) minutes, a group two (2) mattress and gel cushion to chair, follow up in seven (7) days. Interview and clinical record review with the Infection Control Nurse, Registered Nurse (RN) #3, on 9/19/17 at 11:47 AM identified that once a pressure ulcer was identified as healed by the wound physician subsequent area monitoring was the responsibility of the floor nurses. RN #3 stated she had not been notified that Resident #137's sacral wound had reopened until she completed the skin assessment on 3/27/17. Interview with a charge nurse, Licensed Practical Nurse (LPN) #1 on 9/19/17 at 3:21 PM identified that if a resident's wound was not showing signs of healing and/or increased in size she would notify the Nursing Supervisor for a wound assessment to be completed. LPN #1 identified the facility policy directed notification of the wound care nurse (RN #3), physician and family. LPN #1 stated that documentation would include the wound assessment, a change in condition and Braden scale assessment. Review of the skin integrity report identified although LPN #1 had documented the wound assessment on 3/15/17 the clinical record failed to reflect communication of a change in the wound and/or a wound assessment conducted by the Registered Nurse. Subsequent interview, clinical record review and review of the facility policy with RN #3 on 9/20/17 at 12:27 PM identified the facility had noted that the skin integrity report from 2/6/17 through 3/23/17 was completed by the charge nurses on the floor. Review of facility Skin Integrity Care Delivery Process Policy and the Change in condition policy indicated the center must immediately inform the Resident, consult with the resident's physician and notify the Resident's Health Care Decision Maker when there is a change in condition such as a significant unanticipated decline of a wound and a need to alter treatment.

Based on clincal record reviews, review of facility policies and procedures, and interviews with facility personnel, for three six sampled residents (Residents #85, 193 and 414) reviewed for accidents, the facility failed to ensure supervision and/or interventions were implement to prevent accidents. The findings include: 1. Resident #85's [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] identified the resident as severely, cognitively impaired and required extensive assistance of two for bed mobility, transfers, and toileting. A care plan dated [DATE] identified a problem of Resident #85 being dependent for activities of daily living and transfers with interventions to transfer with assistance of 2 into the customized wheelchair. physician's orders [REDACTED]. Nurse's Notes dated [DATE] at 11:07AM identified the resident was noted to have painful, swelling over the tibia or the right leg, midway between the knee and the ankle. The Physician was notified and a portable x-ray was completed that identified a fracture involving the distal third of tibia with slight lateral and anterior displacement. The resident was transferred to the Emergency Department and returned to the facility on [DATE] at 11:15PM with the right leg splinted from the toes to above the knee and directed to follow up with the Orthopedic Physician in 7 days. The Emergency Department right lower leg x-ray dated [DATE] identified a spiral fracture through the middle to distal third of the tibia with anterior displacement of the distal fragment. The x-ray further identified a displaced spiral fracture through the distal third of the fibula. Orthopedic Consultation dated [DATE] identified the cast was dry, the resident was to be non-weight bearing, and was to return in 3 weeks. Interview with the DNS on [DATE] at 10:50AM identified that during the facility investigation, NA#2 initially reported that she/he transferred the resident with assistance of the Charge Nurse. The DNS further identified that upon review of the surveillance footage, it was identified that NA#2 was seen bringing the resident alone to the room and exiting the room alone/without another staff member assisting. Interview with NA#2 on [DATE] at 11:21AM identified that she/he worked on the 11:00PM to 7:00AM shift on [DATE]. NA#2 further identified that the resident was out of bed in the wheelchair when the shift started and was told by the nurse to keep the resident up in the wheelchair until the resident became tired. NA#2 further identified that approximately 5:00AM she/he transferred the resident by herself (without the assistance of another staff member) and placed the resident in bed. NA#2 further identified that she/he was unaware the resident was to be transferred with 2 staff members because she/he did not read the NA care card. NA#2 further identified that she/he always transfers the resident alone and never has any issues. On [DATE] at 1:35PM a phone call was placed to the Orthopedic physician for interview. 2. Resident #193's [DIAGNOSES REDACTED]. The quarterly minimum data set ((MDS) dated [DATE] identified that Resident #193 scored a 3 out of fifteen on the brief interview of mental status (BIMS), indicative of severe congitive impairment and that Resident #193 needed one to two nursing home staff to provide extensive physical assistance with activities of daily living. The resident's care plan dated [DATE] identified that Resident #193 was dependent on the nursing home staff for activities of daily living. Interventions included to transfer Resident #193 with 2 assistants to the wheelchair and to provide complete assistance with ADL's. Review of Resident #193's nursing notes indicated that Resident #193 had 16 falls since ,[DATE]. Review of the facility investigations indicated that Resident #193 had slid out of the wheelchair with 5 of the 16 falls investigated. A review the investigation of the falls indicated that on [DATE] and [DATE] Resident #193 slid out of the wheelchair and that the cushion on the wheelchair was removed to be evaluated by the physical therapy department. Review of the clinical record and interview with the Director of Physical Therapy (DPT) on [DATE] at 12:05PM failed to reflect documentation that the wheelchair and/or cushion on the wheel chair was evaluated. Interview with DPT identified that he/she was not aware that the wheelchair cushion was an issue of concern related to Resident #193's falls. Although the DPT indicated that he/she meets weekly with the fall committee he/she was not informed that Resident #193's wheelchair cushion needed to be evaluated by the physical therapy department. Interview with RN#3 on [DATE] at 11:15AM indicated that he/she recalls submitting the request for PT to evaluate the resident's wheelchair cushion however it is the unit manager's responsibility to ensure that the evaluation was completed. Although review of Resident #193's care plan dated [DATE] indicated that a PT consult was initiated for seating and/or positioning, there was no documentation that the wheelchair cushion was evaluated. A Rehabilitation Referral Form dated [DATE] indicated that Dycem was delivered and placed on R#193's wheelchair however there was no documentation that a physical therapist evaluated the resident. Observation of Resident #193 on [DATE] at 12PM with LPN#4 identified that Resident #193 was sitting in his/her wheelchair on a cushion without the benefit of a Dycem to the wheelchair. Interview with LPN#4 indicated that a Dycem should have been on the chair. LPN could not determine who provided the cushion for the chair. Additional review of the clinical record indicated that R#193 slid out of the wheelchair on [DATE], [DATE], [DATE], and [DATE]. A review of the facility investigation on [DATE] for the [DATE] fall indicated that the wheelchair cushion would be evaluated by PT. Interview with the DPT on [DATE] at 12:15PM identified that he/she was not aware that the wheelchair cushion needed to be evaluated. Interview and review of the facility's policy with the DNS indicated that it is the responsibility of the DNS to ensure that the new interventions are implemented within 5 working days. Interview with the DNS indicated that he/she should have ensured that the interventions were implemented as per the facility's policy. 