Every finding on record at Aviata at Seminole

Based on interviews and record reviews, the facility did not ensure four residents (#1, #3, #6, #10) out of five residents reviewed were informed in advance of changes to their plan of care related to medication.Findings included: An interview was conducted on 12/15/25 at 10:45 a.m. with Resident #1. The resident said she was very upset because the facility changed her medications and did not discuss it with her or even let her know. Resident #1 said she had been on Clonazepam for a long time and was taken off. The resident said she was not aware she had been taken off the medication until she started feeling different and spoke to the nurse. She said her nurse informed her she was no longer taking Clonazepam and something else. Resident #1 said she had heard of this happening to several other residents in the facility as well. Review of admission Records showed Resident #1 was admitted on [DATE] with diagnoses including major depressive disorder, suicidal ideations, generalized anxiety disorder, chronic pain and bipolar disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. Review of Resident #1 physician orders showed:-Clonazepam 0.5 milligram (mg). Give 2 tablets by mouth two times a day for anxiety. Start date 7/8/25. Discontinued 11/13/25.-Clonazepam 0.5 mg. Give 1 tablet by mouth two times a day for anxiety for 7 days. Start date 11/13/25. Discontinued 11/19/25-Clonazepam 0.5 mg. Give 1 tablet by mouth one time a day for anxiety for 7 days. Start date11/21/25. Discontinued 11/27/25.-Remeron 15 mg. Give 1 tablet by mouth at bedtime for depression. Start date 7/2/25. Discontinued 11/13/25.-Seroquel XR oral tablet extended release (ER). 150 mg. Give 1 tablet at bedtime for bipolar. Start date 7/2/25. Discontinued 11/13/25.-Seroquel 50 mg. Give 2 tablets by mouth at bedtime for bipolar for 7 days. Start date 11/13/25. Discontinued 11/19/25.-Seroquel 50 mg. Give 1 tablet by mouth at bedtime for bipolar for 5 days. Start date 11/20/25. Discontinued 11/24/25.-Seroquel 50 mg. Give 0.5 tablet by mouth at bedtime for bipolar for 3 days. Start date 11/25/25. Discontinued 11/27/25.-Gradual dose reduction (GDR) documentation related to discontinuing Remeron, decrease clonazepam, and Seroquel x 7 days. Every shift document in the medication administration record (MAR). Start date 11/14/25. Discontinued 11/17/25.-GDR documentation related to discontinuing Remeron, decrease clonazepam, and Seroquel x 7 days. Every shift for 4 days. Start date 11/17/25. Discontinued 11/17/25. Review of psychiatry notes showed: 11/13/25 Interval History: The information obtained was from nursing staff, observation, and chart review. Physical ROS [review of symptoms]: All systems negative except symptoms mentioned in Patient's most current H&P. [History and Physical]Assessment and Plan for today's visit:The patient is being seen today for an assessment for gradual dose reduction (GDR), as recommended by CMS guidelines. The patient's current psychotropic medications were reviewed and assessed for the need for any changes or adjustments. According to the staff, the patient has been stable and cooperative with care. There have been no reports of behavioral disturbances, anxiety, or agitation. The patient's behavior has been stable and uneventful. Medication compliance is good and no side effects have been reported or evidenced.Recommendation: It appears that the patient can tolerate the GDR and will likely remain stable. The risks versus benefits of a gradual dose reduction (GDR) have been considered, and it has been determined that this approach is appropriate. The patient is believed to be able to tolerate a GDR with the possibility of discontinuing the medication completely. Will decrease Clonazepam 1 mg to 0.5 mg PO [by mouth] bid x 7 days, decrease to QD [every day] x 7 days, then d/c [discontinue]; d/c Mirtazapine 15 mg PO qhs[at bedtime]; reduce Seroquel XR 150 mg to IR 100 mg PO qhs x 7 days, decrease to 50 mg qhs x 5 days, reduce to 25 mg qhs x 3 days, then d/c. The other psychiatric medications will be continued at their current dosages. The gradual dose reduction will be conducted over the next several days to weeks to safely discontinue the medication, with close monitoring for any adverse effects or worsening of mental health symptoms. Close monitoring of the patient's response to the medication changes will be necessary, and a follow-up visit to the facility will be scheduled as needed to assess the patient's progress and make any necessary adjustments. This approach aims to provide the patient with the most appropriate and effective treatment while considering their complex clinical presentation and unique needs. Regular monitoring and communication with the patient and the interdisciplinary team will be crucial to ensure the best possible outcome. Review of Resident #1's medical record did not show any