Every finding on record at Aviata at Big Bend

Based on interviews and record review, the facility failed to honor and respect resident rights of choices and preferences of care for 1 out 4 residents reviewed. (Resident #1)The findings include:A record review was conducted for Resident #1 on 7/16/26. Resident #1 was admitted to the facility on [DATE] with the diagnoses of Metabolic Encephalopathy (a brain function failure caused by chemical imbalances, organ failure, or toxins in the body), Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure, and Anxiety Disorder.Resident #1 had a care plan written for impaired balance, limited mobility, and activity intolerance. The care plan included the requirement for one staff member to assist with toileting needs, bathing, personal hygiene, and transfers from bed to wheelchair and wheelchair to bed. Resident #1 had a documented history of refusing personal care at times. The plan of care further revealed that Resident #1 had a communication limitation that affected her ability to understand what was being spoken or written. This also caused her to have difficulty expressing her needs and wants. The interventions stated staff were to face [Resident #1] when speaking to her, do not rush her and allow her an adequate amount of time to respond.Resident #1's Minimum Data Set (MDS) assessment, completed on 5/26/26, indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicates she had mild cognitive impairment. This MDS also indicated Resident #1 had no mood or behavior concerns. Resident #1 described her personal preferences as being very important when choosing her activities, choosing what clothes to wear, and when to bathe and shower.An interview was conducted with Resident #1 on 7/16/26 at 9:10 AM. Resident #1 stated she was attacked by staff members on 7/6/26. Resident #1 further stated she had asked to be changed due to her pants being soiled because she wanted to go outside. Resident #1 had told Staff C, a Certified Nursing Assistant (CNA), she did not want to go to the shower room and did not want a shower. Resident #1 further stated Staff C continued to push her wheelchair toward the shower room when Resident #1 put her feet down on the floor of her doorway and stated, No, I don't want to go. Resident #1 then hit her arm on the handrail in the hallway, causing a skin wound to her right forearm.An interview was conducted with Staff C on 7/16/26 at 11:35 AM. Staff C described Resident #1 as being a little crazy. Staff C recalled that she had returned to the unit from a staff meeting around 4:00 pm on 7/6/26 and was told that Resident #1 was requesting to be changed because her pants were soiled. Staff C instructed Resident #1 to get a change of clothes and told her let's go to the shower room. Staff C then stated, I was behind [Resident #1] pushing the wheelchair to assist [Resident #1] to the shower room when [Resident #1] started pushing back against me and [Resident #1] had put her feet on the floor to stop from pushing the wheelchair any further. Staff C confirmed that Resident #1 made the statement, No, I do not want to go to the shower room and Resident #1 grabbed a hold of the handrail and Resident #1 received a skin tear to her right forearm. Staff C stated that was when Resident #1 started freaking out and yelling call the police. Staff C stated that was when she put her hands up in the air and backed away from Resident #1. Staff C explained that Resident #1's bed was made with clean linens earlier in the shift and she did not want to mess up the bed by changing Resident #1 in the room.An interview was conducted with Staff B, another CNA, on 7/16/26 at 02:20 PM. Staff B confirmed on 7/6/26 that Resident #1 had requested to be changed and as Staff C was taking [Resident #1] to the shower room, Resident #1 stated clearly, No, I don't want to go to the shower room.An interview was conducted with Staff H, Unit Manager, on 7/16/26 at 3:30 PM. Staff H revealed they spoke to Resident #1 on a daily basis and encouraged Resident #1 to allow staff members to provide care. Staff H further stated, [Staff C] should have stopped when [Resident #1] said 'no, I don't want to go', left [Resident #1] alone, and re-approached [Resident #1] at a later time. All the staff on the unit know how to do this when [Resident #1] or any resident becomes upset.An interview was conducted with the facility's Director of Nursing (DON) on 7/16/26 at 3:00 PM. The DON explained her expectation was that staff was trained to provide care for all residents every two hours and as needed and stated, the residents in the facility deserve the best care. The DON further stated, residents have the right refuse care and services, but we always try to encourage them, if they still refuse, we give them some time and then re-approach them.A review of the facility policy titled Resident Rights, dated for 4/15/26 demonstrated the facility will inform the residents both orally and in writing that the residents will understand his or her rights, will be informed of their rights, all residents will be treated equally, and the facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Residents have the right to request, refuse, and discontinue treatment. Residents have the right to make choices about his / her life.

Based on observations and interview, the facility failed to maintain a clean and comfortable environment for 7 of 16 sampled occupied resident rooms. (Rooms # 100, #105, #201 #202, #206, #305, and #401)The findings include:room [ROOM NUMBER] On 3/23/26 at approximately 11:30 AM, room [ROOM NUMBER] was observed with a resident on a pillow with numerous small tears and a dinner plate sized hole with exposed inner foam stained brownish yellow. There was no pillowcase on the pillow. The wardrobe was observed to have a door hanging off the hinge with the sleeve of a long-sleeved shirt draped over the top through the gap. The dresser had exposed particle board along the top border of each drawer. The privacy curtain was soiled with multiple reddish-brown splotches. A follow up observation was conducted in room [ROOM NUMBER] with the Staff F/Registered Nurse. The soiled and ripped up pillow was observed resting on the seat of a wheelchair beside the resident's bed. Staff F observed the pillow and stated the damaged and soiled pillow should have been thrown away. A follow-up observation on the dresser and wardrobe was conducted with the Maintenance Director on 2/26/26 at approximately 10:00 AM. The Maintenance Director observed the dresser and stated that they had ordered new dressers and would replace when received. When asked when the order was placed and who placed it, he stated he was not sure. He also observed the broken drawer on the wardrobe and stated that it would be fixed today. A follow-up observation was conducted for the soiled privacy curtain with the Environmental Services (EVS) Director. He stated that today was the assigned day for replacing all the soiled privacy curtains on the hall. room [ROOM NUMBER] On 3/23/26 at approximately 12:15 PM, room [ROOM NUMBER] was observed with the privacy curtain soiled along the outer border from top to bottom with splotches of dried light brown colored fluid. A follow up observation with the EVS director was conducted on 3/26/26 at 10:05 AM. He stated that the privacy curtain would be replaced along with the other soiled curtains on the hall today. room [ROOM NUMBER] An observation of room [ROOM NUMBER] was conducted on 3/23/26 at 11:59 AM. The fitted sheet on the resident's bed had a brown substance stain on the right side of the bed. An additional observation of room [ROOM NUMBER] was conducted on 3/23/26 at 03:18 PM, the fitted bed sheet remains with the same brown substance stain as seen on the previous observation. Additional observations on 03/23/26 at 02:46 PM, 3/24/26 at 09:55 AM, and 3/25/26 at 09:35 AM revealed that the bed linens continued to be soiled with a brown substance. An interview was conducted with room [ROOM NUMBER]'s resident at 09:35 AM. The resident stated that the linens get changed while being bathed or when the linens need to be changed. The resident stated that the staff have not offered to change the bed linens. On 3/25/26 at 02:10 PM an interview was conducted with Staff B (Registered Nurse). Staff B stated that each resident has a scheduled bath and shower day. Staff B also stated that when residents are bathed and are out of their beds that beds should be changed. Staff B stated that bed linens are changed when they are visibly soiled. Staff B additionally stated that the resident in room [ROOM NUMBER] is pleasant and hardly refuses care. Staff B stated that the resident is not known to refuse bed linen changes and is compliant with care. Staff B went to room [ROOM NUMBER] and viewed the fitted bed sheet with the brown substance that has been on the linen since Monday 3/23/26. Staff B stated that the resident is out of bed and the bed linens are visibly soiled and the linens should have been changed. room [ROOM NUMBER] An observation of the restroom for room [ROOM NUMBER] was conducted on 3/23/26 at 2:55 PM. The sink faucet in the restroom was discolored and there were several small holes in the bathroom wall. A follow-up observation of room [ROOM NUMBER] was conducted with the Maintenance Director. He observed the sink faucet and stated the sink had calcium build-up and he could probably remove it with cleaner or replace it. He also stated there was a mirror on the wall that fell and left holes in the wall and he would patch them. (Photographic evidence obtained.) room [ROOM NUMBER] An observation of room [ROOM NUMBER] was conducted on 3/23/26 at 2:17 PM. The B bed overbed table was in disrepair and missing the border, exposing rough particle board. The restroom sink faucet handles were discolored. A follow-up observation of room [ROOM NUMBER] was conducted on 3/26/26 at 9:49 AM with the Maintenance Director. He observed the overbed table for 202 B and stated they will replace the table. He also observed the restroom sink faucet handles and stated they were hard water stains and there was no excuse for this. (Photographic evidence obtained.) room [ROOM NUMBER] On 03/23/2026 at 12:10 PM, room [ROOM NUMBER] had bubbled paint all around window and had baseboards in disrepair. The bed's headboard and footboard trim were missing. Tiles below the window were in disrepair. On 03/26/2026 at 9:27 AM, room [ROOM NUMBER]'s bed headboard trim and footboard trim were missing. Wall baseboards were undone and had bubbled paint. (Photographic evidence was obtained.) On 03/26/2026 at 10:10 AM, the Administrator and Maintenance Director entered room [ROOM NUMBER]. Staff E stated he will place the bed's trim today. Staff E further stated bubbled paint and baseboards on wall will be repaired, as well as the tiles below the window. room [ROOM NUMBER] On 03/23/2026 at 2:28 PM, room [ROOM NUMBER] was noted with holes in the block walls and cracked block revealing concrete. Plastic baseboards were both missing and pulled away in more than one place. The bathroom toilet was running and the bowl was dark brown. Patches of bathroom flooring missing or peeled away. Bathroom doorway was rusted on both sides of the jam. (Photographic evidence was obtained) A further observation on 3/26/26 9:15 AM confirmed that all issues were still present. On 3/26/26 at 10:10 AM, an observation wasr conducted with the Administrator and the Maintenance Director. They both stated that the resident will be moved and a total restoration of room and bathroom will be completed, including replacement of toilet.

Based on observations, staff interviews and record review, the facility failed to develop a smoking care plan to address smoking supervision and assistance requirements for 1 of 3 residents sampled for smoking. (Resident #11)The findings include:Resident #11 was observed smoking in the designated smoking area with staff supervision on 3/24/26 at approximately 1:25 PM and on 3/25/26 at approximately 9:34 AM and 3:33 PM. The facility supplied a resident smoker list on 3/23/26 with Resident #11 on the current list.A review of the resident's care plan revealed no care plan or interventions related to smoking and the resident requiring assistance with personal care due to weakness. A list of the resident's evaluations revealed one smoking evaluation completed on 2/20/26 at 3:39 PM.A review of the resident's progress notes from the Nurse Practitioner, with the date of 12/22/25, revealed the nicotine patch was discontinued due to the resident's smoking.An interview was conducted with Employee J (certified nursing assistant (CNA)) on 3/24/26 at approximately 1:30 PM, who indicated the resident attends the scheduled smoking times on a regular basis and confirmed Resident #11 had a current smoker agreement that was signed by the resident on 2/20/26.An interview was conducted on 3/26/26 at approximately 9:16 AM with the care plan nurse. She confirmed there was no care plans for this resident for smoking, but it should have been added. The care plan nurse indicated a smoking care plan should be placed in the resident's chart upon admission or when the resident starts smoking.A review of the facility policy revealed the facility will evaluate the residents that wish to smoke on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. Also, if a resident is identified during the smoking evaluation to require assistance or supervision with smoking, the center will include the appropriate information in the care plan.

Based on staff interview, resident record reviews, and review of the facility's policy and procedure, the facility failed to implement their policy and procedure to ensure residents were provided with education of the risk and benefits of the vaccine and offered the COVID-19 vaccine in accordance with current CDC (Center for Disease Control and Prevention) guidelines for 4 of 5 residents sampled for immunizations. (Residents #20, #28, #29, and #32)The findings include: On 03/24/2026, a record review was conducted for Resident #20. The record revealed documentation on 03/05/2024 that the resident refused the COVID-19 vaccine. There was no documentation to indicate if the resident was provided with education or offered the 2025/2026 COVID-19 vaccine.On 03/25/2026, a record review was conducted for Resident #28 record revealed no documentation on COVID-19 consent, education, or documented offer of the COVID-19 vaccine to Resident #28 since the resident was admitted on [DATE]. There was no documentation indicating Resident #28 was offered the 2025/2026 vaccination.On 03/25/2026, a record review was conducted for Resident #29. Resident #29 was offered the COVID-19 vaccine on 11/21/24. However, there was no documentation of Resident #29 being offered the current 2025/2026 vaccination or offered the booster as per CDC guidelines and facility policy.On 03/25/2026, a record review was conducted for Resident #32. The record revealed a signed informed consent and education on 5/2/24 for the COVID-19 vaccination. However, the resident was not offered the current 2025/2026 vaccination.During an interview with the Infection Prevention and Control Program facility representative (IPCP) on 03/25/2026 at 11:37 AM, she stated that the COVID-19 vaccine is offered to residents upon admission and re-entries during facility assessment. She stated that vaccination administration is followed per facility policy and vaccinations are offered based on resident eligibility and CDC guidelines.An interview with the Regional Nurse Consultant on 03/25/2026 at 02:16 PM revealed that they were unable to locate records for the assessment and offer of the 2025-2026 COVID-19 vaccine for the sampled 4 out of 5 residents. She stated that Residents 32, 29, and 20 were not offered the updated 2025/2026 COVID-19 vaccination since 2024. She also stated that Resident #28 was never offered or assessed for the COVID-19 vaccination since the resident's admission on [DATE]. Staff A states that the facility policy indicates for the facility to follow the updated guidelines for CDC COVID-19 vaccinations.The 2025-2026 COVID-19 Vaccination Guidance, last updated on November 4, 2025, revealed that the COVID-19 vaccination continues to be recommended for individuals residing in long-term care facilities, with emphasis on older adults and those at increased risk for severe illness. The guidelines indicates that all residents should be assessed for vaccination status and offered the updated COVID-19 vaccine based on age, risk factors, and vaccination history. Additionally, current standards reflect that nursing homes are expected to offer COVID-19 vaccination to residents unless medically contraindicated and ensure appropriate educations, access, and documentation of consent or refusal of the COVID-19 vaccine.A review of the facility's policy and procedure titled Coronavirus Disease (COVID-19) - Vaccination of Residents last on revised June 2022. The facility's COVID-19 Vaccination policy was reviewed on 03/25/2026 at 12:17 PM. The policy revealed each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized. The facility policy states vaccine recommendations and schedules are consistent with the Centers for Disease Control Interim Clinical Considerations for the Use of COVID-19 Vaccines in the United States. The facility policy continues to state that booster vaccine doses are provided in accordance with current CDC guidance.