3. Resident #414's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified Resident #414 with severe impairment in cognition, required extensive assistance of two staff for bed mobility and transfers and extensive assistance of one staff for dressing and toilet use, as not steady with transtions/transfers, and had no falls since admission. Fall assessment dated [DATE] indicated one fall since admission or since prior assessment. physician's orders [REDACTED]. Resident care plan for mobility in effect in [DATE] included bed mobility and transfers with the assistance of two staff members. ADL record for [DATE]-[DATE] indicated Resident #414 required extensive physical assistance of two of more staff for transfers. Facility documentation dated [DATE] at 4:15 PM identified Resident #414 was taken into the shower room, attempted to stand, was lowered to the floor by CNA#5 and sustained a skin tear to the lateral aspect of the right knee. Documentation further indicated the resident did not hit his/her head. Functional status before and after the event indicated the resident was alert, oriented to person, and remained a transfer with assistance of two staff. Additional facility documentation dated [DATE] at 4:45 PM identified Resident #414 was lying in bed and noted to have bleeding skin tears to the upper right arm and lower right leg. Functional status before the event indicated the resident was alert and sometimes confused and continued to require two person assistance with transfer and after the event was documented as unresponsive. Nursing note dated [DATE] at 5:09 PM indicated the resident was transferred to the hospital and a note at 11:45 PM indicated the resident expired at 7:00 PM. Hospital documentation dated [DATE] described the resident as obtuned status [REDACTED]. Review of a second statement of the event given by NA#5 on [DATE] to the facility indicated NA#5 transferred the resident back to bed with the assistance of one after the shower. In addition NA#5 indicated she was aware the resident care card indicated the resident was an assist of two and asked other staff for help but they were busy and transferred the resident by herself. NA#5 indicated the resident did not fall or slide during the transfer into bed. Facility documentation dated [DATE] indicated termination of employment of NA#5 on [DATE] due to failure to follow the patient's care plan card which identified a two person assist required for transfer. This failure to follow the policy contributed to a negative patient outcome. Facility fall policy includes to develop and follow a plan of care to reduce falls risk.

Based on clinical record review and interview for one of three sampled residents (Resident #1) reviewed for repetitive falls with injuries, the facility failed to provide the appropriate supervision and/or implement interventions for a resident who was a high risk for falls. The findings include: 1. Resident #1's [DIAGNOSES REDACTED]. The Admission Record identified Resident #1 was admitted to the facility on [DATE]. The Reportable Event Form dated 2/15/15 at 12:40 PM identified that Resident #1 was found on the floor next to the bed and had sustained no apparent injury. The report indicated that Resident #1 was unsteady on his/her feet, could not be left alone and bedside mats were implemented. The investigation dated 2/15/15 identified that Resident #1 was a high risk for falls and the resident had fallen four times at the hospital prior to admission to the facility. The 5-day Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required extensive two person assistance with transfers in and/or out of the bed and/or chair and bed mobility and extensive one person assistance with movement between locations in his/her room and the adjacent corridor, the resident's balance during transitions and walking was not steady and was only able to stabilize with staff assistance, was always incontinent of urine and bowel movements, and had a history of [REDACTED]. The resident care plan dated 2/19/15 identified Resident #1 was at risk for falls related to poor safety awareness. Interventions directed to assess for changes in medical, pain, mental status and report to physician as indicated, bedside mats, bed in a low position and call light in reach. The nurse's note dated 2/19/15 identified at 5:00 PM Resident #1 had fallen out of bed, was unresponsive for thirty seconds, vital signs were stable, within normal neurological examine and subsequent to physician notification Resident #1 was transferred to the hospital. Review of the hospital discharge summary dated 2/24/15 identified Resident #1 had sustained a left temporal bone fracture with adjacent hemorrhagic contusion. The care plan was revised and directed the use of non-skid socks while in bed. The nurse's note dated 2/26/15 identified 1:00 PM Resident #1 was witnessed walking in the hallway alone and before staff could intervene, Resident #1 fell and sustained a right forearm approximately 8-10 inches. Resident #1 was transferred to the hospital and admitted . The laceration required 24 sutures and at that time the resident was noted to have old rib fractures and two acute fractures. Subsequent to the incident, a scoop mattress was placed on the bed, padded side rails, and a self-releasing Velcro alarm belt to act to remind the resident not to get up unassisted. The Reportable Event Form dated 3/3/15 at 8:00 PM identified Resident #1 was noted to have a bruise and swelling over the right eye and the resident had reported he/she fell from the bed, got up and returned back to bed. A care plan revision directed to off assistance with toileting after meals and at bedtime. The nurse's note dated 3/20/15 identified at 1:30 PM Resident #1 was found on the floor in the bathroom and was noted to have a left eye laceration. The Reportable event Form dated 3/20/15 at 1:30 PM identified Resident #1 had sustained a small superficial laceration that measured 1.0 by 0.25 centimeters (cm) and there was edema of the right orbital. Review of the facility's investigation dated 3/20/15 identified that Resident #1 was last observed by Nurse Aide (NA) #1 at 1:00 PM and the resident was agitated trying to get out of bed. At 1:30 PM Resident #1 was found in the bathroom sitting on his/her heels in front of the toilet. The care plan was revised to again address toileting needs. Review of the hospital discharge summary dated 3/20/15 identified Resident #1 sustained an acute on chronic scalp hematoma without new osseous injuries. The nurse's note dated 3/29/15 at 3:00 AM identified Resident #1 was found sitting on the floor on her buttocks in the hallway with legs folded and having no idea other than he/she fell out of bed, no injury was noted. Review of the facility's documentation failed to identify that Resident #1 had been wearing the non-skid socks as directed in the care plan. The care plan revision directed when Resident #1 was restless, transfer the resident out of bed to the wheelchair with the Velcro alarm belt and tray table and bring to the common area for monitoring. The nurse's note dated 4/9/15 identified Resident #1 had been sleeping all morning until 10:00 AM when Licensed Practical Nurse (LPN) #1 assisted the resident out of bed to the wheelchair for safety and a large hematoma was noted over the left brow. Resident #1 was unable to explain what happened and subsequently was transferred to the hospital. The hospital discharge summary dated 4/11/15 identified Resident #1 sustained a non-displaced fracture of cervical seventh superior facet and an old compression fracture in the lumbar two vertebral body was identified. Review of the facility's investigation dated 4/13/15 identified that Resident #1 will have a bed alarm ordered to alert staff when he/she tries to gets out of bed and side rails to prevent the resident from hitting the head against the side rails. Review of the resident care plans from 2/14/15 through 4/9/15 identified that although the care plan was reviewed and revised after each of the six falls, the facility failed to implement interventions and/or provide the appropriate supervision until 4/13/15, after the seventh fall, when an alarm was initiated which would alert the staff when Resident #1 was attempting and/or had gotten out of bed. Interview with NA #1 on 8/12/15 at 10:00 AM identified that she recalled Resident #1 was often agitated. Interview and review of the facility's documentation with the Unit Manager and the Director of Nursing (DON) on 8/11/15 at 2:00 PM identified that Resident #1 was placed on one to one observations at times after the falls and the one to one observation was discontinued on 3/18/15 after the application of the scoop mattress. The staff attempted to monitor the resident all the time because Resident #1 was impulsive when the one to one observation was discontinued. The Unit Manager did not recall whether staff had reported to her Resident #1 was getting out of bed after the scoop mattress was applied. Interview with LPN #1 on 8/12/15 at 2:00 PM identified when Resident #1 slept the staff chose not to disrupt the resident because Resident #1 would get agitated when awake. LPN #1 stated the staff tried to monitor Resident #1 at all times because of the frequent falls. LPN #1 did recall that Resident #1 was able to get out of the scoop mattress independently but did not recall if he actually observed the resident doing so. Review of facility policy directs that the care plan must be customized to each individual patient's needs and is reviewed and revised a minimum of quarterly and as needed to reflect response to care and changing needs of the resident.