documentation medication changes were discussed with the resident or that the resident was involved in the change to the plan of care. Review of primary care provider note showed: 11/19/25 Interval History: Patient seen at bedside. Patient reports she is under stress regarding banking issues (currently on the phone with [bank] investments). Patient upset with GDR of clonazepam. She denies SI/HI [suicidal ideation /homicidal ideation] however does report ongoing anxiety. Psychiatry is following. Review of Resident #1's progress notes showed:11/24/2025 6:23 p.m. Nursing Progress Note: Patient was experiencing shaking from not having her clonazepam 11/28/2025 6:14 p.m. Nursing Progress Note: Patient is having trouble without the clonazepam. She has episodes of shaking and anxiety. her antibiotics are working without any problems 12/11/2025 4:02 p.m. Orders Progress Note: IDT [Interdisciplinary team] team met for GDR discussion. [Resident #1] has been stable at this time and no changes will be made. Review of Resident #1's Psychiatry note dated 12/11/25 showed: Interval History: The information obtained was from nursing staff, observation, and chart review. Physical ROS: All systems negative except symptoms mentioned in Patient's most current H&P.Assessment and Plan for today's visit:The patient is being seen today for an assessment for a gradual dose reduction (GDR), as recommended by CMS guidelines. The patient's current psychotropic medications were reviewed and assessed for the need for any changes or adjustments. According to staff, the patient has been stable and cooperative with care, displaying no signs of agitation. The patient has good medication compliance and no reported side effects. 2. An interview was conducted on 12/16/25 at 9:12 a.m. with Resident #3. The resident said she had been in the facility for a year but had recently had a concern with some medication changes. Resident #3 said she had not been told someone cut her dose of clonazepam in half. She said she cried for days and didn't know why. Resident #3 said she had a history of severe depression and anxiety, and certain sounds/noises are triggering. The resident said no one spoke to her before changing the medication she only spoke to the psychiatry nurse practitioner (NP) after she found out about the change. The resident was tearful throughout the conversation.Review of admission Records showed Resident #3 was admitted on [DATE] with diagnoses including major depressive disorder and anxiety.Review of Resident #3's Quarterly MDS, dated [DATE], Section C, Cognitive Patterns, showed her BIMS score was 13, indicating she was cognitively intact.Review of Resident #3's physician orders showed:-Clonazepam 1 mg. Give 1 tablet by mouth two times a day related to anxiety disorder. Start date 9/6/25. Discontinued 11/14/25.-Clonazepam 1 mg. Give 1 tablet by mouth two times a day related to anxiety disorder. Start date 11/14/25. Discontinued 12/11/25.-Clonazepam 1 mg. Give 0.5 tablet by mouth two times a day for anxiety for 10 days. Start date 12/11/25. Review of Resident #3's Psychiatry note dated 12/11/25 showed: Interval History: The information obtained was from nursing staff, observation, and chart review. Physical ROS: All systems negative except symptoms mentioned in Patient's most current H&P.Assessment and Plan for today's visit: The patient was seen and evaluated today, and medications were reviewed to consider dose reduction (GDR), as recommended by CMS guidelines. After a careful review of the chart and evaluation of the patient's current conditions, discontinuation of all psychotropic medication would not achieve the desired therapeutic effects. Based on documented history and current behaviors the following medication changes will be made today as noted in the assessment/plan-reduce Clonazepam 1 mg PO bid to 0.5 mg PO bid x 10 days, reduce to QD x 10 days then d/c on 12/31. Review of Resident #3's medical record did not show any documentation medication changes were discussed with the resident or that the resident was involved in the change to the plan of care. Review of Resident #3's Psychiatry note dated 12/15/25 showed: Patient is seen today for follow up appointment following recent medication changes. She is alert and oriented, seen in her wheelchair. Patient reports difficulty adjusting to the reduction in clonazepam and expresses that she needs this medication to control her anxiety. She understands the clinical reasoning behind the medication adjustment but would like to like to discuss reinstatement of her previous clonazepam dosage with her primary medical provider. Patient counseled on smoking and marijuana use history.Staff Reports: Staff reports that patient is having a hard time adjusting to the clonazepam reduction but presents without behavioral issues, agitation, or restlessness. 