Based on observation and interview, the facility failed to ensure a functioning call light system in the bathroom that could be activated from the floor for 2 of 2 sampled residents. (Residents #4 and #23)The findings include:On 3/24/26 at approximately 3:00 PM, an observation of a bathroom shared between Resident #4 and Resident #23 revealed a call light cord approximately 2 inches long by the toilet and not reachable from the floor in the event of a fall.An interview was conducted on 3/24/26 at approximately 3:05 PM with Employee G, Registered Nurse (RN). She confirmed the call light cord was too short to be activated by residents if they were on the floor following a fall. The RN indicated she would submit a work order for maintenance to address the concern.An interview was conducted on 3/25/26 at approximately 9:33 AM with the Maintenance Director that confirmed the call light cord was too short and required replacement. The Maintenance Director indicated the staff should submit work orders when repairs are needed and he had not been notified of the issue.

Based on interviews and record review, the facility failed to ensure a thorough investigation was conducted of the allegation to protect residents for 1 of 7 residents sampled for mandated reporting. (Resident #1)The findings include:On 2/10/26 at approximately 3:10 PM, an interview was conducted with the Social Service Director (SSD) who stated on 1/19/26 she reported the abuse allegations made by Resident #1 to the Administrator, who is also the facility's abuse coordinator, and felt the allegations were verbal abuse and Staff A needed to be suspended. On 2/10/26 at approximately 4:40 PM, an interview was conducted with the Human Resource Director (HRD), who stated on 1/19/26, while in morning meeting, she heard the SSD report the abuse allegations to the Administrator and that Staff A needed to be suspended. The HRD stated she also went to the Administrator and told her Staff A needed to be suspended. The HRD stated she began a workplace investigation on 1/19/26 and Staff A was terminated on 2/9/26.On 2/10/26 at approximately 4:45 PM, an interview was conducted with Resident #1, who stated he told the Administrator and Director of Nursing (DON) he felt like Staff A, Registered Nurse (RN), verbally abused him and that he was being retaliated against. Resident #1 stated he could not remember the exact date, but it was the week of 1/19/26.On 2/11/26 at approximately 10:00 AM, an interview was conducted with the Administrator who stated she had been informed of the abuse allegation on 1/19/26. The Administrator stated she did not suspend Staff A or report abuse to the state agency stating she did not feel it was verbal abuse because Staff A was outside of Resident #1's room. The Administrator stated on 1/21/26 she became aware the Social Worker Aide (SWA) was a witness and Staff A gave a false witness statement. The Administrator confirmed she did not suspend Staff A for abuse or report the allegations to the state agencies. The Administrator confirmed she should have suspended Staff A and reported abuse to the state agencies. Review of the facility's investigation revealed witness statements and interviews dated 1/19/26 indicating knowledge of the alleged verbal abuse. Review of the facility's reports revealed a report was filed with the state agencies on 2/10/26. (Photographic evidence obtained).A review of Facility's Abuse policy (dated 11/16/2022) page #6 of 9 reveals: All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the vents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator. (Photographic evidence obtained).

Based on interviews and record review, the facility failed to protect residents from abuse for 1 of 7 residents sampled for abuse. (Resident #1)The findings include: On 2/10/26 at approximately 12:00 PM, an interview was conducted with Resident #1, who stated that, on 1/19/26, Staff A, Registered Nurse (RN) entered his room speaking loudly, stating that he is a liar and he is going to get her mom written up. Resident #1 went on to state that the Social Worker Aide (SWA) was present and instructed Staff A to leave the room. Resident #1 went on to state he did not receive a bath on 1/19/26 and 2/3/26 and felt he was being retaliated on from Staff A. Resident #1 stated on another occasion after 1/19/26, Resident #5 was in his (Resident #1) room visiting when Staff A entered his room yelling. Staff A stated she heard him talking about her and to keep her name out of his mouth. Resident #1 stated he wrote a grievance on the missing baths and reported the verbal abuse from Staff A to the Administrator and the Director of Nursing (DON).On 2/10/26 at approximately 1:00 PM, an interview was conducted with Resident #5, who confirmed she was in Resident #1's room and Staff A came in Resident #1's room yelling at Resident #1 to keep her name out of his mouth.On 2/10/26 at approximately 1:35 PM, an interview was conducted with Staff C, Unit Manager (UM), who stated Resident #1 reported the alleged verbal abuse from Staff A that occurred on 1/19/26. Staff C, UM stated she reported the incident to the DON.On 2/10/26 at approximately 2:50 PM, an interview was conducted with the SWA who stated, on 1/19/26, she was present in Resident #1's room when Staff A entered the room. The SWA stated Staff A began loudly speaking to Resident #1, saying that he is lying all the time and she is going to tell her mom to get off his slot. The SWA stated she instructed Staff A to leave the room. The SWA stated she felt the incident by Staff A was verbal abuse and reported the incident to the Social Service Director.On 2/10/26 at approximately 3:10 PM, an interview was conducted with the Social Service Director (SSD), who stated on 1/19/26 she reported the verbal abuse to the Administrator.On 2/10/26 at approximately 3:35 PM, an interview was conducted with the DON, who stated he reported the allegation Resident #1 made against Staff A to the Administrator. During the interview, the DON acknowledged that verbal abuse was a form of abuse. On 2/11/26 at approximately 8:20 AM, an interview was conducted with Staff A, who stated on 1/19/26 she was upset because Resident #1 was speaking with the SWA. Staff A went on to state she received a phone call from Staff B, another RN, stating Resident #1 was threatening to call 911. Staff A stated she was angry that Resident #1 was calling 911 and entered Resident #1's room to confront him. Staff A went on to state Resident #1 is a liar. On 2/11/26 at approximately 8:55 AM, an interview was conducted with the Staffing Coordinator, who stated on 1/19/26 she heard the Social Service Director report the verbal abuse to the Administrator.On 2/11/26 at approximately 10:00 AM, an interview was conducted with the Administrator, who stated that, on 1/19/26, it was reported that Staff A allegedly made statements outside of Resident #1's room. The Administrator went on to state on 1/21/26 she became aware of a witness statement made by the SWA who was present in Resident #1's room when Staff A was yelling at Resident #1. During the interview the Administrator acknowledged that verbal abuse was a form of abuse.Review of the facility's grievance log revealed Resident #1 did not receive a shower/bath on 1/19/26 and 2/2/26.A review of Facility's Abuse policy (dated 11/16/2022) page #6 of 9 reveals: All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the vents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator. (Photographic evidence obtained).

Based on interviews and record review, the facility failed to immediately identify and report an allegation of verbal abuse for 1 of 7 residents sampled for abuse. (Resident #1).The findings include:On 2/10/26 at approximately 12:00 PM, an interview was conducted with Resident #1, who stated that, on 1/19/26, the Social Worker Aide (SWA) was present while Staff A, Registered Nurse (RN), entered his room yelling at him. Resident #1 stated he reported the verbal abuse from Staff A and the feeling of retaliation to the Administrator and the Director of Nursing (DON).On 2/10/26 at approximately 3:35 PM, an interview was conducted with the DON, who stated he spoke to the Administrator about the allegation of verbal abuse on 1/19/26 and was under the impression that the Administrator reported to the state agencies on 1/19/26.On 2/10/26 at approximately 4:00 PM, an interview was conducted with the Administrator, who stated she had been informed of the allegation on 1/19/26. The Administrator went on to say she did not report the abuse to the state agency, stating she did not feel it was abuse.On 2/11/26 at approximately 10:00 AM, an additional interview was conducted with the Administrator who is the facility's Abuse Coordinator, stating the abuse allegations should have been reported to the appropriate state agencies on 1/19/26.A review of Facility's records revealed the facility reported to the state agency on 2/10/26. (Photographic evidence obtained).A review of Facility's Abuse policy (dated 11/16/2022) page #6 of 9 reveals: All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the vents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator. (Photographic evidence obtained).

Based on interviews, records reviews, a review of the facility QAPI (quality assurance and performance improvement) plan, facility assessment, and event investigation documents, the facility failed to maintain an effective QAPI program to ensure the supervision of residents at risk for elopement, self-harm, and aggressive behaviors (Residents #1, #2, and #4). Cross reference F600, F689.These failures resulted in substandard quality of care at the Immediate Jeopardy level beginning on 8/8/2025.The facility's QAPI committee failed to perform and/or document analysis of events following the elopement while under one-to-one supervision for Resident #2. The facility failed to investigate and/or develop an improvement plan to meet the needs for Resident #4 who had multiple discharges and readmissions to the facility, including after the Administrator issued a transfer discharge notice on July 4, 2025, which identified that Resident #4's needs could not be met at the facility.This situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 9/11/2025 at 2:30 PM. The Immediate Jeopardy was determined to have begun on 8/08/2025. At the time of the survey exit on 9/11/2025, the Immediate Jeopardy was ongoing.The findings include:Resident #4A record review for Resident #4 included the following diagnoses: schizoaffective disorder, anxiety, trauma, brittle diabetic, anemia, other impulse disorders, restlessness and agitation, major depressive disorder, single episode, personal history of traumatic brain injury, mixed hyperlipidemia, epilepsy, intractable with status epilepticus, abnormal involuntary movements.A care plan was initiated on 1/11/2022 and most recently revised on 8/6/2025 for behaviors related to agitation, physically aggressive and combative with staff/residents and refusal of care, described that Resident #4 gets on the floor on his hands/knees disrobing and wandering in and out of others room, suffers from impulse disorder (sexual) and banging head/face episodes against wall. Resident #4 refuses to wear his helmet daily. The care plan included documentation under the heading Interventions that, on 8/31/2024, Resident #4 was 1:1 supervision and became hostile and overpowered the aide and entered into a fellow resident's room and struck the resident after he exited out the opposite door when using the restroom. Both parties were separated and addressed.Another care plan was initiated on 1/11/2022 for elopement risk wanderer related to disorientation to place, impaired safety awareness, resident wanders aimlessly, significantly intrudes on the privacy or activities. Interventions included: 1:1 supervision 24/7 for safety due to aggressive behaviors with others. DO NOT sit inside resident's room - sit in the doorway facing him so that he remains in your visual field - If he goes into the restroom, you are to stand by the door with it cracked, to ensure that he does not go through the door on the other side. This care plan was initiated on 3/12/2023 with a most recent revision on 9/8/2025.Other interventions include distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (blank) date initiated 1/11/2022.Progress notes describe events of exiting the facility, self-harm, and/or physical aggression towards others. These included an event on 8/15/2025 when Resident #4 attempted to exit the building and punched a staff member in the chest. The record documented that the staff member restrained resident to ensure safety and resident then head-butted him. A psychiatric progress note dated 8/18/2025 documented The patient is seen today at the request of the staff after a report of the patient hitting a staff member. Staff reports that the patient was informed not to exit building, and he responded aggressively and hit staff. The patient was temporarily restrained by holding his hands/arms in order to prevent him from further hitting the staff and once he was calm, his 1:1 CNA was changed out.Another event occurred on 9/4/2025 when Resident #4 began attempting to exit through the doors and became agitated. Resident #4 exited the building and 3 staff members followed. The resident attempted to leave the premises and fell into the bushes hitting his head and was noted with abrasions to his left forehead and left knee. Law enforcement was called to respond and Resident #4 continued to be combative and agitated. A psychiatric progress note dated 9/6/2025 documented Resident #4 remains psychiatrically unstable in the context of worsening psychotic symptoms and concurrent medical decompensation. Resident #4 was transferred to the emergency room for medical clearance and stabilization of hyperglycemia; resume psychiatric management following clearance.On 9/8/2025 at approximately 3:15pm, Resident #4 was observed with a red, raised area to his forehead. The medical record documented on 9/8/2025 that a CNA reported Resident #4 hit and head butted his head on the floor, on his bed siderail, and then got up to go to the bathroom and hit his head on the door.On 9/9/2025, Resident #4 punched a nurse in the face and was removed from the facility by law enforcement. A certificate of Professional Initiating Involuntary Examination dated 9/9/2025 at 11:30am listed that [Resident #4] has become psychotic, and violent, impulsive and has been physically aggressive towards staff. He has also assaulted the nurses. He is danger to others in his current state and needs a higher level of care to ensure his safety and the safety of others. Pt has failed all interventions by staff to help alleviate his current symptoms, due to these impulsive, unpredictable and violent behaviors, he needs a higher level of care to ensure the safety of others.In an interview on 9/10/2025 at 5:12pm, the psychiatric nurse practitioner assigned as the psychiatric services provider seeing Resident #4 said she has been seeing Resident #4 for about one month and agreed that the facility is not a safe setting for Resident #4, emphasizing not at all. She added, I reached out today to ask why he isn't in a mental health facility and it's so clear that he can't manage his voices and they said that is a good idea. It takes specialized people to help to take care of them. I was talking to another resident and he said, 'that guy was standing over me in my bed the other day - is he violent?' And the nurse came and they are all scared of him, I know that's true.On 9/11/2025 at approximately 9:50am, an interview took place with the facility administrator, the RVPO, and the RDCS regarding the facility's ability to meet the needs for safety for Resident #4 and why the facility continues to readmit Resident #4 after multiple discharges related to aggression and exiting the facility in which an involuntary psychological examination was ordered. The RVPO said that they have discussed it and reached out to the Long-Term Care Ombudsman and other facilities, who refuse to accept Resident #4, and they take him back because we'll be in trouble with the state if we don't. The Administrator was asked about the discharge notice signed on July 4, 2025, which she signed and documented that Resident #4's needs could not be met at the facility and what had changed in Resident #4's condition or the services offered by the facility that indicated his needs could be met at the facility. The response was that he's our resident and we have to take him back. During the interview, copies of documentation of communication with the Ombudsman and requests to other facilities to accept Resident #4 were requested but not provided.Resident #1 and #2A police report related to the elopement of Residents #1 and #2, which occurred on 8/30/2025, included documentation that a call was received from the facility at 7:13PM to report a missing person - adult endangered. The description given stated a window was broken during the escape attempt. The officer responded to a missing person and stolen vehicle at the facility. During the course of investigation, it was discovered that room [ROOM NUMBER] had a broken window and was used by Resident #1 and Resident #2 to escape the nursing home. At approximately 8:04 pm, dispatch received a call reporting the potential whereabouts of Resident #2 at a store approximately 1.8 miles from the facility. At approximately 11:59 pm, dispatch received a call with the whereabouts of Resident #1, who was observed walking on the interstate. The stolen vehicle was located a mile back on the side of the road. The location where Resident #1 was located was approximately 40 miles from the facility. Resident #1 had an active warrant and was arrested and transported to jail.The facility is surrounded by wooded areas on the back and left and right sides, with access to highways in front and on the sides of the building. There is easy access to a creek area with a portion of the creek unfenced near the facility. Both Resident #1 and #2 faced hazards along the paths of the elopement which included the potential of being hit by a vehicle, being involved in a motor vehicle accident, being abducted, falling, and/or drowning which could have resulted in serious physical injury or death. Resident #1, who stole a facility employee's vehicle which was left unsecured with the window open and keys in the vehicle from the parking lot and drove it approximately 40 miles on a busy Interstate and then abandoned the vehicle and was found walking along the interstate near midnight in the dark experienced an increased level of risk based on the distance, method, and location traveled. A timeline of events of the elopement of Residents #1 and #2 on 8/30/2025 based on witness statements collected by the facility describe the following:Staff Member F, a certified nursing assistant, was assigned to 1:1 supervision of Resident #2 on 8/30/2025. According to the Administrator, who is also the Risk Manager, based on the facility investigation, Residents #1 and #2 were last seen on 8/30/2025 between 6:30 - 6:50 pm during change of shift. An announcement was made on the overhead page system for elopement at 7:05PM (which was 7 minutes prior to the time Staff Member F reported to ask for help in finding the residents). At approximately 7:00 PM, per witness statement, Resident #1 went to the bathroom and Staff Member F exited the doors of the locked unit where Residents #1 and #2 resided to get someone to sit with Resident #2 while she used the restroom. At 7:10pm, Staff Member F knocked on the door to check on him and there was no answer. Staff Member F entered the room next door and noticed the window was busted out and at approximately 7:12 PM ran to the nurses' station to get help finding the two residents. Staff Member P made a witness statement that the elopement announcement occurred at 7:15pm. The Administrator reported that Resident #2 was spotted in town at 7:44PM.On 9/11/2025, an interview was conducted with Staff Member H, who found Resident #2 after he eloped from the facility on 8/30/2025. Staff Member H said she was in a vehicle and observed Resident #2 walking across the highway to the store and stopped next to Resident #2 speaking with him. She stated Resident #2 had a mouth full of snuff and asked if she would take him to Lake City. Staff Member H described that three other staff members pulled into the parking lot along with law enforcement and she observed Resident #2 state to law enforcement that he and Resident #1 left the facility through the window, Resident #1 got into a truck in the parking lot, but he did not because he does not steal. She reported Resident #2 said, I am no thief. Staff Member H described the facility's procedure for elopement as Once a page is announced of an elopement, we report to the nurses station of where the elopement occurred and receive a blue card telling us where we are assigned to search for missing resident, once that area is searched, we return it to the nurses' station. If the resident is not located after 10 minutes, law enforcement is to be notified.During an interview with the administrator on 9/9/2025 at 11:40am, the Administrator identified herself as the Risk Manager.The QAPI minutes reviewed and dated 8/19/2025 included a review of reports that listed reports concerning neglect/abuse and misappropriation which were submitted in July 2025. Despite the inclusion of five reports of neglect, three of which were documented as substantiated, 2 reports of abuse documented as substantiated, and one report of misappropriation documented as substantiated, there is no indication in any of the documentation provided that the facility recognized abuse/neglect/misappropriation as a concern which required a response, action plan, or further investigation through the QAPI program.In an interview with the administrator on 9/10/2025 at 6:16pm, she said they had not considered QAPI review of Resident #4's behavioral needs because the behaviors just started escalating over the past month.In an interview on 9/11/2025 at 9:50am with the Regional [NAME] President of Operations (RVPO), the Regional Director of Clinical Services (RDCS), the Administrator, and the Regional Social Services Director, the Administrator was asked about a transfer discharge notice from his record dated July 4, 2025 which documented that the facility cannot meet his needs. A discussion ensued with the facility leaders present as to why the facility continued to admit Resident #4 with the documented history of aggressive behaviors and the Administrator said she has only been here for 8 months. The RVPO said they have discussed it and reached out to the Ombudsman and other facilities who refuse to take Resident #4 and they take him back because they will be in trouble with the state if they don't. A request was made to provide any documentation they have of refusals to admit and who they have reached out to for assistance in determining their options for accepting or refusing a re-admission for Resident #4. At the time of exit from the survey on 9/11/2025 at approximately 3:00pm, the facility had not provided the documentation.The question was posed to the group to explain what had changed in the resident's condition or with the services offered by the facility between the times when Resident #4 was discharged and the facility documented an inability to meet the needs for Resident #4 and when they readmitted him and they said again that he's our resident and we have to take him back.A review of an ad hoc QAPI meeting dated 5/16/2025 documented the reason was for an elopement event. Under the heading Opportunity for Improvement the facility documented to ensure that residents who exhibited exit seeking behaviors and/or are at risk of elopement receive adequate supervision and behavioral observance by staff in order to prevent elopements and that care is received in accordance with the person-centered plan of care created to address the unique factors that contribute to wandering or elopement risks. The columns on the form labeled data and analysis were blank. There was no evidence provided that data to determine the root cause of the elopement was gathered or analyzed. The facility assessment dated [DATE] was reviewed and documented that staff training/education and competencies included abuse, neglect, and exploitation, care management for persons with dementia and resident abuse prevention. Trauma informed care, mental health/substance use disorders, behavior, dementia, activities of daily living, caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, substance use disorder and implementing nonpharmacological interventions.A review of the facility's 2025 QAPI plan included a plan for systematic analysis as follows: the facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its cause, and implications of a change. The QAPI team will review data, prioritize opportunities for improvement based on risk, frequency, relevance, cost and feasibility and determine which opportunities will require a performance improvement project. The PIP [performance improvement projects] Team will analyze the problem area by conducting a root cause analysis, identify solutions and develop a performance improvement plan to be implemented. The Plan Do Study Act quality improvement cycle and Root Cause Analysis will be used to address problems and drive performance improvement. Examples of root cause analysis tools include the 5 Whys and the fishbone diagram. QAPI Committees and PIP Teams will review targeted outcomes and will also monitor for potential unintended outcomes created from systematic or process changes. A review of an ad hoc QAPI meeting dated 8/31/2025 consisted of a one-page document identified under the heading of Opportunity for Improvement the facility documented 1:1 supervision procedure and elopement. Under the heading data (assess current situation - what were the results/trend), the facility documented 1:1 supervision requirements not being followed adequately to ensure resident safety and prevent elopement. Under the heading analysis (root cause analysis) the facility documented staff not ensuring resident was correctly supervised while on 1:1 observation allowing an elopement. There was no evidence of an analysis of the data to include the examples listed in the facility QAPI plan such as the 5 Whys and the fishbone diagram.