Based on review the clinical record, review of facility documentation, and interview for 1 of 6 sampled residents reviewed for accidents (R#179, R#39), the facility failed to implement the Resident Care Plan resulting in a fall and/or provide protective smoking equipment and/or for 1 of 36 sampled residents who had a leave of absence with a responsible party (R#312), the facility failed to adequately supervise the resident's whereabouts within the facility until the resident was noted to be missing for greater than nine hours and/or for 1 of 6 sampled resident reviewed for resident to resident altercations (R# 383) the facility failed to provide supervision. The findings include: 1. Resident # 179's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified the resident as severely cognitively impaired, total dependence on staff for ADL's, and extensive assistance of one with transfers. The Resident Care Plan dated 10/14/14 identified the resident at risk for falls related to an abnormal gait. Interventions included the use of gripper socks when in and out of bed, and the assistance of one for transfers. Review of the NA Care Card failed to identify the resident required the use of gripper socks for fall prevention and the use of black boots while in bed. Nurse's note dated 11/29/14 identified at 4:00 AM the resident was found lying on the floor next to the bed. A complete assessment was initiated and the resident complained of right hip pain. The physician was notified and the resident was transferred to the emergency room for evaluation. Further review of the nurses notes identified the resident was admitted to the hospital with [REDACTED]. Interview with RN#8 and review of the clinical record on 12/2/14 at 9:45 AM identified the resident often attempts to stand without assistance and previously required the use of a bed alarm. Additionally, according to corporate policy, the facility was directed to reduce and/or eliminate the use of alarms as a fall prevention measure. Resident # 179's bed alarm was recently discontinued and not in use at the time of the fall. Staff were directed to monitor the resident more closely. Further interview identified RN#8 was unsure why the RCP and the NA Care Card identified the use of different footwear. Interview with LPN#13 and review of facility documentation on 12/2/14 at 10:30 AM who was on duty at the time of the fall, identified that NA#19 heard the resident yelling and reported to LPN#13 that the resident fell from the bed. When entering the room the resident was observed lying on the floor, in a hospital gown and without footwear. Interview with NA #19 and review of facility documentation on 12/02/14 at 2:00 PM identified that she/he was not aware that the resident required the use of gripper socks to prevent falls. Interview, review of the clinical record, and review of facility documentation on 12/02/14 at 9:00 AM verified that that the facility is attempting to reduce/ eliminate the use of alarms. 2. Resident #39's [DIAGNOSES REDACTED]. The 5-day MDS assessment dated [DATE] identified the resident as cognitively intact and requiring extensive assistance with activities of daily living. A Smoking assessment completed on 11/06/14 identified that the resident cannot smoke safely without the use of a smoking apron. The resident care plan dated 11/06/14 identified that the resident was unsafe with smoking habits and must wear a smoking apron. Observations on 11/19/14 at 12:30 PM identified R#39 in the smoking area smoking without the benefit of a smoking apron. Interview with the DNS on 12/03/14 identified that the resident had not been smoking since his/her re-admission from the hospital, and that this was his/her first time smoking since his/her return. The DNS indicated that the resident has always required the use of a smoking apron. 3. Resident #312's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified that Resident #312 had poor decision making cognitive skills, feelings of depression and hopelessness, required extensive assistance with transfers in and out of the bed and/or chair, personal hygiene, and toilet use, was expected to be discharged to the community and exhibited no behavior of wandering. The attending physician's (MD #2) progress note dated 10/28/14 identified that Resident #312 had progressed in rehab and was scheduled for discharge on 10/29/14 but was concerned for discharge because of underlying cognitive impairment. The note indicated that Resident #312 had refused cognitive testing, seemed to be very impaired to MD #2 and lacked insight into his/her deficits. The social service progress note dated 10/31/14 described a meeting of the Medical Director, Administrator, Advanced Practice Registered Nurse, a legal representative for the facility and the Social Worker. It was identified that Resident #312 lacked insight and exhibited poor judgment. At the meeting it was explained to Resident #312 that the discharge was on hold and a psychiatrist would be in to complete an official evaluation. Interventions were discussed to keep Resident #312 safe over the weekend that included fifteen minute checks and a photo at the desk. Review of the elopement assessment dated [DATE] identified Resident #312 was an elopement risk stating that he/she wanted to leave. The resident care plan updated 11/1/14 identified Resident #312 at risk for elopement related to resident's confused status and stating he/she wanted to leave the facility. Interventions directed to educate health care decision maker and staff of elopement potential and prevention measures, if unable to redirect resident, stay with resident and provide support and supervision until able to redirect, provide picture of resident to staff located near exits and utilize sign in/out records when resident leaves center with escort. The Medical Director's progress note dated 11/1/14 identified that Resident #312 had consented to neuropsychiatry testing and the paperwork was completed for the court to review the case for competency. The physician's note indicated that Resident #312 had not attempted to leave the building, felt that a sitter was not justified and stated that staff will check on Resident #312 unobtrusively frequently and if he/she were to attempt to leave, a one-to-one observation and even calling security would be justified. Review of the clinical record from 10/31/14 through 11/19/14 failed to reflect documentation that fifteen minute checks and/or unobtrusively frequent observations were conducted. A physician's orders [REDACTED]. Review of the October 2014 treatment kardex directed the administration of Calazime cream to the sacrum every shift and when necessary and non-skid footwear is to be applied for safety every shift. The November 2014 kardexes were unable to be located by the facility for review. The nurse's note dated 11/19/14 identified that at 10:00 PM, the 3-11 PM Nursing Supervisor was notified that Resident #312 was not in his/her room. A missing resident code was called, rooms searched, responsible parties called and the resident was not found therefore 911 was called and the resident was ultimately located at his/her home. Review of the Reportable Event Form and investigative report dated 11/20/14 identified that at 10:00 PM Nurse Aide (NA) #9 reported to the charge nurse that Resident #312 was not in his/her room. A search was initiated, the police were called and the resident was located at his/her