3. An interview was conducted on 12/15/25 at 2:20 p.m. with Resident #6. The resident said he has been on gabapentin for over a decade, and it had been changed to Lyrica (Pregabalin) for a while. He said he was then taken of Lyrica and put back on gabapentin and didn't know why. He said no one ever spoke to him about it or asked him what he needed. He said Lyrica worked better than the gabapentin had previously. Resident #6 said the same happened with his baclofen; at the beginning of the year, he was transitioned to Methocarbamol and this past week he was taken off of that and put back on Baclofen. The resident said he didn't know who was doing this but there was no discussion with him about the changes. Resident #6 said he had wanted more Tylenol and his Percocet was stopped and then it got added back after several days. Review of admission Records showed Resident #6 was admitted on [DATE] with diagnoses including muscle wasting and atrophy, chronic pain syndrome, generalized anxiety disorder, major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. Review of Resident #6's 10/31/25 MDS, Section C, Cognitive Patterns showed a BIMS score of 15, indicating he was cognitively intact. Review of Resident #6's physician orders showed:- Pregabalin Oral Capsule 300 mg. Give 1 capsule by mouth every 12 hours for neuropathy. Start date 2/6/25. Discontinued 12/11/25. -Methocarbamol Oral Tablet 750 mg. Give 1 tablet by mouth every 12 hours as needed for muscle spasm. Start date 1/14/25. Discontinued 12/11/25. -Baclofen Oral Tablet 10 mg. Give 1 tablet by mouth every 12 hours for chronic muscle spasms, pain. Start date12/11/25. -Percocet Oral Tablet 10-325 mg (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 6 hours for Nonacute pain. Hold for sedation. Total Acetaminophen dose not to exceed 3gm/day. Start date 10/4/25. Discontinued 12/2/25. - Percocet Oral Tablet 10-325 mg (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 6 hours for nonacute chronic pain. Hold for sedation, lethargy, confusion, hypotension, decreased respirations. Start dated 12/8/25. Review of Resident #6's Progress notes showed: 12/11/2025 3:48 p.m. Orders Progress Note: IDT team met for GDR discussion. [Resident #6] has been stable at this time and no changes will be made. Review of Resident #6's psychiatry provider note from 12/11/25 showed: Plan: Given the patient's stability and minimal effective dosages of psychotropic medications, a GDR was deemed contraindicated as it could potentially lead to an exacerbation of the patient's psychiatric symptoms and instability. Therefore, all current psych medications were continued without any changes. Review of Resident #6's medical record did not show any documentation medication changes were discussed with the resident or that the resident was involved in the change to the plan of care. An interview was conducted on 12/16/25 at 3:02 p.m. with Staff H, Registered Nurse (RN)/Unit Manager (UM). Staff H reviewed Resident #6's medical record including psychiatry notes and progress notes. Staff H said she did not see any documentation as to why the medications were changed on 12/11/25. She confirmed the resident's psychiatry notes showed the medications were not going to be changed on that date. Upon further review Staff H said a nurse practitioner (NP) with a third party company that saw the resident made the changes to the medications, but the facility did not have any notes or documentation for the visit or information about why the medications were changed.An interview was conducted on 12/16/25 at 4:00 p.m. with Staff I, NP. Staff I said she was new to seeing Resident #6 and had only had him on her assignment for three weeks. Staff I said she made the medication changes on 12/11/25 for a gradual dose reduction. Resident #6's progress notes and psychiatry notes from 12/11/25 were reviewed with Staff I, NP indicating no GDR was needed for the resident. Staff I said she did not know the facility had reviewed Resident #6 for a GDR that day. Staff I said she often saw the facility's psychiatry provider in other buildings and they communicate but did not communicate about this resident's GDR and plan of care. Staff I said she saw Resident #6 on 12/11/25 and told him she was changing his medication but the resident didn't want to wake up .but I told him. 4. An interview was conducted on 12/15/25 at 9:55 a.m. with Resident #10. The resident said the facility cut off her sleep and anxiety medication about a month ago. Resident said it was not discussed with her, and she doesn't know why they stopped them. She said she had a diagnosis for the medications she was on. Resident #10 said she started having symptoms of anxiety and not sleeping well so she asked and was told her medication had been stopped. The resident said when she asked why the facility told her the pharmacist's license was on the line and the state said she could not have the medication for sleep. Resident #10 was tearful and emotional while discussing her concerns. Review of admission Records showed Resident #10 was admitted on [DATE] with diagnoses including complete paraplegia, post-traumatic stress disorder, chronic pain, major depressive disorder, and generalized anxiety disorder. Review of Resident #10's Quarterly MDS, dated [DATE], Section C, Cognitive Patterns, showed her BIMS score was 15, indicating she was cognitively intact. Review of Resident #10's physician orders showed:-Buspirone HCl Oral Tablet 10 mg. Give 1 tablet by mouth three times a day for anxiety. Start date 5/15/25. Discontinued 11/4/25.