Based on observations, record reviews, interviews, and policy reviews, the facility failed to prevent abuse and neglect resulting in an elopement for two residents (Residents #1 and #2) while in a secured and locked unit and while Resident #2 was under one-to-one supervision creating a potential for serious injury or death for both residents. The facility failed to prevent neglect for Resident #3, who was immobile and left in her room with the body of her deceased roommate for three hours resulting in serious psychosocial harm. The facility failed to prevent abuse by Resident #4, who suffered injuries from self-harm and was removed from the facility because of physical aggression toward a staff member while under one-to-one supervision. The cumulative effect of the failures resulted in potential for abuse and/or neglect for 85 out of 85 residents. Cross reference to F689 (Residents #1, #2, and #4), F550 (Resident #3), and F656 (Residents #1, # 2, and #4).This situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 9/11/2025 at 2:30 PM. The Immediate Jeopardy was determined to have begun on 8/08/2025. At the time of the survey exit on 9/11/2025, the Immediate Jeopardy was ongoing. Resident #1 and #2 A record review for Resident #1 included diagnoses of chronic kidney disease stage 3, hyperlipidemia, generalized anxiety, hypertension, Atrial fibrillation, chronic systolic heart failure, and Traumatic Brain Injury. A minimum data set (MDS) assessment, dated 8/12/2025, included a brief interview for mental status score (BIMS) of 7. A score of 0-7 indicates severe problems with thinking or memory according to Cleveland Clinic, accessed at my.clevelandclinic.org on 09/17/2025. A comprehensive care plan initiated for Resident #1 on 8/5/2025 included a care plan for elopement risk/wanderer related to impaired safety awareness/wanders aimlessly with a goal for safety to be maintained. Interventions included assess for elopement risk, distract from wandering by offering pleasant diversions, electronic monitoring device, and place on secured unit under increased supervision. A psychiatric admission note dated 8/6/2025 documented “patient presents guarded and non-cooperative initially during interview, patient states, I don't ever sleep, and I just want to get out of here.” A record review for Resident #2 documented admission to the facility occurred on 6/17/2025 with diagnoses of unspecified dementia, type 2 diabetes, difficulty in walking, cognitive deficits, and mood disorder. On 6/17/25, an elopement risk screen was completed which indicated a score of 3.0, indicating at risk for elopement. Review of the care plan for Resident #2 revealed there was a care plan initiated on 6/18/2025 documenting “resident is an elopement risk/wanderer related to disoriented to place, impaired safety awareness, and resident wanders aimlessly. Interventions include assess for elopement risk, distract resident from wandering by offering pleasant diversions and structured activities, electronic monitoring device per MD (doctor) orders, and place on the unit for increased supervision. On 6/20/2025, Resident #2's care plan was updated to “resident being placed on 1:1 supervision due to cutting off his wander guard bracelet and exit seeking.” A progress note dated 6/20/2025 at 11:40 pm stated “at approximately 2225 pm (10:25PM) CNA (certified nursing assistant) assigned as 1:1 stated Resident #2 was missing, the nurse checked patient's room and confirmed Resident #2 was not present, observed patient window inside of room was opened, and no visual of resident outside of room, DON (Director of Nursing) was notified and elopement protocol was initiated. A progress note dated 7/13/2025 stated, “ .alarm to the back door going off, when checking it out, they said that [Resident #2] was messing with the alarm on the door, they saw him doing it and told him several times to leave the door alone, after the alarm would not shut off, this nurse trouble shooting the problem and noticed that [Resident #2] had pulled the wires and tripping the connections to the alarm. A temporary fix on the door alarm, risk manager and maintenance is aware. [Resident #2] continues on 1:1 supervision.” A 7/26/25 behavior progress note stated that. while the nurse was in the lock down unit, Resident #2 was witnessed using a butter knife to attempt to take the brackets off the window or pry the window open, the aide that witnessed this got him to give her the knife. A police report related to the elopement of Residents #1 and #2, which occurred on 8/30/2025, included documentation that a call was received from the facility at 7:13PM to report a missing person – adult endangered. The description given stated a window was broken during the escape attempt. The officer responded to a missing person and stolen vehicle at the facility. During the course of investigation, it was discovered that room [ROOM NUMBER] had a broken window and was used by Resident #1 and Resident #2 to escape the nursing home. At approximately 8:04 pm, dispatch received a call reporting the potential whereabouts of Resident #2 at a store approximately 1.8 miles from the facility. At approximately 11:59 pm, dispatch received a call with the whereabouts of Resident #1, who was observed walking on Interstate 10 near the 255 east bound mile marker. The stolen vehicle was located at mile marker 254 on the side of the road. The location where Resident #1 was located was approximately 40 miles from the facility. Resident #1 had an active warrant and was arrested and transported to jail. In an interview with the Facility Administrator on 9/8/2025 at 1:18pm, the Administrator confirmed the facility does not have a policy for resident supervision or one-to-one (1:1) supervision. A follow up interview with the Regional [NAME] President of Operations (RVPO) and the Regional Director of Clinical Services (RDCS) on 9/8/2025 at 4:08 pm confirmed there is not a policy for supervision, and this includes no policy for staff expectations for staff observing residents on 1:1 supervision, but there was training after the previous elopements happened. The RDCS was not able to answer what type of training or expectations occurred prior to the elopements. Staff training information that was given to the staff reveals: one to one supervision is assigned to a resident based on behaviors that require monitoring. This could be risk of elopement, suicidal ideation, attempts to harm self or others. The staff should always place themselves in a location where they have a clear view to maintain observation of the resident and to be close enough to the resident to intervene should a behavior occur. Resident #3 On 9/8/25, an interview was conducted with Resident #3 that indicated that she has been very upset lately because of her roommate's death on 8/27/25. She stated, “It was a horrible and upsetting event for me. We became close friends since I got here a year ago. She didn't have any family, so we looked out for one another”. Resident #3 stated “I stayed with her until she took her last breath. I specifically told them that I would, but once she passed, I want to be moved out of the room. I did not want to stay in the room with a dead body”. With tears in her eyes, she stated “I was told that I had to stay in my room with the door closed so the room could stay cool until the funeral home came “. At this time the resident began crying and was visibly shaking and trembling in her upper body and hands. Her face was red in color and constantly wiping tears from her face as she describes listening to Staff Member D come into the room to bathe and dress her roommate. Afterwards, Staff D left the room and shut the door. Resident #3 stated she was left inside the room with her roommate's dead body in the bed beside her for almost three hours. Resident #3 stated that she asked to be moved into a room across the hall that was empty until the funeral home came. She stated she was told that they did not have time to move her. Resident #3 begins crying again with a trembling voice and visibly shaking when she stated, No one came in to check to see if I was okay, and when someone finally came into my room, it was some man with a gurney. I lost it then, I had to stay in here by myself with all of that going on. I had to listen to everything that man from the funeral home was doing, taking the bag out, lifting the body up, and putting her in the bag. Listening as he zipped up the bag was horrible. All I could do was cry and listen. I had to watch him push her body out of the room, he came right in front of me with her on the gurney. No one from the facility ever came in to help or check on me. That is an image I didn't want to see and now I can't get it out of my mind. I haven't been able to sleep or eat since then. And now I am having to get therapy because of it. It has just added more stress to me and to my anxiety. A record review for Resident #3 included a diagnosis of generalized anxiety disorder, muscle wasting and atrophy, chronic pain and depression. A minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status score (BIMS) of 15. A score of 13-15 indicates intact cognition according to Cleveland Clinic accessed at my.clevelandclinic.org on 09/17/2025. A comprehensive care plan was initiated on 10/16/2024 for Resident #3 indicating that she is dependent on staff to meet emotional, physical, intellectual, and social needs related to her diagnosis of generalized anxiety and has a mood problem related to anxiety and depression. Interventions include administering medications as ordered and monitoring for side effects, assisting resident to identify strengths and positive coping skills. A psychiatry progress note dated 8/20/25 revealed Resident #3 discussed recent stressors such as coping with her roommate's terminal diagnosis. On further review, a progress note dated 8/27/25 at 2:20 pm stated that Resident #3 was seen by a therapist indicating she has “increased anxiety related to the death of her roommate early this AM”. On 9/5/25, a progress note from the therapy services was reviewed indicating the need of ongoing psychotherapy for anxiety and grief related to the death of her roommate. Resident #3 discussed ongoing symptoms of not sleeping, particularly around the time of death, and increased anxiety. Psychotherapy services will continue and will address trauma symptoms related to the passing of the roommate. An Interview with the Medical Director for Resident #3 was conducted on 9/9/25 at 3:35 pm. The Medical Director revealed that she is seen by her physician on a weekly basis most of the time. The Medical Director does not recall if Resident # 3 expressed any emotions related to her roommate's death, but does state, I know she was very close to her roommate, and I do believe there would be some definite emotional stress. I know I wouldn't want to be in a room with a dead body, I would have a problem with it myself”. An interview with Staff Member R (Nurse Unit Manager) on 9/9/25 at 4:30 pm was conducted. She stated that staff receives ongoing training on abuse and types of abuse. Staff member R was able to explain the definition of abuse and different examples. Staff member R further stated, “the protocol for death of any resident with a roommate would be to move the other resident out of the room before providing postmortem care”. She agreed that “it is undignified to have another resident present I room for postmortem care and the facility should take every possible measure to honor the roommates request to be removed from the room”. A follow up interview was conducted with Resident #3. She stated the Administrator came to see her on 9/9/25 around 6:20 pm in regard to the event that took place on 8/27/25. She further states the Administrator apologized to her for what she went through on 8/27/25 with her roommate's passing and the events that took place afterwards. Resident #3 stated that she let the Administrator know she was still having difficulty sleeping because every time she closed her eyes all she could see is her roommate being zipped up in the body bag and leaving her room on the gurney. Resident #3 states she asked the housekeeper earlier today to make up the roommate's bed because it was too upsetting to see the empty blue mattress where her roommate once resided. Resident #3 continues to receive counseling services due to issues coping with her roommate's death. The facility policy for Abuse, Neglect and Exploitation (N-1265 effective date 11/30/2014 revised date 11/16/2022) states, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. One of the examples states that involuntary seclusion is defined as separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will or the will of the resident representative. Resident #4 On 9/8/2025 at 3:15 pm at the end of a hallway with patient rooms, a staff member and a younger resident were observed standing. The resident, later identified as Resident #4, had a raised red mark in the center of his forehead. A record review for Resident #4 included a progress note dated 9/8/2025 and described that Resident #4 “hit and head butted his head on the floor, he later hit his head on his bed siderail and then got up to go to the bathroom and hit his head on the door. A later note at 5:14 pm documented the medical director was notified and advised “if resident is not complaining then just continue to monitor. Resident has not had any change in condition.” During an interview on 9/9/2025 at 11:35am, Certified Nursing Assistant (CNA) B said Resident #4 used to wear a safety helmet, but it had been awhile since she's seen it; no training was provided in regard to the helmet. She said she was aware he tried to leave and was here Saturday when he left but wasn't assigned to him. On 9/9/2025 at approximately 3:00pm, several law enforcement vehicles and personnel were observed in front of the facility entrance. At 3:19 pm, an interview took place with Registered Nurse (RN) I, who explained Resident #4 punched her in the face and then assaulted a law enforcement officer when they were taking him out of the building. During an interview with the interim director of nursing (DON) on 9/10/2025 at 12:24 pm, she explained that Resident #4 had been on 1:1 supervision since she came to the facility in January 2025 and said she is involved in his care planning. She described that “after the behaviors started getting more aggressive, we moved staff from sitting in the room to sitting outside the room. We have been trying to get things in place to get him more comfortable. The change to having staff sit outside the room was sometime in June.” In an interview with the Social Services Assistant (Staff Member L) on 9/10/2025 at 9:55am, she explained that she has performed 1:1 supervision duties for Resident #4 and received training for this which included “talk in soft tones and try to deescalate and talk in a calm voice and keep hands down; if that doesn't work, keep doing the same thing and get out of his way.” She further explained that she was not provided with a form of communication such as a phone or walkie talkie to ask for help and that she would use her personal phone or shout for help if she needed it. She said that, when performing duties with Resident #4, sometimes she felt safe and sometimes she didn't. In an interview on 9/10/2025 at 5:12pm, the Psychiatric Nurse Practitioner assigned as the psychiatric services provider seeing Resident #4 said she has been seeing Resident #4 for about one month and agreed that the facility is not a safe setting for Resident #4, emphasizing “not at all.” She added, “I reached out today to ask why he isn't in a mental health facility and it's so clear that he can't manage his voices and they said that is a good idea. It takes specialized people to help to take care of them. I was talking to another resident and he said, 'that guy was standing over me in my bed the other day – is he violent?' And the nurse came and they are all scared of him, I know that's true.” During an interview on 9/11/2025 at 10:46am, the interim director of nursing (DON) provided the task documentation for the one-to-one activities for Resident #4 for August 2025 and there were only 5 days when diversional activities were documented. The DON said that there is a problem with ability to document and agreed that there is no other place in the record where the care plan interventions for diversional activities would be documented. During the entrance conference on 9/8/2025 at 1:18pm, the Facility Administrator said there was no facility policy for resident supervision or 1:1 supervision. On 9/8/2025 at 4:08pm, the regional director of clinical services (RDCS) confirmed in an interview that the facility does not have a policy for supervision and this includes no policy for staff expectations for staff observing residents on 1:1 supervision. A record review for Resident #4 included the following diagnoses: schizoaffective disorder, anxiety, trauma, “brittle” diabetic, anemia, other impulse disorders, restlessness and agitation, major depressive disorder, single episode, personal history of traumatic brain injury, mixed hyperlipidemia, epilepsy, intractable with status epilepticus, abnormal involuntary movements. A care plan was initiated on 1/11/2022 and most recently revised on 8/6/2025 for behaviors related to agitation, physically aggressive and combative with staff/residents and refusal of care, described that Resident #4 gets on the floor on his hands/knees disrobing and wandering in and out of others room, suffers from impulse disorder (sexual) and banging head/face episodes against wall. Resident #4 refuses to wear his helmet daily. The care plan included documentation under the heading “Interventions” that, on 8/31/2024, Resident #4 was 1:1 supervision and became hostile and overpowered the aide and entered into a fellow resident's room and struck the resident after he exited out the opposite door when using the restroom. Both parties were separated and addressed. Another care plan was initiated on 1/11/2022 for elopement risk wanderer related to disorientation to place, impaired safety awareness, resident wanders aimlessly, significantly intrudes on the privacy or activities. Interventions included: 1:1 supervision 24/7 for safety due to aggressive behaviors with others. DO NOT sit inside resident's room – sit in the doorway facing him so that he remains in your visual field – If he goes into the restroom, you are to stand by the door with it cracked, to ensure that he does not go through the door on the other side. This care plan was initiated on 3/12/2023 with a most recent revision on 9/8/2025. Other interventions include distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (blank) date initiated 1/11/2022. A psychiatric progress note dated 8/17/2025 documented that “staff note that he becomes easily bored and that his attention fluctuates during interactions. His presentation remains consistent with chronic psychosis, with ongoing negative symptoms such as blunted affect and reduced motivation. Behavioral interventions have recently been introduced, focusing on structured reward-based strategies to encourage engagement and reduce maladaptive behaviors. Initial staff feedback suggests that he responds intermittently to these supports.” Another psychiatric noted dated 8/29/2025 noted “Staff report that the patient's attention fluctuates during interactions and that he becomes easily bored.” A task list for one-to-one activities reviewed for past 30 days listed documentation for only the following days: 8/12/2025, 8/13/2025, 8/15/2025, and 8/20/2025. Resident #4 was observed to be on 1:1 observation with staff on 9/8/2025 (date of survey entry) and the date of this review was 9/9/2025 – no documentation identified for 9/9/2025. The activities/participation (Question 2) documenting for each of the 4 dates that talking was the only activity used out of several listed which included arts and crafts, board games, exercise, games, gardening, meditation/relaxation, music, and others. A progress note dated 8/15/2025 noted “Resident attacked PCA (patient care assistant) assigned to 1:1 with him. Resident was informed not to exit building and punched staff in chest. Staff member restrained resident to ensure safety and resident then head-butted him. PCA removed from 1:1, new 1:1 placed with resident.” A psychiatric progress note date 8/18/2025 documented “The patient is seen today at the request of the staff after a report of the patient hitting a staff member. Staff reports that the patient was informed not to exit building, and he responded aggressively and hit staff. The patient was temporarily restrained by holding his hands/arms in order to prevent him from further hitting the staff and once he was calm, his 1:1 CNA was changed out.” A progress note dated 9/4/2025 at 5:40am documented “Resident was observed waking from sleep and immediately began pacing rapidly up and down the halls. Assigned CNA followed for supervision. Resident began attempting to exit through the doors and became agitated. Resident [#4] went out the facility along with 3 other staff members. The other nurse on shift attempted to support the resident to prevent him from falling. During the intervention, the resident forcefully moved his head forward and made contact with nurse. Resident then attempted to leave the premises and fell into the bushes hitting his head. Resident was noted with abrasions to his left forehead and left knee. Due to continued attempts to leave the facility and inability of staff to maintain control, law enforcement was contacted. Resident [#4] was redirected back into the facility prior to their arrival. Police arrived shortly thereafter. Resident[#4] continues to be combative and agitated.”