home. The video camera was reviewed on 11/20/14 by the facility Associate Administrator and Director of Plant Operations. The review identified that Person #1 in a black trench coat came into the facility at 12:37 PM through the main lobby entrance and did not sign the guest book. Person #1 proceeded to the main elevator and up to the 2B wing. At 12:42 PM, Person#1 was observed exiting the main elevator at 12:43 PM through the main lobby door out of the center with Resident #312 and without signing a leave of absence log. Review of facility policy directs that patients will be evaluated for elopement risk upon admission, quarterly and with a change in condition as part of the admission process. Those determined to be at risk will receive appropriate interventions to reduce risk and/or minimize injury. Interview with NA #9 on 11/25/14 at 2:00 PM identified that on 11/19/14 she initiated first rounds at 3:15 PM. At that time when she walked by Resident #312's room the bathroom door was closed and she assumed that Resident #312 was in the bathroom. NA #9 indicated that the supper trays were delivered at around 6:00 PM and Resident #312 was not in the room therefore she left the tray on Resident #312's overbed table. NA #9 stated that she asked the charge nurse where Resident #312 was and the charge nurse did not respond to her. NA #9 stated that after the residents were fed supper, she took her break and returned to the floor at 8:00 PM. Resident #312 was not on the unit she thought the resident was out on a leave of absence and was going to ask the charge nurse, but the nurse was not around. From 8:00 PM to 10:00 PM NA #9 identified that she had rendered care to the other residents on her assignment and Resident #312 did not cross her mind. NA #9 indicated that last rounds were completed between 9:00 PM-10:00 PM and when Resident #312 was not in his/her room she asked the charge nurse, Licensed Practical Nurse (LPN) #7. Resident #312 was not located and a facility search was initiated. Interview with the 3-11 PM Licensed Practical Nurse (LPN) #7 on 11/25/14 at 2:30 PM identified that on 11/19/14 during safety rounds at the beginning of the shift she glanced quickly into Resident #312's room and thought the resident was in the room however it might have been the roommate. LPN #7 explained that she was called down to the Director of Nurse's office for a meeting and when she returned to the floor she was delayed in passing medications. LPN #9 indicated that she did not attempt to give Resident #312 the scheduled 5:00 PM medications because the resident usually refused the medications and she was already late. LPN #7 did not recall NA #9 asking about Resident #312 around 6:00 PM and stated that it was never reported to her that the supper tray was not touched. LPN #7 did recall that Resident #312's picture was posted on the unit, but did not recall if the picture was still posted that night. Interview with LPN #8 on 12/1/14 at 10:14 AM identified that on the evening of 11/19/14 she was the treatment nurse and Resident #312's treatment included the application of a cream to his buttocks and to check that he/she had gripper socks on. LPN #8 stated that there were two admissions that evening and she never had an opportunity to go in to conduct the treatment. LPN #8 stated that she did walk by the room at one time and assumed the resident was in the bathroom. Interview with the Medical Director on 12/1/14 at 9:45 AM identified that Resident #312 had demonstrated poor judgment and the process of appointing a conservator had been initiated. Resident #312 had not been exhibiting exit seeking behaviors and she did not want to place a wanderguard on and/or initiated one-to one observations. The Medical Director indicated that she expected close monitoring for any indication of general signs of anxiety and/or escalating behavior. Interview with the receptionist on 12/1/14 at 11:00 AM identified that she was the full time receptionist and typically did not leave the desk for break until 1:00 PM. The receptionist stated that Resident #312's picture was included in the elopement risk book and was also posted at the desk. She did not recall observing Resident #312 exit the building on 11/19/14. Interview with the Manager of Clinical Operations on 12/1/14 at 12:00 PM identified that on the video surveillance when Resident #312 was leaving the front lobby, the receptionist was noted to be turned away assisting another resident. The Manager of Clinical Operations stated that although there was no written policy for resident rounds at the change of shift, it is the expectation that staff report off to the next shift including those residents who may be out of the facility. A tour of the unit was then expected to verify the presence of residents. The facility failed to ensure the whereabouts of Resident #312 when the resident was not visually observed starting with the initial rounds at the beginning of the 3-11 PM shift and thereafter until 10:00 PM. 4. Resident (R) #383 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] indicated R#383 had severely impaired cognition with long and short term memory deficits. A Resident Care Plan (RCP) dated 8/5/14 indicated R# 383 had episodes of physically combative behaviors. Psychiatry progress notes indicated on 8/7/14 R#383 pushed R#259 and R#259 fell to the floor causing a bump on R#259 ' s head. Psychiatry saw R#383 on 8/8/14 and noted that he/she did not appear to act in a violent manner and was not a risk to others. Psychiatry increased R#382's Risperdal and decreased his/her Trazodone. The RCP indicated R#383 was to be redirected away from R#259. Psychiatry notes identified on 8/29/14 Depakote sprinkles 125 milligrams (mg.) twice a day was added to R# 383 ' s medication regimen for combativeness with staff and the inability to be redirected at times. On 9/12/14 Depakote was increased to 250 mg. twice a day for continued combativeness and refusal of care. In addition on 9/14/14 Risperdal was decreased. A psychiatry note dated 9/18/14 indicated on 9/15/14 R#31 accused R#383 of pushing him/her to the floor. No injury was identified. No changes in medications were made. Psychiatry evaluated R#382 and no changes in treatment were made. The RCP indicated R#383 was to be redirected when in close proximity of R#31. Facility documentation indicated on 10/5/14 R#383 grabbed R#249 after R#249 had touch R#383 on the back. According to facility documentation on 10/6/14 R#382 was observed pushing R#294 and pulling his/her hair. No injuries had occurred. No changes in treatment were identified. The RCP indicated R#383 should be redirected away from R#249 and R#294 when he/she approaches. A psychiatry note indicated on 10/14/14 Risperdal was increased to 1 mg. three times a day in addition Trazodone 75 mg. every 6 hours was added to R# 383 ' s nighttime dose for increased combativeness since the Risperdal was decreased on 9/14/14. A psychiatry progress note dated 10/20/14 indicated R#382 was not a risk to him/herself or others. A subsequent psychiatry note dated 10/29/14 indicated R#382 had had several episodes of provoked resident to resident altercations within a 1 month period in which R#382 made soft physical contact with other residents. R#383 was transferred to facility #1 for inpatient psychiatric evaluation. In review of R# 383 ' s RCP the RCP indicated R#383 was to be redirected after each incident however redirection from