-Buspirone HCl Oral Tablet 10 mg. Give 1 tablet by mouth two times a day for anxiety for 5 Days AND Give 0.5 tablet by mouth two times a day for anxiety for 5 Days AND Give 0.5 tablet by mouth one time a day for anxiety for 4 Days. Start date 11/4/25. Discontinued 11/18/25.- Eszopiclone Oral Tablet 1 mg. Give 1 tablet by mouth at bedtime for insomnia hold for sedation. Start date 5/7/25. Discontinued 11/17/25. An interview was conducted with Staff H, RN/UM. Staff H said she had not been at the facility very long but the GDR meeting she attended included the facility's psychiatry NP, the UMs, Director of Nursing (DON), Assistant DON (ADON), and social services. Staff H said the psychiatry NP comes with a list of residents that need to be reviewed for GDR and the UMs or DON add any residents they had concerns with. She said the group discussed which residents were stable or not. She said after the decisions were made to do a GDR the psychiatry NP spoke to the residents that were cognitively intact, and the staff called the representatives for residents that were not cognitively intact. Staff H said she had a couple of residents tell her they had medications changed without being notified or included in the discussion. Staff H said she had the psychiatry NP go speak to those residents. An interview was conducted on 12/16/25 at 12:38 p.m. with the facility's psychiatry NP. The NP said they had monthly GDR meetings at the facility with herself, the UMs, DON and social services. She said the process for the GDR meeting was that the pharmacy sent recommendations for GDR and the facility followed state guidelines for GDR. The NP said when she saw a patient for a while and they were stable she tried to GDR their medication to find the lowest effective dose or reduce the number of medications needed. The NP said during the meeting they also looked at how many residents were on antipsychotic medications and what affected the facility's quality assurance measures and what the team could do to bring those measures up. The NP said after it was decided which residents they were doing a GDR with, and she spoke to those residents. She said a lot of the residents are not happy because she took them off of controlled substances. The NP said several residents go out on leave of absences and consume alcohol or marijuana and her policy was if the resident did that, she took them off of controlled substances. She said she had residents not happy about it, but she said it was risking her license, and it was what was supposed to be done. The NP said she usually put it in her notes when she talked to the residents. An interview was conducted on 12/16/25 at 2:10 p.m. with the Regional [NAME] President (RVP). The RVP said they reviewed medical records for Residents #1, #3, #6, and #10 and did not see documentation the residents were included in a discussion about medication changes. The RVP said they spoke to the psychiatry NP and the head of psychiatry and determined the form they used to document psychiatry notes did not have a place to indicate communication with the resident regarding changes to medication or the plan of care and they were going to add it. An interview was conducted on 12/16/25 at 3:45 p.m. with the Nursing Home Administrator (NHA). The NHA said for Resident #6 they were not aware the third-party NP started a GDR on the resident. She was not sure why there was no communication with the facility and the psychiatry team. The NHA said they would reach out to that company. The NHA said she expected there to be communication with residents when medications were changed. Review of a facility policy titled Notification of Change in Condition, revised 12/16/20, showed: Policy: The center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition.Procedure:The nurse to notify the attending physician and Resident Representative when there is a(n):Need to alter treatment significantly -new treatment -discontinuation of a current treatment due to but not limited to:S Adverse consequencesS Acute conditionS Exacerbation of a chronic condition Review of a facility policy titled Resident Rights, dated 11/30/14, showed: Policy:It is the policy of the company to:1. Make residents and their legal representatives aware of residents' rights.2. Ensure that residents' rights are known to staff.