Based on record reviews, interviews, and policy reviews, the facility failed to provide adequate supervision for residents identified as high risk for elopement for 2 out of 14 vulnerable residents (Residents #1 and #2) and for one resident identified as physically aggressive towards self, staff, and residents (Resident #4). The facility failed to provide supervision to prevent an unwitnessed exit from the facility for Resident #1 and Resident #2 on 8/30/2025 while Resident #2 was assigned to one-to-one (1:1) supervision and both Residents #1 and #2 were located on a secured, locked unit of the facility. The facility failed to prevent Resident #4 from self-injury while on one-to-one supervision on 9/8/2025 and failed to prevent physical aggression by Resident #4 on 9/9/2025 resulting in Resident #4 punching a nurse in the face and being removed from the facility by law enforcement under an order for involuntary psychiatric examination. The cumulative effect of these events resulted in deficient practice the level of Immediate Jeopardy starting on 8/8/2025.This situation resulted in a finding of Immediate Jeopardy at a scope and severity of Pattern, (K). The facility's Administrator was notified of the Immediate Jeopardy on 9/11/2025 at 2:30 PM. The Immediate Jeopardy was determined to have begun on 8/08/2025. At the time of the survey exit on 9/11/2025, the Immediate Jeopardy was ongoing.Cross reference to F600.The findings include:Resident #1 and #2 A record review for Resident #1 included diagnoses of chronic kidney disease stage 3, hyperlipidemia, generalized anxiety, hypertension, Atrial fibrillation, chronic systolic heart failure, and Traumatic Brain Injury. A minimum data set (MDS) assessment, dated 8/12/2025, included a brief interview for mental status score (BIMS) of 7. A score of 0-7 indicates severe problems with thinking or memory according to Cleveland Clinic, accessed at my.clevelandclinic.org on 09/17/2025. A comprehensive care plan initiated for Resident #1 on 8/5/2025 included a care plan for elopement risk/wanderer related to impaired safety awareness/wanders aimlessly with a goal for safety to be maintained. Interventions included assess for elopement risk, distract from wandering by offering pleasant diversions, electronic monitoring device, and place on secured unit under increased supervision. A psychiatric admission note dated 8/6/2025 documented “patient presents guarded and non-cooperative initially during interview, patient states, I don't ever sleep, and I just want to get out of here.” A record review for Resident #2 documented admission to the facility occurred on 6/17/2025 with diagnoses of unspecified dementia, type 2 diabetes, difficulty in walking, cognitive deficits, and mood disorder. On 6/17/25, an elopement risk screen was completed which indicated a score of 3.0, indicating at risk for elopement. Review of the care plan for Resident #2 revealed there was a care plan initiated on 6/18/2025 documenting “resident is an elopement risk/wanderer related to disoriented to place, impaired safety awareness, and resident wanders aimlessly. Interventions include assess for elopement risk, distract resident from wandering by offering pleasant diversions and structured activities, electronic monitoring device per MD (doctor) orders, and place on the unit for increased supervision. On 6/20/2025, Resident #2's care plan was updated to “resident being placed on 1:1 supervision due to cutting off his wander guard bracelet and exit seeking.” A progress note dated 6/20/2025 at 11:40 pm stated “at approximately 2225 pm (10:25PM) CNA (certified nursing assistant) assigned as 1:1 stated Resident #2 was missing, the nurse checked patient's room and confirmed Resident #2 was not present, observed patient window inside of room was opened, and no visual of resident outside of room, DON (Director of Nursing) was notified and elopement protocol was initiated. A psychiatric progress note dated 6/21/2025 documented Resident #2 was able to engage in a rational process of relevant information, able to recognize the importance of medication and treatment compliance, able to recognize his medical condition and consequences of lack of treatment and had the capacity to make decisions related to his need for healthcare or long-term placement. He was documented as able to understand the nature, extent, and probable outcome of not receiving medical care and was alert and oriented to self, place, time, and situation. On 6/21/2025, an elopement risk evaluation was repeated and again indicated a score of 3.0, indicating at risk for elopement. On 6/23/2025, the care plan for Resident #2 was updated for behaviors due to “refusing care and medications, becoming agitated and will curse at staff. He slams the door and tells staff to stop following him, removes his wander guard, and is able to unscrew his window to leave facility. Interventions include administer medications as ordered, anticipate resident's needs, explain all procedures to resident before starting care, if reasonable discuss residents behaviors and why behavior is inappropriate.” On 6/29/2025, Resident #2 was transferred from the facility for an involuntary psychiatric evaluation due to mood disorder unspecified with documentation stating “patient has become violent towards staff, he is attempting to assault them and commit battery, he has a knife and is trying to break out the windows and exit facility. Due to his current state, he cannot be managed safely at this location and requires a higher level of care. Patient has failed all interventions by staff to help alleviate current symptoms. Due to these impulsive unpredictable and violent behaviors, the patient requires a higher level of care to ensure the safety of others at this time.” Resident #2 was discharged and re-admitted on [DATE] to facility. An MDS assessment for Resident #2 dated 6/23/2025 documented a BIMS score of 5 (severe problems with thinking or memory). During the 7-day assessment period associated with the MDS, wandering was documented to have occurred on 1-3 days and to place the resident at significant risk of getting to a potentially dangerous place. Diagnoses included: dementia, neurological disorders, diabetes, malnutrition, anxiety, bipolar disorder, encephalopathy, muscle weakness, difficulty walking, cognitive communication deficit, history of alcohol abuse. A progress note dated 7/13/2025 revealed: “alarm to the back door going off, when checking it out, they said that [Resident #2] was messing with the alarm on the door, they saw him doing it and told him several times to leave the door alone, after the alarm would not shut off, this nurse trouble shooting the problem and noticed that [Resident #2] had pulled the wires and tripping the connections to the alarm. A temporary fix on the door alarm, risk manager and maintenance is aware. [Resident #2] continues on 1:1 supervision.” Documentation demonstrated Resident #2 continued to refuse medications from the facility except for metformin. On 7/22/2025, Resident #2 refused medications, education was provided. Resident #2 stated he is going home and doesn't need anything from here. A progress note dated 7/23/2025 documented Resident #2 was not sleeping at night, stayed up all night, and was verbally aggressive to staff. Nurse able to re-direct resident. A 7/26/25 behavior progress note stated that while the nurse was in the lock down unit Resident #2 was witnessed using a butter knife to attempt to take the brackets off the window or pry the window open, the aide that witnessed this got him to give her the knife. Progress note dated 8/6/25 stated that Resident #2 declined to have a wander guard on his ankle. Resident #2 takes the wander guard off and continues on 1:1 care. A police report related to an elopement of Residents #1 and #2, which occurred on 8/30/2025, included documentation that a call was received from the facility at 7:13 PM to report a missing person – adult endangered. The description stated a window was broken during the escape attempt. The officer responded to a missing person and stolen vehicle at the facility. During the course of the investigation it was discovered that room [ROOM NUMBER] had a broken window, which was used by Resident #1 and Resident #2 to escape the nursing home. At approximately 8:04 pm, dispatch received a call reporting the potential whereabouts of Resident #2 at a local store approximately 1.8 miles from the facility. At approximately 11:59 pm, dispatch received a call with the whereabouts of Resident #1, who was observed walking on Interstate 10 near the 255 east bound mile marker. The stolen vehicle was located at mile marker 254 on the side of the road. The location where Resident #1 was located was approximately 40 miles from the facility. Resident #1 had an active warrant and was arrested and transported to jail. The facility is surrounded by wooded areas on the back and left and right sides, with access to highways in front and on the sides of the building. There is easy access to a creek area with a portion of the creek unfenced near the facility. Both Resident #1 and #2 faced hazards along the paths of the elopement which included the potential of being hit by a vehicle, being involved in a motor vehicle accident, being abducted, falling, and/or drowning which could have resulted in serious physical injury or death. Resident #1, who stole a facility employee's vehicle which was left unsecured with the window open and keys in the vehicle from the parking lot, drove it approximately 40 miles on a busy Interstate and then abandoned the vehicle and was found walking along the interstate near midnight in the dark experienced an increased level of risk based on the distance, method, and location traveled. A timeline of events of the elopement of Residents #1 and #2 on 8/30/2025 based on witness statements collected by the facility describe the following: Staff Member F, a certified nursing assistant, was assigned to 1:1 supervision of Resident #2 on 8/30/2025. According to the Administrator, who is also the Risk Manager, based on the facility investigation, Residents #1 and #2 were last seen on 8/30/2025 between 6:30 – 6:50 pm during change of shift. An announcement was made on the overhead page system for elopement at 7:05PM (which was 7 minutes prior to the time Staff Member F reported to ask for help in finding the residents). At approximately 7:00 PM, per witness statement, Resident #1 went to the bathroom and Staff Member F exited the doors of the locked unit where Residents #1 and #2 resided to get someone to sit with Resident #2 while she used the restroom. At 7:10pm, Staff Member F knocked on the door to check on him and there was no answer. Staff Member F entered the room next door and noticed the window was busted out and at approximately 7:12 PM ran to the nurses' station to get help finding the two residents. Staff Member P made a witness statement that the elopement announcement occurred at 7:15pm. The Administrator reported that Resident #2 was spotted in town at 7:44PM. On 9/11/2025, an interview was conducted with Staff Member H, who found Resident #2 after he eloped from the facility on 8/30/2025. Staff Member H said she was in a vehicle and observed Resident #2 walking across the highway to the store and stopped next to Resident #2 speaking with him. She stated Resident #2 had a mouth full of snuff and asked if she would take him to Lake City. Staff Member H described that three other staff members pulled into the parking lot along with law enforcement and she observed Resident #2 state to law enforcement that he and Resident #1 left the facility through the window, Resident #1 got into a truck in the parking lot, but he did not because he does not steal. She reported Resident #2 said, “I am no thief.” Staff Member H described the facility's procedure for elopement as “Once a page is announced of an elopement, we report to the nurses station of where the elopement occurred and receive a blue card telling us where we are assigned to search for missing resident, once that area is searched, we return it to the nurses' station. If the resident is not located after 10 minutes, law enforcement is to be notified.” In an interview with the Administrator on 9/8/2025 at 1:18 pm, the administrator confirmed the facility does not have a policy for resident supervision or one-to-one (1:1) supervision. A follow up interview with the Regional [NAME] President of Operations (RVPO) and the Regional Director of Clinical Services (RDCS) on 9/8/2025 at 4:08 pm confirmed there is not a policy for supervision, and this includes no policy for staff expectations for staff observing residents on 1:1 supervision but there was training after the elopements happened. The RDCS was not able to answer what type of training or expectations occurred prior to the elopements. The RVPO brought a set of toenail clippers to the interview and described them as the implement thought to have been used by Resident #2 to cut the wire located in his room which powered the gate alarm to the gate believed to have been used to exit the facility during the elopement on 8/30/2025. The RVPO and RDCS confirmed the wires powering the alarm were located in a resident room on a secured, locked unit and accessible to the resident. The facility policy Elopement (N-1031 effective date 9/21/2016 revised 8/1/2020) revealed, Patients to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change, and elopement event using the risk tool. Further review of best practice training only reveals that an organized search will be conducted immediately when a resident is determined missing (usually the resident does not go far from the facility unless it is an alert-oriented resident who has planned his leave). During the first 10 minutes of discovering that a resident is missing states time is important, announce all staff to a central location, search facility, search outside grounds, notify the executive director and director of clinical services, notify the police within 10 minutes of discovering the resident is missing. Staff training information that was given after the 8/30/25 incident reveals, One to one supervision is assigned to a resident based on behaviors that require monitoring. This could be risk of elopement, suicidal ideation, attempts to harm self or others. The staff should always place themselves in a location where they have a clear view to maintain observation of the resident and to be close enough to the resident to intervene should a behavior occur. Resident #4 A record review for Resident #4 included the following diagnoses: schizoaffective disorder, anxiety, trauma, “brittle” diabetic, anemia, other impulse disorders, restlessness and agitation, major depressive disorder, single episode, personal history of traumatic brain injury, mixed hyperlipidemia, epilepsy, intractable with status epilepticus, abnormal involuntary movements. A care plan was initiated on 1/11/2022 and most recently revised on 8/6/2025 for behaviors related to agitation, physically aggressive and combative with staff/residents and refusal of care, described that Resident #4 gets on the floor on his hands/knees disrobing and wandering in and out of others room, suffers from impulse disorder (sexual) and banging head/face episodes against wall. Resident #4 refuses to wear his helmet daily. The care plan included documentation under the heading “Interventions” that, on 8/31/2024, Resident #4 was 1:1 supervision and became hostile and overpowered the aide and entered into a fellow resident's room and struck the resident after he exited out the opposite door when using the restroom. Both parties were separated and addressed. Another care plan was initiated on 1/11/2022 for elopement risk wanderer related to disorientation to place, impaired safety awareness, resident wanders aimlessly, significantly intrudes on the privacy or activities. Interventions included: 1:1 supervision 24/7 for safety due to aggressive behaviors with others. DO NOT sit inside resident's room – sit in the doorway facing him so that he remains in your visual field – If he goes into the restroom, you are to stand by the door with it cracked, to ensure that he does not go through the door on the other side. This care plan was initiated on 3/12/2023 with a most recent revision on 9/8/2025. The most recent MDS assessment for Resident #4 was completed on 7/1/2025 and documented a BIMS score of 9, which indicated “moderate problems with thinking or memory” according to Cleveland Clinic accessed at https://my.clevelandclinic.org/health/diagnostics/bims-score on 9/17/2025. A progress note dated 9/4/2025 at 5:40am documented “Resident was observed waking from sleep and immediately began pacing rapidly up and down the halls. Assigned CNA followed for supervision. Resident began attempting to exit through the doors and became agitated. Resident [#4] went out the facility along with 3 other staff members. The other nurse on shift attempted to support the resident to prevent him from falling. During the intervention, the resident forcefully moved his head forward and made contact with nurse. Resident then attempted to leave the premises and fell into the bushes hitting his head. Resident was noted with abrasions to his left forehead and left knee. Due to continued attempts to leave the facility and inability of staff to maintain control, law enforcement was contacted. Resident [#4] was redirected back into the facility prior to their arrival. Police arrived shortly thereafter. Resident [#4] continues to be combative and agitated.” A psychiatric progress note date 8/18/2025 documented “The patient is seen today at the request of the staff after a report of the patient hitting a staff member. Staff reports that the patient was informed not to exit the building, and he responded aggressively and hit staff. The patient was temporarily restrained by holding his hands/arms in order to prevent him from further hitting the staff and once he was calm, his 1:1 CNA was changed out.” A psychiatric service note dated 8/17/2025 documented Resident #4 “has consistently demonstrated psychotic symptoms, including fixed delusions, auditory hallucinations, disorganized speech with derailment and incoherence, and grossly disorganized behavior.” A progress note dated 8/15/2025 noted “Resident attacked PCA (patient care assistant) assigned to 1:1 with him. Resident was informed not to exit building and punched staff in chest. Staff member restrained resident to ensure safety and resident then head-butted him. PCA removed from 1:1 new 1:1 placed with resident.” A transfer/discharge notice signed by the Administrator on 07/04/2025 documented that a discharge notice was provided to the resident/legal guardian for the reason “Your needs cannot be met in this facility” and “the safety of other individuals in this facility is endangered.” The document also included a brief explanation to support this action as “physical aggression toward staff, safety of staff and others compromised by his impulsive aggressive behaviors. Intervention unsuccessful in managing his behavior and impulsive aggressive behavior resulting in [involuntary psychological examination]. A PASRR (pre-admission screening and resident review) level 2 dated 7/11/2025 documented that any receiving nursing facility should assess the patient to confirm they are able to meet his needs and ensure the patient's safety, as well as the safety of others. On 9/8/2025 at 3:15 pm at the end of a hallway with patient rooms, a staff member and a younger resident were observed standing. The resident, later identified as Resident #4, had a raised red mark in the center of his forehead. A record review for Resident #4 included a progress note dated 9/8/2025 and described that Resident #4 “hit and head butted his head on the floor, he later hit his head on his bed siderail and then got up to go to the bathroom and hit his head on the door. A later note at 5:14pm documented the medical director was notified and advised “if resident is not complaining then just continue to monitor. Resident has not had any change in condition.” On 9/9/2025 at 11:30 am, Resident #4 was observed in the tv area sitting in a chair with CNA S near him. CNA S said she was trained to be within arm's reach for 1:1 observation and agreed Resident #4 exhibits aggressive behavior but said she had not received any training in how to deal with these behaviors. On 9/9/2025 at approximately 3:00 pm several law enforcement vehicles and personnel were observed in front of the facility entrance and, at 3:19 pm, an interview took place with Registered Nurse (RN) I, who explained Resident #4 punched her in the face and then assaulted a law enforcement officer when they were taking him out of the building. A certificate of Professional Initiating Involuntary Examination dated 9/9/2025 at 11:30am listed that “[Resident #4] has become psychotic, and violent, impulsive and has been physically aggressive towards staff. He has also assaulted the nurses. He is danger to others in his current state and needs a higher level of care to ensure his safety and the safety of others. Pt has failed all interventions by staff to help alleviate his current symptoms, due to these impulsive, unpredictable and violent behaviors, he needs a higher level of care to ensure the safety of others.” The form was signed by a doctor of nursing practice who is a psychiatric advanced practice registered nurse. On 9/9/2025 at 11:35am, Certified Nursing Assistant (CNA) B said in an interview that she doesn't feel safe working with Resident #4 and has observed aggressive behaviors and is aware Resident #4 tries to leave the building. She expressed that they were trained to back away and let him calm down, try to redirect him, and just stay close to him when he's running and alert the nurse. She said there isn't a specific way for staff to communicate or respond when the events happen. An interview with the Nurse Unit Manager (Staff Member R) on 9/9/2025 at 4:27 pm revealed that she said she has worked at the facility since May 13, 2025 and Resident #4 has been assigned 1:1 supervision for all the time she has worked at the facility. She described the 1:1 supervision duties for Resident #4 as “to make sure we kept ourselves and him safe, to be close enough to prevent bodily harm, to keep eyes on. We sit in the door[way] because it was very sporadic with his behaviors. He's been here the whole time I've been here and the behaviors are the same since he came. I was trained to keep him in the room as much as possible, to stay in the room, and to keep him at arms distance and to keep him from getting out. The only training we had was abuse and neglect training and told us to redirect him. I try to talk to him; I can't put my hands on him. I can't put my hands on him to restrain him. When he's on the floor I was told not to do anything to him because if I put my hands on him he thinks I'm part of his game.” She confirmed that if staff see him involved in acts of self-harm there is no action other than to watch him and report it. In an interview on 9/10/2025 at 5:12 pm, the psychiatric nurse practitioner assigned as the psychiatric services provider seeing Resident #4 said she has been seeing Resident #4 for about one month and agreed that the facility is not a safe setting for Resident #4, emphasizing “not at all.” She added, “I reached out today to ask why he isn't in a mental health facility and it's so clear that he can't manage his voices and they said that is a good idea. It takes specialized people to help to take care of them. I was talking to another resident and he said, ‘that guy was standing over me in my bed the other day – is he violent?' And the nurse came and they are all scared of him, I know that's true.” On 9/11/2025 at approximately 9:50am, an interview took place with the Administrator, the RVPO, and the RDCS regarding the facility's ability to meet the needs for safety for Resident #4 and why the facility continues to readmit Resident #4 after multiple discharges related to aggression and exiting the facility in which an involuntary psychological examination was ordered. The RVPO said that they have discussed it and reached out to the Long-Term Care Ombudsman and other facilities who refuse to accept Resident #4, and they take him back because “we'll be in trouble with the state if we don't.” The Administrator was asked about the discharge notice signed on July 4, 2025, which she signed and documented that Resident #4's needs could not be met at the facility and what had changed in Resident #4's condition or the services offered by the facility that indicated his needs could be met at the facility. The response was that “he's our resident and we have to take him back.” During the interview, copies of documentation of communication with the Ombudsman and requests to other facilities to accept Resident #4 were requested but not provided.