individual residents did not prevent R#383 from being involved in altercations with other residents. In addition the use of and/or adjustment of medications were not identified after the medications were added and/or changed. In addition R# 383 ' s RCP did not include identified factors that would trigger combativeness and/or behaviors R#382 would exhibit prior to altercations with other residents requiring intervention. During a review of R# 383 ' s RCP with the Director of Nursing (DNS) on 11/19/14 at 1:05 PM the DNS indicated R# 383 ' s RCP should have included the addition and/or alteration in medications in addition to identified factors which would trigger R# 383 ' s inappropriate behaviors such as yelling and loud noises. During an interview with the Dementia Program Director on 11/19/14 at 11:30 AM he/she indicated R#383 spends the majority of his/her time walking up and down the hallway and usually is around the nurse's station. He/she indicated all staff monitor R#383 ' s location and intervenes as needed when R#383 approaches other restricted resident rooms. R#383 wanders into other residents rooms when he/she becomes tired therefore when R#383 exhibits signs of tiring, such as dragging his/her feet, R#383 is brought to his/her room to rest.

Based on observations, review of clinical records, review of facility documentation and staff interviews for 1 of 3 sampled residents (Resident #194) who had an unwitnessed fall, the facility failed to communicate to the physician that the resident had a significant change in neurological status and/or for 1 of 1 sampled residents reviewed for specialized services (R# 42) the facility failed to follow through with a recommendation from the [MEDICAL TREATMENT] unit and/or for 1 of 3 sampled residents reviewed for allegations of abuse/neglect (R#216) the facility failed to provide timely incontinent care and/or for 1 of 1 sampled resident reviewed for hand contractures (R#240) the facility failed to document a change in skin integrity and/or for 2 of 6 sampled resident reviewed for falls (R#316, R#329) the facility failed to complete a neurological assessments as per facility policy and/or for 1 of 3 sampled residents (Resident #312), the facility failed to administer medications in accordance with the physician's orders [REDACTED]. 1. Resident #194's [DIAGNOSES REDACTED]. The readmission Minimum Data Set assessment dated [DATE] identified that Resident #194 had severe cognitive impairment, exhibited no behavioral symptoms, required limited to extensive one person assistance with activities of daily living, balance was not steady with transitions of levels and walking, a history of falls and received an anticoagulant medication daily. Review of the [DATE] Medication Administration Record [REDACTED]. The nurse's note dated [DATE] at 10:56 PM identified that Resident #194 was found on the floor in the sitting position by the bed, neurological checks were initiated and within normal limits. Review of the Neurological Assessment Flow Sheet from [DATE] at 9:15 PM through [DATE] at 8:15 AM identified six of eleven occasions Resident #194 refused and/or was uncooperative to have the neuro checks completed, one time was blank and at 8:15 AM the resident was sleeping. The nurse's note dated [DATE] at 4:11 AM identified that Resident #194 was noncompliant with neuro checks and vital signs this shift, restless several times for short periods, redirection given with poor effect and staff one to one observation initiated at times. The nurse's note dated [DATE] at 11:01 AM identified that Resident #194 was found unresponsive to verbal and physical stimuli. The physician was notified and the resident was transferred at 10:50 AM to the hospital. Review of the hospital report dated [DATE] identified an acute subdural hematoma and on [DATE] at 5:30 AM Resident #194 expired, likely cause of death an intra-cranial bleed. Interview with RN #1 on [DATE] at 12:23 PM identified that neurological checks were started on Resident #194 because the fall was unwitnessed. RN #1 stated that he was not aware that the resident had refused the neurological checks and had he been notified he would have attempted to conduct the neuro checks and/or report the resident's non-compliance to the physician because Resident #194 was transferred from another unit and the staff did not know the resident's baseline. Interview with ,[DATE] AM charge nurse, LPN #5, on [DATE] at 9:15 AM identified that she was unfamiliar with Resident #194 and the resident was uncooperative refusing to have the neuro checks completed. LPN #5 indicated that she did not report to the Nursing Supervisor that the resident refused the assessments because she was used to taking care of residents that had behaviors. LPN #5 stated that the last time she saw the resident was when she assisted the nurse aide with personal care around 5:30 AM and the resident was falling asleep during the care. Interview with ,[DATE] PM charge nurse, LPN #2, on [DATE] at 11:45 AM and [DATE] at 11:10 AM identified that at the start of the shift she conducted safety checks on the residents and noted that Resident #194 was sleeping. LPN #2 stated that at 8:15 AM she went into the resident's room to complete the neuro checks and the resident was still sleeping so she left without conducting the assessment. LPN #2 stated that she did not want to wake the resident because she did not want him to become anxious and fall again. LPN #2 identified that between 8:,[DATE]:00 AM she went back into the room and tried to wake Resident #194 by rubbing the residents chest, tapping his/her face and calling the resident's name but Resident #194 did not wake. LPN #2 stated she called LPN #3 into the room to check the resident and LPN #3 could not wake the resident. LPN #2 stated she called the Physician Assistant (PA) who was in-house and reported that the resident had congestion, green mucus and that she could not wake the resident up. The PA directed to administer a nebulizer treatment and obtain a chest x-ray. LPN #2 stated that she did not report that she tried rubbing the resident's chest and/or tap his/her face and the resident did not respond. LPN #2 indicated that she called the attending physician because of the congestion after nebulizer treatment but did not inform him that Resident #194 would not wake up. LPN #2 stated that although she tried to contact the unit manager (RN #3) to come assess the resident, she could not get a hold of RN #3 and waited until RN #3 came back onto the unit. Interview with RN #3 on [DATE] at 11:30 AM identified that she observed Resident #194 sleeping at approximately 8:00 AM and went to morning report. RN #3 stated that she was unsure what time she got out of the meeting but the meetings usually ended between 9:30 and 10:30 AM. RN #3 stated that after LPN #2 reported she could not wake the resident, she went into assess the resident and could not get the resident to respond so she notified the physician and Resident #194 was transferred to the hospital. RN #3 indicated that LPN #2 should have notified her and/or communicated to the physician a complete assessment when she could not get the resident to respond. 2. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified the resident required extensive assistance with ADL's. physician's orders [REDACTED]. The RCP dated [DATE] identified the resident required [MEDICAL TREATMENT] for [MEDICAL CONDITION] with intervention that included transfer to [MEDICAL TREATMENT] as ordered. A [MEDICAL TREATMENT] communication record dated [DATE] directed to discontinue the [MEDICATION NAME]. Interview with LPN#12 on [DATE] at 10:10 AM identified he/she was unaware of the recommendation and placed a call to the [MEDICAL TREATMENT] unit for clarification. Review of the clinical record failed to reflect that [MEDICATION NAME] was discontinued on [DATE] and the Medication Administration Record [REDACTED]. Interview with the DNS on [DATE] at 11:10 AM identified that the licensed staff that accepted the resident back from [MEDICAL TREATMENT] should have called the physician to notify him/her of the recommendations. Interview with RN#11 on [DATE] at 11:45 AM identified that all doses of [MEDICATION NAME] were to be discontinued because the resident's blood pressures had been running high, and that medication keeps the blood pressure up. 3. Resident #216's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as cognitively impaired, requiring extensive assistance with ADL's and no behaviors. A RCP dated [DATE] identified the resident required assistance with ADL's with interventions that included to encourage resident participation while providing appropriate ADL care. A RE dated [DATE] at 8:00 AM identified R#216 was found with dried stool in the bed and on the resident's back. Facility investigation concluded that the resident had loose stool and a history of playing in stool as per family interview. Actions taken to prevent future incidents included that the resident will have more frequent checks while in bed. Review of facility's summary dated [DATE] indicated R#216 was found with dried stool on his/her back on the ,[DATE] shift. The investigation consisted of staff interviews, review of hallway cameras and family interview. The investigation concluded that the resident had last received incontinent care at approximately 5:15 AM. The resident had loose stool at the time and a complete bed change had been completed. Review of facility investigation dated [DATE] identified a written statement by NA#11 indicating he/she started last rounds on everyone at 5:00 AM and completed 2 full bed changes. NA#11 indicated he/she provided care to the resident during that time frame. Facility statement dated [DATE] obtained from NA#12 identified that he/she saw NA#11 doing care on the resident at 6:15 AM and the resident had loose stools. Review of statement dated [DATE] obtained from NA#13 identified he/she saw the resident between 7:35 AM and 7:40 AM and indicated the resident was uncomfortable, was yelling and had feces up the back, in the hair and diaper. He/she reported to the charge nurse, LPN#9. A written statement dated [DATE] obtained from LPN#9 identified the resident was observed laying in feces. A written statement dated [DATE] obtained from NA#14 indicated linen came up around 7:40 or 8:00 AM and resident had stool up the back, in the hair and fingers. NA#14 indicated she gave the resident a shower. Interview with RN#2 on [DATE] at 6:45 AM identified that he/she was on duty the day of the incident and was called downstairs to the office. RN#2 indicated that there were 3 NA's on duty on the ,[DATE] shift, one went home sick leaving 2 to care for residents and the assignment was redistributed. RN#2 indicated he/she saw R#216 with feces visible over the upper portion of the diaper, but indicated that it did not appear as though resident was in feces all night and the diaper looked fresh and with clean linen. RN#2 indicated the resident does have a history of [MEDICAL CONDITION] and loose stools. RN#2 indicated the nurse aide did provide care, however he/she was unsure of time frame, and indicated it could have been 2 to 3 hours before the resident was found. The last time care was provided was early at 4:00 or 5:00 AM. Interview with NA#14 at 12:50 PM identified she was assigned the resident and completed safety checks at 7:00 AM and the resident was covered with the blanket at that time. NA#14 indicated that although they conduct safety rounds at the beginning and end of the shift, staff does not check under the blanket or visualize the resident. NA#14 indicated at 7:30 AM when she went into the room she removed the blankets and found the resident with feces on her back, on the back of the hair and dried feces on the linen. At that time NA#14 called the supervisor so she could see the condition the resident was left in and then put the resident in the shower to be cleaned up. Interview with NA#13 at 1:05 PM identified she was assigned the resident's roommate and heard R#219 yelling and complaining he/she was uncomfortable. NA#13 indicated she informed the resident she would get the NA assigned to his/her care, and noticed dried stool up the resident's back, sheets, hands and hair. NA#13 indicated the resident may have been playing in the stool. Attempts to interview NA#11 on [DATE] at 1:35 PM were unsuccessful. Interview with DNS on [DATE] at 8:25 AM identified the resident was found with loose stools on the ,[DATE] shift, had loose stool on the ,[DATE] shift and was cleaned up at that time. 4. Resident #240's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified that the resident as cognitively impaired and required total care for activities of daily living. physician's orders [REDACTED]. Review of the clinical record failed to reflect any documentation regarding the laceration to the right palm. Interview with LPN # 14 on [DATE] at 2:30 PM identified that the area was not a laceration and indicated that the OT#1 reported that R # 240 had a laceration to the right hand and he/she then wrote the order for the [MEDICATION NAME] but did not assess the area until later on in the shift. LPN#14 indicated that h/she found the area to be dry, scaly and peeling. LPN#14 indicated h/she forgot to change the order, write a nurse's note describing the area, or fill out a skin integrity report. Interview with OT#1 identified that R # 240 was referred by nursing staff because the resident was not tolerating his/her hand positioning device. Upon evaluation of the right hand she noted the area to appear "crusty and scabby" with an odor, he/she then reported her findings to LPN #14. Review of an OT progress note dated [DATE] identified that the palmar surface was malodorous, macerated, scaly, and with a discolored palmar crease. Interview with DNS on [DATE] identified that it would be her expectation for the nurse to evaluate the residents palm when the issue was reported, as well as document her findings in the nurse's notes and/or skin integrity report. 5. Resident #316's [DIAGNOSES REDACTED]. A 14-day MDS assessment dated [DATE] identified R#316 as severely cognitively impaired and independent with bed mobility and ambulation. A care plan dated [DATE] identified R#316 is at risk for falls due to a history of Parkinson, and a history of falls with interventions that included to encourage activities after dinner in common areas, attempt to offer rest periods after activities at bedtime, and gripper socks on while while out of bed. Interview and review of neurological check reports for unwitnessed falls dated [DATE], [DATE], [DATE] and [DATE] with the DNS on [DATE] at 12:30 PM identified that neurological checks were not completed according to the facility policy. Additionally, The DNS indicated that when a resident is being uncooperative he/she should be re-approached and/or if a resident is sleeping he/she should be awoken in order to obtain neurological checks. 