Based on observation, interview, and record review, it was determined the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective Action Plan to improve findings of deficient practice on the recertification survey conducted on 12/15/2025-12/16/2025 regarding maintaining a clean, sanitary and safe physical environment.Findings included: The facility plan of correction completion date was 11/07/2025. The plan of correction for F584 showed, Closet, wall and floors in identified rooms were cleaned on 10/7/2025. Facility wide audit completed with no other rooms identified. 100% education for housekeeping staff on 5 and 7 step cleaning and 100% Department Heads/IDT (Interdisciplinary team) on identification and appropriate notification of dark spots, discoloration and bio-growth. Audits will be done 4 x weekly for 1 month then then weekly Biweekly for 4 weeks and 1xmonthly ongoing. Audits will be brought to QAPI Committee until the QAPI Committee reports substantial compliance has been met. until substantial compliance An observation was conducted on 12/15/2025 at 3:45 p.m. with Staff E, Certified Nursing Assistant (CNA) of the shower room. Staff E noticed the black growth on the floor in the past and informed the nurse so it could be entered into the facility's maintenance system. However, she was unaware if the nurse submitted the cleaning request as the growth was still there. Staff E stated she had seen housekeeping clean the shower room, so she knew the room had been cleaned. An observation and interview were conducted on 12/15/2025 at 3:46 p.m. with the Housekeeping Director about cleaning procedures for the shower room. He stated the last time the shower room equipment was pressure washed was November 28th, 2025. He stated there was no documentation or logs ensuring the pressure washing had been done. An observation and interview were conducted on 12/16/2025 at 9:29 a.m. with the Maintenance Director about room [ROOM NUMBER]A (loose sink and bed lamination), room [ROOM NUMBER] (loose toilet), room [ROOM NUMBER] (shower chair and shower floor) and room [ROOM NUMBER] (loose toilet and sink). He did not remember the shower repair visit for room [ROOM NUMBER]A. The Maintenance Director was informed that the resident stated she told him of the loose sink during that shower repair visit. However, review of work orders did not show an order for the sink in room [ROOM NUMBER]. The Maintenance Director asked if the loose sink and bed lamentation work order was on the list. He said, then no I do not know about it. He stated if there were any issues, an order needs to be put in facility's maintenance system. He said that whoever the resident told was supposed to do it. He then stated he should have put in the order himself. He stated a lot of times residents tell him stuff as he is passing by so he cannot put in the work orders right away. An observation and interview were conducted on 12/16/2025 at 10:47 a.m. with the NHA and Regional [NAME] President about the expectations of the facility's QA process. The NHA stated it was the unit manager's responsibility to ensure cleanliness of shower rooms. The NHA stated the Housekeeping Director conducts random checks to ensure cleanliness of the facility. He then reports findings to the NHA. She stated that housekeeping staff do not have a system or log that tracks things/rooms needing to be cleaned as the staff directly reports it to the Housekeeping Director. The NHA said the expectation was to adhere to the cleaning schedule for rooms, shower room, and shower room equipment. The NHA stated the daily room rounds conducted by staff and herself included caulking, cracks in the rooms, floors and equipment such as shower chairs. After the checks, she would inform maintenance about any issues. The NHA said that staff were to report anything wrong into the facility's maintenance system, and the staff have been trained on how to access and utilize this maintenance system. The NHA stated the administration performed education refreshers on this, as well as annual education about the maintenance system. The NHA stated if the residents told Maintenance Director, he was really good about addressing the concerns as he would put it into the maintenance system himself. However, if it were something quick, he would not put it in the system. The NHA and Regional [NAME] President were informed of the situation in room [ROOM NUMBER]A about the loose sink that the resident told the Maintenance Director about, and it was still not fixed. The Regional [NAME] President stated more features could be added to the checklist which would prompt staff to inspect more. The NHA and Regional [NAME] President were also informed that on 12/15/2025, concerns about room [ROOM NUMBER] discoloration around the toilet, shower room floors, shower room equipment having bio growth, and room [ROOM NUMBER] shower chair and floor had bio growth had been relayed to the Maintenance and Housekeeping