Based on interview, observation, record, and policy reviews, the facility failed to implement care plan interventions for 4 residents (#1, #2, #5, and #11). Resident #11 was negatively impacted by the failure to implement the care plan to assist the resident in communicating his emotional, intellectual, physical, and social needs. The facility's failure to implement care plans related to adequate supervision for residents #1, #2, and #4 resulted in their ability to exit the facility for residents #1, #2, and #4 and for Resident #4 to cause physical injury to himself and others.Cross reference F600, F689.The findings include:Resident #1 and #2 A record review for Resident #1 included diagnoses of chronic kidney disease stage 3, hyperlipidemia, generalized anxiety, hypertension, Atrial Fibralation, chronic systolic heart failure, and TBI. A minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status score (BIMS) of 7. A score of 0-7 indicates severe problems with thinking or memory according to Cleveland Clinic accessed at my.clevelandclinic.org on 09/17/2025. A comprehensive care plan initiated for Resident #1 on 8/5/2025 included a care plan for elopement risk/wanderer related to impaired safety awareness, wanders aimlessly with a goal for safety to be maintained. Interventions included: assess for elopement risk, distract from wandering by offering pleasant diversions, electronic monitoring device and place on secured unit for increased supervision. A psychiatric admission note dated 8/6/2025 documented “patient presents guarded and non-cooperative initially during interview, patient states I don't ever sleep, and I just want to get out of here.” A record review for Resident #2 documented admission to the facility occurred on 6/17/2025 with diagnoses of unspecified dementia, type 2 diabetes, difficulty in walking, cognitive deficits, and mood disorder. On 6/17/25 an elopement risk screen was completed which indicated a score of 3.0, indicating at risk for elopement. Review of the care plan for Resident #2 revealed there was a care plan initiated on 6/18/2025 documenting “resident is an elopement risk/wanderer related to disoriented to place, impaired safety awareness, and resident wanders aimlessly. Interventions included: assess for elopement risk, distract resident from wandering by offering pleasant diversions and structured activities, electronic monitoring device per MD (doctor) orders and place on the unit for increased supervision. On 6/20/2025 Resident #2's care plan was updated to “resident being placed on 1:1 supervision due to cutting off his wander guard bracelet and exit seeking.” Review of physician orders indicates an order for 1:1 supervision was initiated on 8/29/25 for elopement at 1900. A progress note dated 6/20/2025 at 23:40 pm stated “at approximately 2225 pm (10:25PM) CNA (certified nursing assistant) assigned as 1:1 with Resident #2 was missing, the nurse checked patients room and confirmed Resident #2 was not present, observed patient window inside of room was opened, and no visual of resident outside of room, DON (director of nursing) was notified elopement protocol was initiated. A psychiatric progress note dated 6/21/2025 documented Resident #2 was able to engage in a rational process of relevant information, able to recognize the importance of medication and treatment compliance, able to recognize his medical condition and consequences of lack of treatment and had the capacity to make decisions related to his need for healthcare or long-term placement. He was documented as able to understand the nature, extent, and probable outcome of not receiving medical care and was alert and oriented to self, place, time, and situation. On 6/21/2025, an elopement risk evaluation was repeated and again indicated a score of 3.0, indicating at risk for elopement. On 6/23/2025, the care plan for Resident #2 was updated for behaviors due to “refusing care and medications, becoming agitated and will curse at staff. He slams the door and tells staff to stop following him, removes his wander guard, and is able to unscrew his window to leave facility. Interventions include administer medications as ordered, anticipate resident's needs, explain all procedures to resident before starting care, if reasonable discuss residents' behaviors and why behavior is inappropriate.” A progress note dated 7/13/2025 stated, “ .alarm to the back door going off, when checking it out, they said that [Resident #2] was messing with the alarm on the door, they saw him doing it and told him several times to leave the door alone, after the alarm would not shut off, this nurse trouble shooting the problem and noticed that [Resident #2] had pulled the wires and tripping the connections to the alarm. A temporary fix on the door alarm, risk manager and maintenance is aware. [Resident #2] continues on 1:1 supervision.” A 7/26/25 behavior progress note stated that while the nurse was in the lock down unit, Resident #2 was witnessed using a butter knife to attempt to take the brackets off the window or pry the window open, the aide that witnessed this got him to give her the knife. A police report related to the elopement of Residents #1 and #2, which occurred on 8/30/2025, included documentation that a call was received from the facility at 7:13PM to report a missing person – adult endangered. The description given stated a window was broken during the escape attempt. The officer responded to a missing person and stolen vehicle at the facility. During the course of investigation, it was discovered that room [ROOM NUMBER] had a broken window and was used by Resident #1 and Resident #2 to escape the nursing home. At approximately 8:04 pm, dispatch received a call reporting the potential whereabouts of Resident #2 at a store approximately 1.8 miles. At approximately 11:59 pm, dispatch received a call with the whereabouts of Resident #1, who was observed walking on Interstate 10. The stolen vehicle was located a mile back on the side of the road. The location where Resident #1 was located was approximately 40 miles from the facility. Resident #1 had an active warrant and was arrested and transported to jail. In an interview with the facility administrator on 9/8/2025 at 1:18pm, the administrator confirmed the facility does not have a policy for resident supervision or one-to-one (1:1) supervision. A follow up interview with the Regional [NAME] President of Operations (RVPO) and the Regional Director of Clinical Services (RDCS) on 9/8/2025 at 4:08pm confirmed there is not a policy for supervision, and this includes no policy for staff expectations for staff observing residents on 1:1 supervision but there was training after the elopements happened. The RDCS was not able to answer what type of training or expectations occurred prior to the elopements Resident #4 A record review for Resident #4 included the following diagnoses: schizoaffective disorder, anxiety, trauma, “brittle” diabetic, anemia, other impulse disorders, restlessness and agitation, major depressive disorder, single episode, personal history of traumatic brain injury, mixed hyperlipidemia, epilepsy, intractable with status epilepticus, abnormal involuntary movements. A care plan was initiated on 1/11/2022 and most recently revised on 8/6/2025 for behaviors related to agitation, physically aggressive and combative with staff/residents and refusal of care, described that Resident #4 gets on the floor on his hands/knees disrobing and wandering in and out of others room, suffers from impulse disorder (sexual) and banging head/face episodes against wall. Resident #4 refuses to wear his helmet daily. The care plan included documentation under the heading “Interventions” that, on 8/31/2024, Resident #4 was 1:1 supervision and became hostile and overpowered the aide and entered into a fellow resident's room and struck the resident after he exited out the opposite door when using the restroom. Both parties were separated and addressed. Another care plan was initiated on 1/11/2022 for elopement risk wanderer related to disorientation to place, impaired safety awareness, resident wanders aimlessly, significantly intrudes on the privacy or activities. Interventions included: 1:1 supervision 24/7 for safety due to aggressive behaviors with others. DO NOT sit inside resident's room – sit in the doorway facing him so that he remains in your visual field – If he goes into the restroom, you are to stand by the door with it cracked, to ensure that he does not go through the door on the other side. This care plan was initiated on 3/12/2023 with a most recent revision on 9/8/2025. Other interventions include distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (blank) date initiated 1/11/2022. A psychiatric progress note dated 8/17/2025 documented that “staff note that he becomes easily bored and that his attention fluctuates during interactions. His presentation remains consistent with chronic psychosis, with ongoing negative symptoms such as blunted affect and reduced motivation. Behavioral interventions have recently been introduced, focusing on structured reward-based strategies to encourage engagement and reduce maladaptive behaviors. Initial staff feedback suggests that he responds intermittently to these supports.” Another psychiatric noted dated 8/29/2025 noted “Staff report that the patient's attention fluctuates during interactions and that he becomes easily bored.” A task list for one-to-one activities reviewed for past 30 days listed documentation for only the following days: 8/12/2025, 8/13/2025, 8/15/2025, and 8/20/2025. Resident #4 was observed to be on 1:1 observation with staff on 9/8/2025 (date of survey entry) and the date of this review was 9/9/2025 – no documentation identified for 9/9/2025. The activities/participation (Question 2) documenting for each of the 4 dates that talking was the only activity used out of several listed which included arts and crafts, board games, exercise, games, gardening, meditation/relaxation, music, and others. A progress note dated 8/15/2025 noted “Resident attacked PCA (patient care assistant) assigned to 1:1 with him. Resident was informed not to exit building and punched staff in chest. Staff member restrained resident to ensure safety and resident then head-butted him. PCA removed from 1:1, new 1:1 placed with resident.” A psychiatric progress note date 8/18/2025 documented “The patient is seen today at the request of the staff after a report of the patient hitting a staff member. Staff reports that the patient was informed not to exit building, and he responded aggressively and hit staff. The patient was temporarily restrained by holding his hands/arms in order to prevent him from further hitting the staff and once he was calm, his 1:1 CNA was changed out.” A progress note dated 9/4/2025 at 5:40am documented “Resident was observed waking from sleep and immediately began pacing rapidly up and down the halls. Assigned CNA followed for supervision. Resident began attempting to exit through the doors and became agitated. Resident [#4] went out the facility along with 3 other staff members. The other nurse on shift attempted to support the resident to prevent him from falling. During the intervention, the resident forcefully moved his head forward and made contact with nurse. Resident then attempted to leave the premises and fell into the bushes hitting his head. Resident was noted with abrasions to his left forehead and left knee. Due to continued attempts to leave the facility and inability of staff to maintain control, law enforcement was contacted. Resident [#4] was redirected back into the facility prior to their arrival. Police arrived shortly thereafter. Resident[#4] continues to be combative and agitated.” Resident #11 On September 8, 2025 at 3:15 PM, Resident #11 shared that he has difficulty communicating. His roommate offered that he has asked the staff to get Resident #11 a communication board several times, but they have not. Resident #11 confirmed that he has never received one. When asked how it would assist, he stated that because of his communication difficulties, it would help him to let the staff know what he needs. No communication board was seen in the resident's room. On September 9, 2025 at 10:25 AM, a review of the care plan for Resident #11 (last reviewed 6/23/25) shows a focus area of the resident being dependent on staff for meeting emotional, intellectual, physical, and social needs. The goal of the resident was maintaining involvement in cognitive stimulation and social activities as desired. Interventions included, All staff to converse with resident while providing care; Assist with arranging community activities; Arrange transportation; Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and age appropriate; Invite the resident to scheduled activities; providing a Community Life calendar; notifying resident of any changes to the calendar of activities; thanking resident for attendance at Community Life functions; assisting/escorting to Community Life functions; providing bedside/in-room visits and activities if unable to attend out of room events. Also included in interventions in a note stating Resident #11 has a communication board but can communicate without it if given time. Another focus area is communication problems related to aphasia. One of the interventions is to evaluate the resident for dexterity/ability to use communication board, writing, use of computer, or use of sign language as alternate communication to speech. Also included is to refer to speech therapy for evaluation and treatment as ordered. The date of initiation is 01/21/2022. On September 9, 2025 at 12:10 PM, a review of the resident's orders since admission reveal no order for speech, occupational therapy, physical therapy, or evaluation. On 9/9/25 at 12:18 PM, the MDS Coordinator was asked for evidence of referral to speech therapy as documented in the care plan. The MDS Coordinator was unable to locate the referral. She called the Therapy Director for the facility's contracted speech therapy, and the director was unable to locate a referral or any visit notes. The MDS Coordinator was asked if the referral or communication board was followed up on, and she stated that it doesn't look like it was.