6. Resident # 329's [DIAGNOSES REDACTED]. Review of a RE form dated [DATE] identified the resident was observed sitting on the floor by his/her bed by a nurse walking by the resident's room. R#329 was unable to state what happened due to dementia, and that neurological assessments were started. Review of the neurological assessments dated [DATE] identified that the neurological checks were started at 10:45 AM and continued every 30 minutes until 12:15 PM when they were obtained every hour until 3:15 PM. Neuros were then completed every 2 hours until 7:15 PM thereafter. No further entries were noted after 7:15 PM on [DATE]. Review of the Falls Management policy identified that neurological assessments will be performed for all unwitnessed falls. Review of the Neurological Assessment policy identified that neurological checks should be completed every 30 minutes for 2 hours, every hour for 4 hours and then every 4 hours for 24 hours. Interview with the Director of Nurses on [DATE] identified that the neurological assessment form was not completed according to the policy. 7. Resident #312's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the [DATE] treatment record directed the administration of [MEDICATION NAME] cream to sacrum every shift and when necessary and non-skid footwear is to be applied for safety every shift. Upon further review, the [DATE] medication and treatment kardexes were unable to be located by the facility for review. The nurse's note dated [DATE] identified that at 10:00 PM, the ,[DATE] PM Nursing Supervisor was notified that Resident #312 was not in his/her room. A missing resident code was called, rooms searched, responsible parties called and the resident was not found therefore 911 was called and the resident was ultimately located at his/her home. Review of the Reportable Event Form and investigative report dated [DATE] identified that at 10:00 PM Nurse Aide (NA) #9 reported to the charge nurse that Resident #312 was not in his/her room. A search was initiated, the police were called and the resident was located at his/her home. Interview with Licensed Practical Nurse (LPN) #6 on [DATE] at 2:30 PM identified that on [DATE] she did not administer medications to Resident #312 because the resident usually refuse the medications and she was already late with the administration of medications to her assigned residents.

Based clinical record review and interview for one of three residents in survey sample reviewed for pressure ulcers (R#466) facility failed to provide care and services for the prevention of a pressure ulcer and promote healing. The findings included: 1.a. Resident #466 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified R#466 as severely cognitively impaired and requiring extensive assistance with all activities of daily living (ADL) including bed mobility and transfers between surfaces, such as moving between a bed to chair. It further identified that although R#466 had verbal behaviors directed toward others (e.g. threatening/screaming) s/he did not have a history of and/or presence of a pressure ulcer. A Nursing assessment dated [DATE] identified that R#466 as at moderate risk for developing a pressure ulcer. It further identified that his/her skin was intact with no skin/wound conditions present. Resident care plan (RCP) dated 9/12/12 identified a " focus " of potential for skin breakdown related to cognition, and incontinent of bowel and bladder. Interventions included to provide treatment as ordered, apply protective/preventative barrier to skin as ordered, provision of a specialty mattress and weekly skin assessments. The RCP additionally included direction to turn and reposition R#466 every two (2) hours and as needed. Therapy communication to nursing dated 11/01/12 identified recommendations that included the use of a tilt in space " donated " (adapted) custom wheel chair (CWC) with directions which included CWC use for up to six (6) hours as tolerated with a pelvic positioning belt. The recommendations additionally directed upright after meals and one hour afterward and to, " tilt to tolerance " at other times. Nurse note dated 11/07/12, 7:00 to 3:00 PM shift, identified the resident out of bed to " custom wheel chair " (CWC). It further identified " fissure located on center of coccyx", " balmex applied ", will continue to monitor. However review of the clinical record failed to reflect physician notification of the fissure. A change of condition nurse note dated 11/09/12 at 8:00 PM identified that a nurse aide identified an open area on R#466's coccyx, measuring 1.0 cm by 1.0 cm. The physician and family were notified. physician's orders [REDACTED]. A RCP dated 11/12/12 identified, an alteration in skin integrity related to a stage 2 (pressure ulcer) located on coccyx. Interventions included to follow facility protocol for treating break in skin integrity. Nurse note dated 11/18/12 identified " coccyx wound area worsening " . Nurse note dated 11/21/2012, 7:00 to 3:00 PM shift, wound bed dry, very dark around wound. Nurse's note dated 11/23/12, at 2:00 PM identified, wound bed very dry, and borders of wound bed very dark in color, will have wound nurse assess. physician's orders [REDACTED]. Nurse note dated 11/26/12, 7:00 to 3:00 PM shift, indicated, assessed by physician's assistant (PA#1) " . New orders obtained for air mattress and for physical therapy (PT) to evaluate customized wheel (CWC) secondary to increase in pressure areas. physician's orders [REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. Hospital Discharge Summary dated 12/01/12 identified R#466 ' s was admitted with a stage IV pressure ulcer located on his/her coccyx with necrosis around the borders and purulent exudates at the base of the wound with very foul odor that measured 10.0 cm by 2.0 cm by 0.1 cm. b. Review of facility, " non-pressure " wound and skin condition documentation dated 11/07/12, 11/09/12 and 11/13/12 identified site location of center of coccyx and as noted as incomplete. Review of the only identified facility, Pressure Ulcer documentation dated 11/26/12, identified a deep tissue injury (DTI) that measured 3.5 cm by 3.8 cm by 0.5 cm. Interview with the Director of Nursing on 3/06/12 at 11:30 AM and review of the clinical record failed to provide documentation that the resident was repositioned while in bed and/or while out of bed in a " donated " wheel chair from 11/01/12 through 11/18/12. The DNS She was unable to provide complete and thorough weekly (pressure ulcer) wound condition assessment documentation and/or documentation that a registered nurse had assessed and/or overseen wound assessments, except for an entry dated 11/26/12, which identified a DTI on the coccyx. The DNS was unable to provide documentation that R#466 ' s care plan was revised and/or that the physician was notified on 11/09/12, 11/18/12, 1121/12 and/or 11/23/12 when a change of condition was identified. Interview and review of R#466's clinical record with the ADN's #1 on 3/06/12 at 11:45 AM indicated that as per facility policy a license practical nurse (LPN) could perform weekly pressure ulcer assessments and document them without the benefit of Registered Nurse (RN) oversight, unless there was a change in the wound condition. She further indicated that she was the author of the undated nurse note entry and that it should have been dated 11/26/12.