Directors. room [ROOM NUMBER] had a loose sink and toilet that were not resolved as of 12/16/2025. The NHA said moving forward she would have a meeting with department heads, and she would talk about exactly what needs to be looked at during daily rounds. The Regional [NAME] President stated she would add additional checklist items to the daily rounds and increase the volume of daily audits and follow-ups. Review of a facility policy titled, Policies and Procedures Quality Assurance Performance Improvement Program (QAPI), Revised 10/24/2022, showed: The center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life.Program Design and Scope: 1. The center's QAPI program is on-going comprehensive review of care and services provided to residents. Including but not limited to:i. Environmental Services3. Review of activities may include but not be limited to:f. Environment of care/safety4. The program is a coordinated effort among departments and services within the organization that involves leadership working with input from Center staff, residents and families. Data Collection Systems and Monitoring: The center will collect and monitor data from different departments reflecting its performance.8. The center will identify data sources and timeframe for collection. Data sources may include but are not limited to:d. Incident/Accident logs Systematic Analysis and Action: The center will ensure systems and actions are in place to improve performance12. The center will develop corrective actions based on the information gathered and review effectiveness of the actions Identifying Quality Deficiencies and Corrective Action: The center will monitor department performance systems to identify issues or adverse events.14. Center will review department system data15. If a quality deficiency is identified, the committee will oversee the development of corrective action(s)16. The center may choose the method of corrective action i.e. Plan, Do, Study, Act or Performance Improvement Project Photographic Evidence Obtained.

Based on observations and interviews the facility did not ensure proper infection control practices on five halls (100, 200, 400, 500, 600) out of six halls in the facility related to contact precautions, personal protective equipment (PPE) use, clean linen storage, and improper storage of oxygen equipment.Findings included: Review of a list of residents on Trasmission Based Precautions provided by the facility showed residents in room [ROOM NUMBER], 108, and 511 were on contact precautions. During a tour of the facility on 12/15/25 from 9:45-10:15 a.m. the following observations were made:-room [ROOM NUMBER] had a nebulizer mask uncovered on the bedside table. No bag for mask storage was observed.-An open, unlabeled water bottle sitting on the railing in the 200 hall with a used washcloth underneath.-room [ROOM NUMBER] had an oxygen mask on the bedside table uncovered. No bag for mask storage was observed.-room [ROOM NUMBER] was observed to have a partially obscured contact precaution sign on the door and a staff member was in the room providing care to the resident with no PPE on.-A beside commode was sitting outside room [ROOM NUMBER]. Staff D, Licensed Practical Nurse (LPN) was observed at the door preparing the resident's medication. She said she did not know why the commode was in the hallway. The nurse then entered the room with no PPE on. There was a contact precaution sign on the door of the room. -room [ROOM NUMBER] and 108 did not have contact precautions signs on the door.-The linen cart on the 400 hall had a bottle of cleaner, box of pens, and air freshener stored on the shelf with the clean linen. -The linen cart on the 100 hall and perineal/body wash and an open can of soda on the shelf with the clean linen. An interview was conducted on 12/15/25 at 1:14 p.m. with Staff D, LPN. Staff D confirmed the resident in room [ROOM NUMBER] was on contact precautions for c-diff. PPE should have been worn in the room. An observation conducted on 12/15/25 at 12:29 p.m. revealed room [ROOM NUMBER] had a contact precaution sign on the door and Staff B, Certified Nursing Assistant (CNA) was observed walking into the resident room to deliver and set up a food tray without wearing PPE. An interview was conducted on 12/15/25 at 12:38 p.m. with Staff B, CNA. Staff B said she did not wear PPE into room [ROOM NUMBER] because she only needed to wear it when providing close care. Staff B confirmed wearing PPE only on close contact applied to a resident on contact precautions, such as the resident in room [ROOM NUMBER]. An interview was conducted on 12/15/25 at 12:32 p.m. with Staff C, LPN. Staff C confirmed she was assigned to room [ROOM NUMBER] and 108. Staff C said room [ROOM NUMBER] was the only room on the unit on contact precautions. Staff C said there were a couple of others, but their precautions ended. An interview was conducted on 12/16/25 at 2:29 p.m. with Staff F, Registered Nurse (RN). She