Based on observation, record review and interviews, the facility failed to provide adequate supervision to prevent incidents for 1 to 1 monitoring for 1 of 3 residents. (Resident #1)The findings include:On 8/5/25 at 10:35 AM, during the tour of hall 100, observed Staff Member C (Director of Patient Experience) sitting in the hallway. She was assigned 1:1 monitoring for Resident #3. It was noted that Staff C could not observe Resident #3 for 1:1 due to the door being closed. On 8/6/25 at approximately 3:45 PM, a follow up observation of Hall 100 was performed. Staff Member C was in the hall and assigned to be on 1:1 observation for Resident #3. However, it was not possible to see Resident #3 due to the door only being slightly open with the privacy curtain pulled. On 8/6/25 at approximately 9:24am, an interview was performed with the Regional Nurse about 1:1 procedures. She stated that the facility does not have a 1:1 policy in place. On 8/6/25 at approximately 4:44 pm, an interview with the LPN MDS Coordinator was performed. She was asked about any training for 1:1 procedures for new hires. She stated that she helps with the 1:1 observations for an hour every day. She stated that she had never received formal training on the subject. On 8/6/25, a record review staff in-service trainings revealed a training entitled Education 1:1 with residents conducted on 06/24/25 by the Administrator. This education states, When you are assigned to be 1:1 with a resident, that resident is supposed to be in eyesight, within arm's reach at all times.A review of facility policy confirmed that no facility policy was in place regarding 1:1 observations.