Based on clinical record review, review of facility policies, observation and interviews for one of three sampled residents reviewed for incidents/accidents (R#1), the facility failed to supervise the resident to prevent unsafe smoking incidents potentially impacting the entire facility resulting in a finding of immediate jeopardy. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] identified that the resident was without cognitive or memory impairments, rejected care and displayed physically and/or verbally abusive behaviors 1-3 times in the previous 7 days, was totally dependent on staff for transfers with a mechanical lift, and was independently mobile in a wheelchair on and off the unit. Smoking assessments dated 11/30/11 and 12/29/11 indicated that the resident could safely smoke independently. The next smoking evaluation/assessment dated [DATE] and all subsequent evaluations indicated that the resident required supervised smoking. The care plan dated 1/6/12 and continued through current date of 8/13/12, indicated that the resident was unsafe with smoking habits and non-compliant with smoking regulations. Interventions included educating the resident and family on policy, staff to hold all smoking materials, encourage to smoke in designated areas only, and to provide one to one supervision as indicated by unacceptable behaviors. On 5/8/12, the care plan was updated to include removing the resident ' s oxygen prior to smoking and replacing it after. The following incidents were documented in nursing and/or social service notes: 1/1/12 at 10 PM: Found smoking in bed. 1/13/12 at 8:30 PM: Found smoking in the cafe in the facility. 1/7/12: Found lighter in resident ' s pocket. The resident was outside smoking alone. 1/14/12: Found smoking in 3C lounge; 2 cigarette butts and ashes were found on the piano. Nurse ' s notes identified that there was no staff available to supervise the resident so the nursing supervisor gave the resident cigarettes and a lighter to smoke independently. 1/15/12 and 1/17/12: Found with smoking materials. 3/21/12: Observed smoking with oxygen on. Supervisor gave him/her 2 cigarettes and a lighter to use. 5/1/12: Found smoking with oxygen on outside of the building. 5/14/12: Found smoking with oxygen on outside of the building. 5/21/12: Found with lighter and half a cigarette butt outside of the building. 5/23/12: Found smoking with oxygen on in the building. 6/11/12: At 3 PM the resident was found smoking in the 3rd floor rec room. A hot cigarette was found on the piano. 6/25/12: 7:15 PM. The resident took a cigarette from a visitor and was smoking with oxygen on. 7/30/12: The resident was found smoking with oxygen on at 4;00 PM and again at 6:50 PM. 8/6/12: 3-11 PM shift. Found smoking with oxygen on. Nursing notes from the resident's admission in November of 2011 through current (10/3/12) identified that the resident was both physically and verbally abusive to staff and other residents, including choking and striking nurse's, other residents and/or aides, screaming profanities and racial slurs, and kicking doors and objects when needs were not met immediately. The resident had threatened that he/she had a knife and was going to harm staff. The resident had several incidents of purposely throwing him/herself on the floor when staff didn't respond to requests to return to bed quickly enough. A psychiatric assessment dated [DATE] indicated that although the resident did not require one to one at that time, he/she required monitoring related to smoking. On 1/5/12, the psychiatrist documented "does not seem to recognize the effects his/her actions have on others and wants what he/she does, when he/she wants it, without reflecting on whether it is good for him/her or safe for the building. Of greatest concern is smoking. Having smoked in his/her room after being deemed able to understand and adhere to the smoking policy is consistent with antisocial personality traits. The safety of the unit comes first." On 1/12/12, the psychiatrist documents "understands what is asked for in smoking safety. Is able to obtain own smoking materials from staff or others when he/she chooses to. Staff efforts about a safety plan around smoking are admirable but without at least his/her passive participation, more restrictive efforts may be needed for the safety of the facility." Similar notes were documented on 1/16/12, 2/9/12, 3/1/12 and 5/9/12. On 5/23/12, the psychiatrist documented that there had been several unsafe incidents including smoking with oxygen on, which the resident knew was dangerous. "There is a pattern of him/her acting for him/herself with an eye to immediate wants without regard to the safety of others. The unsafe smoking puts the facility as a whole at risk". He suggested removal of all smoking privileges and the resident ' s power wheelchair which the facility did for a period of time (record lacks documentation of the exact dates). The physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. Review of the clinical record failed to reflect the privilege to leave the facility independently was reassessed despite the unsafe behaviors exhibited by the resident. Interview and review of the clinical record with the DNS and Administrator on 10/3/12 at 2:30 PM indicated that subsequent to the incident on 8/6/12, the resident had been placed on one to one supervision while awake and out of bed (resident requires Hoyer lift for transfers). They indicated that the one to one was discontinued the week prior due to the resident not displaying any negative smoking behaviors. They felt that the use of the electronic cigarette and the Wanderguard alerting staff to exiting the building had addressed the problem. No further interventions had been initiated at that time of discontinuing the one to one, and no increased supervision of the resident while off the unit had been contemplated. Review of the record noted that one to one supervision had only been documented in 3 nurse's notes from 8/6/12 through 9/28/12. Further review noted that the care plan lacked documentation and interventions related to the 15 documented incidents of non-compliance/dangerous smoking. The facility was unable to provide documentation of a system in place to notify administration/nursing management when such unsafe smoking incidents had occurred. Interview with ADNS #1 on 10/2/12 at 1:45 PM noted that the corporation will not allow the facility to place residents on 15 minute checks. ADNS#1 noted that smoking incidents are not documented as reportable events or investigated and just noted in routine nurse's notes. She indicated that after the last incident in August, a Wanderguard was placed on Resident #1's wheelchair to alert staff to attempts at exiting the building and the resident had weaned him/herself off of the oxygen currently. She noted that the resident now has an electronic cigarette to use between smoking times and all smoking is now supervised. Observation of smoking on 10/3/12 at 2 PM noted that the nurse aide supervising the smoking period had her back to R#1 on several occasions. Although R#1 was observed with a smoking apron on, ashes were noted dropping unsafely without intervention from staff. Subsequent to surveyor inquiry, an immediate action plan was initiated and the resident was placed on one to one supervision while out of bed.