said respiratory masks should be bagged at the bedside not sitting out uncovered. Staff F said they do use plastic storage bags on the unit, but she would have to ask central supply for them. Staff F said nothing should be stored in the linen cart with clean linen. An interview was conducted on 12/16/25 at 1:05 p.m. with Staff H, RN/Unit Manger (UM). Staff H said if a resident was on contact precautions, staff should have worn gown and gloves anytime they are in the room and a mask if there is a chance of splattering. Staff H said with enhanced barrier precautions (EBP) PPE was worn when providing close care to a resident. Staff H confirmed room [ROOM NUMBER], 108, and 511 were on contact precautions, although rooms [ROOM NUMBERS] came off precautions in the afternoon of 12/15/25. Staff H said room [ROOM NUMBER] was still on contact precautions and staff should have worn PPE anytime they entered the room. Staff H said nothing should be stored in the linen carts except clean linen and she will have a discussion with staff. Staff H confirmed it is an infection control concern to have other items with the linen. Staff H said opened water bottles and used washcloths should not be left in the halls. She said she throws water bottles away all the time when she sees them in the hall. Staff H said all staff are educated on infection control but said it could be confusing with EBP and the facility may change to more distinctly colored signs to help clarify. Review of a facility policy titled Infection Control, revised October 2018, showed:Policy StatementThis facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.Policy Interpretation and Implementationl. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source.2. The objectives of our infection control policies and practices are to:a. Prevent, detect, investigate, and control infections in the facility;b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public;c. Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions;d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for Standard and Transmission-Based Precautions;e. Maintain records of incidents and corrective actions related to infections; andf. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. Review of a facility policy titled Initiating Transmission-Based Precautions, revised August 2019, showed:Policy StatementTransmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents.Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions.The facility makes every effort to use least restrictive approach to managing individuals with potentiallycommunicable infections. Transmission-Based Precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures.Policy Interpretation and Implementation2. Transmission-based precautions are utilized when a resident meets the criteria for a transmissible infection AND resident has risk factors that increase the likelihood of transmission. These may include (but are not limited to):a. Uncontained excretions/secretions;b. Non-compliance with standard precautions; orc. Cognitive deficits that restrict or interfere with the resident's ability to maintain precautions.3. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee):a. Clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used;b. Explains to the resident (or representative) the reason(s) for the precautions;c. Provides and/or oversees dle education of the resident, representative and/or visitors regarding the precautions and use of PPE;d. Determines the appropriate notification on the loom entrance door and on die front of resident's chart so that personnel and visitors are aware of the need for and type of precautions:(1) The informs the snffofdle type of CDC precaution(s), instructions for use ofPPE, and/or instructions to see a nurse before entering the room.(2) Signs and notifications comply with the resident's right to confidentiality or privacy.e. Ensures thatprotective equipment (i.e., gloves, gowns, masks, etc.) is maintained outside resident's room so that anyone entering the room can apply the appropriate equipment;f. Ensures that protective equipment and supplies needed to maintain precautions during care are in the resident's room; andg. Ensures an appropriate linen barrel/hamper and waste container, appropriate liner, are placed in or near the resident's room