Based on observations, interviews, and record review, the facility failed to ensure policies were upheld regarding smoking to ensure safety for 6 of 6 residents reviewed for smoking (Resident #42, #37, #65, #36, #6, #30). The findings include: Resident #42 During a tour of the facility conducted on 12/16/24 at 12:20 PM, the surveyor observed Resident #42 sitting at the side of her bed with a vape hanging from a lanyard around her neck. An interview was conducted with Resident #42 at this time. The resident was asked if the facility allowed her to keep her vape on her or if the staff was supposed to keep it for her. Resident #42 shrugged her shoulders in response. A review of Resident #42's record revealed she was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #42 has a medical history significant for Lack of Coordination, Communication Deficit, Muscle Weakness, and Tremor. Review of Resident #42's Quarterly Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview of Mental Status (BIMS) score of 13, which indicates she was cognitively intact. Resident #42's Care Plan revealed there was no care plan in place regarding her being a known smoker. Resident #42's Admission/Readmission Data Collection forms, dated 12/08/24, 09/21/23, 08/17/23, and 06/26/23 revealed all forms documented Resident #42 was not a smoker. A further review of Resident #42's Smoking Evaluation, dated 11/12/24, and the Quarterly Data Collection, dated 01/02/24, revealed these forms documented Resident #42 was a smoker. Resident #37 During a tour of the facility conducted on 12/16/24 at 12:21 PM, Resident #37 was observed sitting in her wheelchair next to her bed. Closer observations revealed she had a vape lying on her bed next to her. An interview was conducted with Resident #37 at this time. She was asked if the facility allowed her to keep her vape on her or if the staff was supposed to keep it for her. Resident #37 stated she thought the staff were supposed to keep the vapes but that no staff had confiscated it from her. A review of Resident #37's record revealed she was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #37 has a medical history significant for Chronic Obstructive Pulmonary Disease, Diabetes, Opioid Abuse, Coronary Artery Disease, and Depression. Resident #37's Quarterly MDS dated [DATE] documented she had a BIMS score of 15, which indicates she was cognitively intact. Resident #37's Care Plan revealed there was a care plan in place regarding her being a known smoker. Resident #37's Smoking Evaluations, dated 11/12/24, 03/25/23, 02/02/23, 06/06/22, 05/03/22, and Quarterly Data Collection, dated 06/06/22, stated that Resident #37 was a smoker. There was no Admission/Readmission Data Collection available for review. Resident #65 During a tour of the facility conducted on 12/17/24 at 1:03 PM, Resident #65 was observed propelling himself through the facility with a cigarette in his mouth. An interview was attempted with Resident #65 at this time, but he indicated he was in a hurry to go to the smoking patio for the designated 1:00 PM smoking time. A review of Resident #65's record revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #65 has a medical history significant for Peripheral Vascular Disease, Lack of Coordination, and Coronary Artery Disease. Resident #65's Annual MDS dated [DATE] documented he had a BIMS score of 15, which indicates he was cognitively intact. Review of Resident #65's Care Plan revealed there was a care plan in place regarding him being a known smoker. Resident #65's Smoking Evaluations, dated 11/04/24, 02/04/24, 08/04/23, 05/04/23, 03/28/23, 02/28/23, and 11/28/22, Admission/Readmission Data Collections dated 11/28/22 and 05/04/23, and Quarterly Data Collections, dated 11/04/24, 02/04/24, 08/04/23, and 02/28/23 revealed these forms all documented Resident #65 was a smoker. Resident #36 During a tour of the facility conducted on 12/17/24 at 2:05 PM, Resident #36 was observed using his vape in his room. Upon being discovered, Resident #36 immediately put the vape into his pocket. An interview was attempted with Resident #36 at this time, but he stated he had nothing to say about it and quickly changed the subject. A review of the record revealed Resident #36 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #36 had a medical history significant for Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Paraplegia, and Brown-Sequard Syndrome (which is a neurological disorder which causes one side of the spinal cord to become damaged). Resident #36's Quarterly MDS dated [DATE] documented he had a BIMS score of 14, which indicates he was cognitively intact. Resident #36's Care Plan revealed there was a care plan in place regarding him being a known smoker. Resident #36's Smoking Evaluations, dated 10/25/24, 06/07/24, and 01/02/24 documented Resident #36 was evaluated to be an unsafe smoker. Further review of Smoking Evaluations, dated 10/03/23, 03/26/23, 02/02/23, 05/03/22, 02/25/22, and 12/21/21 documented Resident #36 was evaluated to be a safe smoker. Resident #36's Admission/Readmission Data Collection, dated 10/02/23, documented Resident #36 was a smoker. Resident #36's Quarterly Data Collection, dated 05/28/24, documented Resident #36 was not a smoker. Further review of Quarterly Data Collections, dated 02/28/24, 03/09/23, and 12/21/21 documented Resident #36 was a smoker. 42756 Resident #6 On 12/16/24 at approximately 11:13 AM, Resident #6 was observed in the hallway with a pack of cigarettes in his pocket. On 12/17/24 at approximately 3:39 PM, Resident #6 was observed smoking in the smoking area. He was being supervised and wearing a smoking safety apron as required by his smoking assessment. On 12/17/24 at approximately 4:00 PM, a review of the resident's record was conducted. The most recent Smoking Evaluation Form dated 10/24/24 for Resident #6 was conducted. The Smoking Evaluation Form indicated that Resident #6 had issues with both short and long term memory. The form indicated that Resident #6 had inadequate short and long term memory required to smoke independently. The form indicated that Resident #6 did not have adequate fine motor skills to hold a cigarette at the time of the assessment. The Smoking Evaluation Form indicated that at the time of the assessment that Resident #6 was unable to light a cigarette safely with a lighter. The observation further indicated that Resident #6 did not smoke safely (Does not allow ashes or lit material to fall while smoking, inhaling, holding or smoking item, remains alert and aware while smoking. Does not burn furniture, clothing, skin, self or others. Turns off oxygen prior to lighting a cigarette and smokes only in designated area.) The Summary of the smoking evaluation section of the form indicated that Resident #6 was an unsafe smoker, required constant supervision, and needed to wear a smoke apron while smoking. The current care plan for Resident #6 indicated that the resident is a smoker and occasionally non-compliant with the smoking policy on 12/21/23. Goals on the care plan included: the resident will not smoke without supervision through the review date on 1/5/24 and the resident will not suffer injury from unsafe smoking practices through the review date on 1/5/24. Interventions on the care plan listed: The resident requires SUPERVISION while smoking dated 12/31/23, the resident's smoking supplies are stored per facility policy dated 12/31/23. The care plan did not mention that Resident #6 was required to wear an apron while smoking as stated in the smoking evaluation. Resident #30 On 12/17/24 at approximately 2:45 PM Resident #30 was observed with a pack of cigarettes in his pocket. On12/17/24 at approximately 4:00 PM a review of the smoking assessment and care plan for Resident #30 was conducted. Although Resident #30 was considered a safe smoker; the care plan dated 11/17/24 indicated that Resident #30 was non complaint with the smoking policy at times. Staff interviews An interview was conducted with Staff A, a Licensed Practical Nurse (LPN), and Staff B, another LPN, on 12/17/24 at 2:15 PM. Staff A stated the residents were not supposed to keep any smoking equipment like vapes, cigarettes, or lighters in their rooms. Staff A further stated there was a smoking box, which was kept at the [NAME] Side nurse's station that housed all the resident's smoking materials. Staff A stated she was unaware of Resident #42 and Resident #37 having vapes in their room. Staff B stated she thought the facility's policy had changed and that residents could keep cigarettes in their rooms but not lighters or vapes. Staff B stated she was unaware of Resident #65 having cigarettes in his room. An interview was conducted with the facility's DON on 12/18/24 at 12:29 PM. She stated the latest is that the residents can keep cigarettes on their person, but no ignition source. However, it was noted that, per the most recent policy, it indicated no smoking supplies were to be kept in the resident's rooms. The DON stated she would ask the regional staff if the policy had officially been changed. Review of additional policies provided by the regional staff revealed there was no policy updated since the above quoted policy dated 02/07/20. Review of the facility's policy titled Smoking-Supervised, last revised 02/07/20 revealed the center will retain and store matches, lighters, etc. for all residents, the same rules that apply to regular tobacco cigarettes also apply to electronic smoking materials, and electronic cigarettes are permitted but only in facility designated smoking areas. Electronic cigarettes and materials will be retained and stored by nursing staff.

Based on observation and interviews, the facility failed to post nursing staffing in an accessible location that included the required information daily on 1 of 3 survey dates. (12/16/2024) The findings include: On 12/16/24 at approximately 12:00 PM, during an observation, no staffing was posted as required anywhere in the facility. The dry eraser board in both the east and west wing did have a date and the total number of actual hours worked by staff, but it was not posted in a clear and readable format in a place accessible to residents and visitors. On 12/16/24 at approximately 1:00 PM, Staff Member M, a Certified Nursing Assistant (CNA), was asked to show where staffing was posted. She indicated that it should be posted on the dry erase board but acknowledged that it was not complete. (photographic evidence was obtained). On 12/17/24, staffing information was posted as required. On 12/18/24 at approximately 2:00 PM, an interview was conducted with the Staffing Coordinator Scheduler was conducted. She was asked to show where staffing was posted on 12/16/24. She initially indicated that she posts staffing every day. She did acknowledge that staffing information was not posted on Monday 12/16/24 as required.

Based on observations, interviews, and record review, the facility failed to ensure physician orders for tube feeding were followed and failed to ensure tube feeding was administered in a proper manner for 1 of 1 resident reviewed for tube feeding. (Resident #242) The findings include: During a tour of the facility conducted on 12/16/24 at 11:53 AM, Resident #242 was observed with a tube feeding bag. Closer observation revealed there were no labels, date, time, or tube feeding formulary written on the bag. The tube feeding machine was set for the tube feeding to instill at 60 milliliters per hour (mL/hr) and for the water flush to instill at 100mL every 2 hours (photographic evidence obtained). The initial record review for Resident #242 revealed that the physician orders for tube feeding included an order written on 12/03/24 for Jevity 1.5 60ml/hr X [run for] 24 hours and an order written on 11/18/24 for Flush g-tube [feeding tube] with 100mL of water every 6 hours for hydration. Resident #242 was admitted to the facility on [DATE]. He has a medical history significant for Congestive Heart Failure, Muscle Weakness, Dysphagia, and Spinal Stenosis with Bone Infection. A review of Resident #242's Admission Minimum Data Set (MDS), dated [DATE], revealed he had a Brief Interview of Mental Status score of 14, which indicates he was cognitively intact. This MDS documented he was receiving tube feeding. A review of Resident #242's Care Plan revealed there was a care plan in place stating requires tube feeding related to swallowing problem. A review of the Dietitian's Nutrition Assessment Form, dated 11/25/24, revealed Resident #242's fluids [were] limited related to [his medical] history of Heart Failure. During a tour of the facility conducted on 12/17/24 at 10:08 AM, Resident #242's tube feeding bag was again unlabeled and infusing at a rate of 60mL/hr with the water flush infusing at a rate of 100mL every 2 hours (photographic evidence obtained). An additional tour of the facility was conducted on 12/17/24 at 1:11 PM. Resident #242's tube feeding bag remained unlabeled and infusing at a rate of 60mL/hr with the water flush infusing at a rate of 100mL every 2 hours. An interview was conducted with Staff A, a Licensed Practical Nurse (LPN) and Staff B, another LPN, on 12/17/24 at 2:23 PM. Both nurses independently reviewed Resident #242's medical record and confirmed he was ordered to receive his water flush at 100mL every 6 hours. The nurses confirmed the settings on the tube feeding pump were programmed incorrectly. Staff A changed the water flush rate to the ordered rate. The LPN's were asked if it was proper procedure to not write on the tube feeding bag. Staff B stated the tube feeding was hung by the night shift staff. The nurses further confirmed that the date, time, and formulary should be written clearly on the tube feeding bag. An interview was conducted with the facility's Director of Nursing on 12/18/24 at 12:53 PM. She stated Resident #242 was the facility's first resident to have continuous tube feeding in a long time. She stated that the expectation was that the staff would properly label the tube feeding bag with the date, time, and formulary. She further stated the staff were expected to properly follow physician's orders regarding rate for the tube feeding and the water flush. Review of the facility's policy titled Enteral Feeding-Enteral Nutrition Pump, last revised date 11/12/18 revealed nurses administer enteral feeding when volume control is indicated and as ordered by physician

Based on observations, interviews, review of records, and policy review, the facility failed to ensure 2 of 3 residents sampled received restorative nursing as recommended. (Resident #31 and #55) The findings include: Resident #31 On 12/16/24 at approximately 12:45 PM, Resident #31 was noted to have his left arm, wrist, and hand contracted. There was a splint lying on his bedside table. On 12/16/24 at approximately 3:52 PM, Resident #31 was observed without a splint in place. The splint was lying on his bedside table. The resident was asked if that splint was for his wrist and hand. He nodded yes in agreement indicating that the brace was for his left arm, wrist, and hand. On 12/17/24 at approximately 8:50 AM, Resident #31 was observed without his splint on. On 12/17/24 at approximately 11:51 AM, Resident #31 was observed up in his wheelchair watching television in a common area. He did not have a brace on at the time of the observation. On 12/17/24 at approximately 3:21 PM, Resident #31 was observed awake in his room. He did not have the brace on at the time of the observation. The resident was asked if he had worn his brace in the last two days, he shook his head no. On 12/17/24 at approximately 3:30 PM, a review of Resident #31's medical records was conducted. Resident #31's profile dated 12/18/2024 showed the resident with a contracted left wrist. A physician's order was initiated on 12/1/2021 stating that Resident #31 may have a restorative maintenance program as indicated. A review of Resdient #31's restorative care plan was conducted. The focus on the care plan was limited physical mobility related to decreased mobility and a contracture of his left hand (date Initiated: 12/02/2021). Goals on the plan included remaining free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, and fall related injury through the next review. Interventions on the care plan included the following: Restorative Nursing placing a left arm splint/brace and to provide Active Assisted Range of Motion (AAROM) and Passive Range of Motion (PROM). The care plan further directed nursing to monitor/document/report as needed any signs and symptoms of immobility including contractures forming or worsening, thrombus formation, skin-breakdown, or fall related injury. A review of the Restorative Tasks section of the electronic medical record was conducted: Restorative progressive range of motion (PROM) to left upper extremity(LUE) was only documented on 12/11/24, 12/13/24 and 12/16/24. Number of minutes spent providing split or brace assistance had entries on 12/11/24 indicated 15, 12/13/24 indicated 15, 12/16/24 indicated 25. Percentage of task completed was marked on 12/11/24 at 100%, 12/13/24 100%, and 12/16/24 100%. For tolerance, there was a check mark on 12/11/24, 12/13/24 and 12/16/24. For verbal cues, there was a check mark on 12/11/24, 12/13/24 and 12/16/24. For programs, there was a check mark on 12/11/24, 12/13/24 and 12/16/24. Neither the care plan nor the task questions documented specific exercises or explanation of what parts of the left upper extremity received the range of motion The documentation did not provide information regarding the number of times specific range of motion exercises were performed. The care plan and tasks did not clearly document the amount of time that Resident #31 wore the splint. The tasks and the care plan only mentioned hand splint and not the elbow splint. A review of the occupational therapy evaluation and plan of treatment for certification period for 8/24/24 to 10/22/24 was conducted. The evaluation noted that Resident #31 had some paralysis (Hemiplegia) of the left side and a contracture of the muscle of his left hand. The occupational therapy discharge summary dated 8/24/24 to 9/12/24 recommended that Resident #31 receive restorative therapy. A splint and brace program was established. Staff was trained. The recommendation was for the resident to safely wear his splint on his left hand for up to 1.5 hours with minimal redness, swelling and discomfort. Resident #31's progress notes were reviewed. The most recent restorative nursing progress note was dated 7/4/24. The note mentioned that Resident #31 continued on restorative range of motion (ROM) and splinting to left upper extremity. He was tolerating restorative services well. There is no documentation in the progress notes regarding restorative services after 7/4/2024. On 12/17/24 at 3:58 PM, an interview was conducted with Staff E, the Restorative Certified Nursing Assistant (RCNA). Staff E was asked to give specific information regarding the restorative services provided for Resident #31. She explained that Resident #31 receives restorative services 3 times a week for 4 hours. Staff E explained that the splint was applied to resident #31. She did not give any explanation about any further therapy or range of motion that was provided. She did not give specific information regarding how long the splint was applied to Resident #31. She did not provide specific information regarding what type of splint or specify if the splint in use was a hand or elbow splint. Staff E showed the surveyor a folded copy of the Interdisciplinary Progress Notes with entries dated 12/2/2024, 12/3/2024, 12/5/2024, 12/7/2024, 12/8/2024 and 12/17/2024. The notes had Resident #31's name written in on 12/2/24 and 4 hours. There was no mention of range-of- motion performed for the client on that date. Resident #31's name was not entered on any of the other dates. Staff E indicated that she had another interdisciplinary progress note form that she left at home with documentation from 12/16/24. She did not provide any additional Interdisciplinary Progress Notes before the end of the survey on 12/18/24. The Interdisciplinary Progress Notes contained a log entry on 12/5/24 that indicated that she was pulled to work on the floor on that date. Review of all of the entries on the log revealed the documentation was not specific or measurable and it was difficult to determine exactly what restorative services Resident #31 was receiving. Staff E provided a copy of the Therapy Communication to Restorative Nursing Program, dated 9/23/24, for Resident #31. The current functional status section of the form indicated that the resident was dependent. The problems needs section of the form listed Resident #31 required restorative therapy for his left upper extremity (LUE). The recommendations section of the form listed two items: 1. Passive Range of Motion (PROM) of the upper extremity. Shoulder, elbow, wrist and fingers. 2. Apply left hand splint for up to 4 hours or as patient tolerance. Three times a week for 12 weeks. The form also hand a note: waiting on elbow splint. Staff E was asked to explain the process for initiating and providing restorative therapy for a resident. She explained that she receives the Communication to Restorative Nursing Program forms from the Director of Nursing (DON). They provide therapy for the residents, log what they have done in their logsm and check it off in the electronic medical record under tasks. She indicated that they have been short of staff since the hurricane and occasionally get pulled to assist the nursing assistants on the floor. The surveyor requested for a list of all residents receiving restorative therapy. A review of the restorative therapy list provided by the facility revealed that the facility was to provide restorative services to 78 residents. An interview with the Director of Nursing (DON) was conducted on 12/17/14 at approximately 4:20 PM. The DON was asked to show documentation regarding specific range of motion information and splinting restorative nursing tasks for Resident #31. She explained that there was a change of department heads. Previously there was a binder that had documentation regarding specifically what was being provided to clients. Each page in the binder had a page for a week's worth of program. When she realized that restorative records needed more documentation, she said a performance improvement plan was put in place today. She explained that the tasks questions can be worded more specifically to provide documentation. She explained that she had been providing more specific measurable information in the tasks for several of the newer residents added to restorative services. She indicated she has not yet been able to go back and correct tasks for residents who had been previously entered. Resident #31's tasks had not been updated to include more specific information in the tasks section. The DON was notified that restorative staff were being pulled to assist Certified Nursing Assistants on the floor. She agreed that restorative staff was being utilized at times to work the floors and indicated that the facility has had staffing difficulties. On 12/18/24 at approximately 12:30 PM, an interview was conducted with Staff P, another RCNA. She indicated that she started working as a restorative aid on 12/12/24. She was asked to look at her documentation for restorative services. Resident #31 was on the log and it was listed that the resident received PROM to left upper extremity and a splint. There was not any further specific information on the log. On 12/18/24 at approximately 2:15 PM, the Director of Rehabilitative Services was interviewed. She explained that they do specific training for restorative aids on how to perform restorative therapy for each individual resident. The Restorative nurse is responsible for supervising the restorative program and ensuring that the tasks are being completed and documented correctly. She was asked if the clients are communicating to her that restorative is not being done. She explained that they do screenings for therapy to check in and see if they need anything. Through this process, the director has been made aware that the restorative aids are being pulled to facilitate staffing. She explained that she consistently provides reminders that restorative therapy is important. On 12/18/24 at 2:40 PM, a second interview was conducted with the DON. She was asked who the facility's restorative nurse was. The DON said that, normally, restorative is assigned to the Assistant Director of Nursing (ADON). But the position was vacant and she was the current restorative nurse until he position can be filled. On 12/17/24 at approximately 11:00 AM, a review of the facility policy for Restorative services (last revised 4/15/22) was conducted. The policy stated, The Restorative Nursing Assistant (RNA) will document the resident's participation and actual number of minutes participating in restorative intervention. The Restorative nurse/designee will review the RNA documentation weekly. Restorative Nurse/designee will document the resident's response to the intervention and progress towards goals. Modify goals and intervention as appropriate. Revise care plan as needed and program changes. The restorative nurse/designee will review restorative programs monthly and document a summary note. Documentation should in include but is not limited to an evaluation of the continued appropriateness of the current restorative nursing program; reflect functional progress made during the entire month and any teaching. 48176 Resident #55 During a review of the record Resident # 55 is ordered to receive restorative services three times a week. However, based on the medical record, Resident #55 has received restorative services only 6 times in the last 30 days. On 12/17/24 at 2:18 PM, an interview with the Director of Nursing (DON) was performed. She stated Resident #55 does receive his restorative on schedule but he often refuses. She stated she would provide all the restorative notes. However, when retrieving the notes, she stated that, while looking for them, she realized they had not been getting done since August, when she took over the program. She also stated staff should be logging in the medical record every time restorative gets done. On 12/17/24 at 4:39 PM, an interview with Staff E (RCNA) was performed. When asked if it was accurate that Resident #55 has received restorative services 6 times in the last 30 days, she stated that sounds accurate based on the amount of days she works. The DON also confirmed that it is correct that the resident is not receiving restorative 3 times a week. On 12/18/24 at approximately 11:00 AM, an interview was held with the Director of Rehabilitation. When asked if she knew why the residents are not receiving restorative services as ordered, she stated, I am aware that staff keep getting pulled to provide care in other areas, but restorative should be its own program and just provide those services. We work very hard in therapy, but the hard work is lost when they do not get them up to walk 3 times a week, or follow the restorative orders as recommended.

Based on observation, record review, and interview the facility failed to provide a sanitary environment in the dining rooms, laundry area and one residential room. The findings include: On 12/16/24 at 11:40 AM, a tour of the dining and kitchen area was conducted. The floor in the kitchen area had several spills of what appeared to be liquid that was now dry and dry food and crumbs were observed at every table. There were some red stains as well. (Photographic evidence obtained) On 12/16/24 at 11:46 AM, an interview with Staff C, Dietary Aide, was performed. When asked her opinion on the condition of the floors, she stated they were disgusting and unacceptable. When asked who was responsible for keeping the floors clean she stated that someone from laundry across usually sweeps and mops but she was unaware why it had not been done. On 12/16/24 at 11:59 AM, an interview was conducted with Staff D, Licenced Practical Nurse Unit Manager. She was assisting in the dining room that day. When asked her opinion on the floors she agreed that they were dirty. When asked if the floors get clean after each meal, she said Not always. On 12/16/24 at 3:24 PM, an interview was held with the Regional [NAME] President of Operations. He stated the expectation is that the dining room should be swept after every meal and mopped daily. 45951 During a tour of the facility conducted on 12/16/24 at 11:53 AM, it was noted in resident room [ROOM NUMBER] that the floor around the residents' beds were dirty with wet/discolored areas and debris present. One of the residents stated during an interview, For two guys that can't get out of bed, the floor sure gets dirty and stays dirty in here. A return visit on 12/17/24 noted that the floor continued to be in the same state, with the same wet/discolored areas and debris present (photographic evidence obtained). A tour of the facility was conducted on 12/16/24 at 2:49 PM with the Account Manager for Healthcare Services Group (the facility's Environmental Services group) and the Facility Administrator. During this tour, the surveyor reviewed the soiled utility and shower rooms on each hallway along with the facility's laundry area. Photographic evidence was obtained of all the following areas of concern. The Soiled Utility Room on the facility's East Side hallway contained a specimen refrigerator. Inside this refrigerator, the surveyor observed a specimen which was double bagged, but unlabeled. Also in this Soiled Utility Room, 1 of 2 linen bins contained linens which were not bagged. In the Shower Room on the [NAME] Side hallway, a wall handrail was observed to be loose and not fully connected to the wall. Upon entering the washing machine side of the laundry area, a large buildup of lint and debris was observed behind the two washing machines, including a drinking straw, a hair tie, glove fingers, wrappers, and peanuts. Closer observation of the washing machines revealed each had a filter located on the outside. Each filter had signs instructing the staff to clean filters daily. However, each of the filters had a large buildup of lint and debris present. When asked how often these areas were cleaned, the Account Manager and Administrator stated the maintenance staff was responsible for cleaning these areas but that they did not know when the filters or drainage area had been cleaned last. Upon entering the dryer side of the laundry room, the ceiling around the ceiling vent was torn and falling away from the ceiling. There was also a large buildup of lint and dark matter on the ceiling. The Account Manager stated two of the three dryers present were not working. He explained that dryer number two had been broken for approximately 2 months and they were actively waiting on parts to complete fixing it. He further explained that dryer number three had been broken for multiple years. Upon observing dryer one, the only working dryer, a large buildup of red/brown matter was observed melted on the inside of the dryer drum. When asked how often the drum was cleaned, the Account Manager and Administrator stated maintenance was responsible for cleaning the dryer drum and that they did not know when it had been cleaned last. Upon observing the dryer lint area, a moderate buildup of lint was present along with foreign objects such as pens, wrappers, and peanuts. The Account Manager stated the laundry staff should be cleaning the lint area each hour.

Based on observations, resident interviews, and staff interview, the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment and ensure sufficient hot water in 6 of 16 sampled resident rooms. (Rooms 110, 206, 207, 212, 214, and 216) The findings include: An observation of room [ROOM NUMBER] was conducted on 10/2/23 at 2:43 PM. The overbed table was missing the plastic border and had exposed rough edges. In addition, the bathroom had a rusted toilet riser and peeling paint on the wall. (Photographic evidence obtained.) It was further discovered that after the hot water ran in the bathroom sink for approximately 3 minutes, the water did not get warm. An interview was conducted with Resident #51 at this time, and she stated they have not had any hot water in the bathroom since Hurricane Idalia about a month ago. An observation of room [ROOM NUMBER] was conducted with the Administrator on 10/4/23 at 2:32 PM. She observed and confirmed the peeling paint in the bathroom, the rusted toilet riser, and the damaged overbed table. She checked the hot water in the bathroom after allowing the hot water to run for about 3 minutes and it read 76 degrees on her thermometer. The Administrator stated the facility had obtained a quote on 10/3/23 for a circulating pump and the hot water had been out on that side of the building since right after the hurricane on 9/15/23. She stated it affected the entire hall. An observation of room [ROOM NUMBER] was conducted on 10/2/23 at 1:28 PM. After allowing the hot water to run in the bathroom sink for about 3 minutes, the water did not get warm. At this time, Resident #72 stated they had not had hot water in the bathroom since Hurricane Idalia. An observation of room [ROOM NUMBER] was conducted with the Administrator on 10/4/23 at 2:34 PM. The Administrator tested the hot water from the bathroom sink after allowing it to run for about 3 minutes and the temperature read 75.9 degrees. The wall around the sink was damaged with peeling paint and there was peeling paint on the wall under the television. The Administrator stated they were aware of damaged walls and had started some repairs. An observation of room [ROOM NUMBER] was conducted on 10/2/23 at 3:43 PM. Several blankets were on the floor under the packaged terminal air conditioner (PTAC) unit and the overbed table was missing the outer border and had exposed particle board. (Photographic evidence obtained) An observation of room [ROOM NUMBER] was conducted with the Administrator on 10/4/23 at 2:40 PM. Several blankets remained in the floor under the PTAC unit and the overbed table remained damaged. The Administrator stated the PTAC was leaking, and it had been discussed in the morning meeting. An observation of room [ROOM NUMBER] was conducted on 10/2/23 at 2:18 PM. The privacy curtain between the 2 beds was observed to be stained. Another observation of room [ROOM NUMBER] was conducted with the Administrator on 10/4/23 at 2:36 PM. She observed and confirmed the stains on the privacy curtain. An observation of room [ROOM NUMBER] was conducted on 10/2/23 at 1:11 PM. After allowing the hot water to run in the bathroom sink for about 5 minutes, it did not get warm. At this time Resident #53 stated there was no hot water in the bathrooms and they must wash themselves with cold water. 48176 On 9/2/23 at approximately 11:54 AM, a tour was done of room [ROOM NUMBER]. The bathroom was dirty. The floor was dirty and the toilet riser was rusty and dirty. There was a dark gray thick build up, especially on the corners of the walls. There was also some sticky like substance on the toilet riser bars. (Photographic evidence obtained) Resident #69, the current occupant of room [ROOM NUMBER], was interviewed. She stated she was very aware of the condition of the bathroom. She stated she hated how dirty the riser was. When asked if she had let staff know, she said she had but nothing happened. She said she hated sitting on the toilet but there was nothing the staff had done about it. A second visit was performed on 9/2/23 after housekeeping had been down that hall and finished cleaning. The issues seen in the bathroom previously had not been addressed.

Based on staff interviews and resident record reviews, the facility failed to ensure they referred all residents with newly evident or possible serious mental disorder or related condition for Level II Preadmission Screening and Resident Review (PASARR) for one of one residents (Resident #74) reviewed for Level II PASARR. The findings include: Record review of the face sheet for Resident #74 revealed the resident was admitted on admitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #74 was added to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the Level I screen for Resident #74 revealed it was conducted on 2-3-20 which was prior to receiving the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/23/22 at 12:01 PM a telephone interview was conducted with the Social Services Director. When asked if she could recall or produce a Level II Review for Resident #74, the SSD admited this could not be produced nor could she recall requesting one for this resident. The SSD stated she completed an audit of all PASARR residents recently, but admitted this one may have slipped by because Resident 74 received the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At this time, the SSD confirmed the PASARR Level II should have been initiated upon the resident receiving a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to implement quality measures previously put into place by failing to ensure the gate lock on the smoking patio was secure after previously identifying that the gate was a source of elopement for one of one residents sampled, resident #1. The findings include: A record review was conducted for resident #1 who was previously identified as an elopement risk. Resident #1 exited the facility through the gate on the smoking patio on 1/1/2019 and proceeded to elope to an adjacent side street next to the facility. A record review was conducted of facility self reporting of the above incident for resident #1 in which they identified the gate on the smoking patio lock to be malfunctioning which resulted in resident #1's source of exit from facility. A quality improvement program was developed after this incident dated 1/1/2019 in which a plan was put into effect to check all door locks and devices for functionality on a daily bases. This plan was to be done within 24 hr of developing plan and implementation of and check to be made daily after that. An observation was made on 3/6/2019 at approximately 3:40pm of the patio gate lock not functioning, the gate was easily pushed open allowing any resident to exit. An interview was conducted 3/6/2019 at approximately 3:45pm with the corporate liaison which identified that the latch was not working properly. An interview was conducted with the maintenance supervisor at 4:15pm on 3/6/2019 in which he stated it was essential to have a functional lock to maintain resident safety. An interview was conducted with the administrator at approximately 3:45pm on 3/6/2019 in which she verified a lock is essential for resident safety, and the gate could be a source of exit for residents from the patio.