Based on observations, record reviews, and interviews the facility failed to obtain a blood pressure prior to the administration of an antihypertensive with physician ordered parameters for one resident (#16) of two residents sampled during medication administration. Findings included: On 11/17/25 at 9:17 a.m. Staff A, Registered Nurse (RN) was observed standing at a medication cart on the 200-hall. Staff A reported finishing up (med administration) with one resident but did have others. The process of medication administration was explained to Staff A. Staff A dispensed the following medications for Resident #16:-Senna Plus 8.6-50 milligram (mg) over the counter (otc) tablet-Amlodipine 5 mg tablet-Aspirin Enteric coated otc 81 mg tablet-Vitamin D 25 microgram (mcg) otc tablet-Pancrelipase Creon Delayed Release (DR) 24000 unit tablet- Dicyclomine 20 mg tablet-Duloxetine 30 mg caplet-Oxycodone 10 mg tabletStaff A dropped the Oxycodone tablet onto the top of medication cart, picking it up with bare hands, and placed it into the medication cup. Staff A signed out the controlled substance in the narcotic book and opened the resident's closed book. Staff A was asked to stop and return to the cart. Staff A stated placing a medication which had dropped onto the cart into the med cup wasn't something normally done, would waste it. Staff A, confirmed the other tablets in cup had been contaminated and the medication would have to be dispensed again. Staff A re-dispensed the medications, entered Resident #16's room, asking if the resident wanted Lactulose or Combivent (which was refused). Staff A returned to the cart.Review of Resident #16's admission Record showed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to unspecified chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, other sequelae following unspecified cerebrovascular disease, and essential (primary) hypertension. Review of Resident #16's November Medication Administration Record (MAR) revealed:-Norvasc 5 mg (Amlodipine) 5 mg - Give 5 mg by mouth once a day for hypertension (HTN). Hold if systolic blood pressure (SBP) is less than 120 or diastolic blood pressure (DBP) is less than 60. The order started on 2/4/25. The MAR documentation showed the medication was to be administered in the morning (MORN) and did not include an area for staff to document a corresponding blood pressure.-Monitor vital signs every day shift. The MAR showed staff documented vital signs were monitored daily without noting the blood pressure, pulse, temperature, and respiration rate. The monitoring was scheduled for 12 Da.-Weekly vital signs every Monday (Mon) (and) Thursday (Thu) for hypertension (HTN). The order started on 8/28/25. The documentation showed nursing staff were documenting blood pressures on Mondays and Thursday with the exception of 11/10/25 which showed not applicable NA for both blood pressure and pulse. The MAR did not require staff to document temperature or respiration rates as part of the vital signs readings. Review of Resident #16's Medication Admin Audit Report for 11/17/25, showed Staff A had administered a dose of Amlodipine (Norvasc) at 9:19 am. and documented the administration at 9:23 a.m. The report revealed the staff member documented on 11/17/25 at 7:13 a.m. monitoring of vital signs had been completed and showed the resident's weekly vital signs were scheduled at 11:45 a.m. (after the Amlodipine was to be administered) and the staff member had administered the vital signs at 2:07 p.m. and documented them at 2:13 p.m. (approximately 5 hours after the administration of Amlodipine). Review of Resident #16's progress notes on 11/17/25 at 1:34 p.m. did not show documentation of the resident's blood pressure at the time of Amlodipine administration on 11/17/25. An interview was conducted with, Staff A on 11/17/25 at 1:39 p.m. Staff A stated Resident #16's blood pressure had been 127/68 or something like that. Staff A reported Resident #16 was currently having chest pain and the blood pressure was lower than that something like 100/48. Staff A reported being able to look up the blood pressure (from this morning), (Staff A was informed to assist the resident by this writer), Staff A went to the computer behind the nursing station and showed the resident's dashboard was active revealing a blood pressure of 124/68 from 11/13/25. Staff A said (pronoun) didn't know why the mornings blood pressure wasn't showing up. Review of Resident #16's progress notes on 11/18/25, showed Staff A had documented on 11/17/25 at 1:58 p.m. the resident had complained of chest pain which radiated down left arm, blood pressure was taken and showed to be 100/47, the nurse practitioner was notified and ordered one dose of nitro(glycerin), the resident refused the dose, and vital signs at the time were 120/55. Review of Resident #16's assessments on, 11/18/25 at 9:26 a.m. showed a weekly skin review had been completed on 11/17 and the previous assessment was a Brief Interview for Mental Status (BIMS) evaluation completed on 11/11/25. The evaluation showed a score of 12 indicating moderate impairment. The assessments did not show staff were completing daily assessments for the resident which could have included vital signs. Review of Resident #16's blood pressure summary on 11/17/25 at approximately 1:00 p.m. showed the latest blood pressure reading was on 11/13/25 at 11:53 a.m. of 124/68. The review showed readings on 11/9, 11/7, 11/6 at 11:32 am. of 150/84 and one at 5:15 p.m. of 150/84, 11/3, 10/30, 10/27,10/23, 10/20, 10/16, 10/14, 10/13, and 10/9/25. Review of Resident #16's November MAR, Blood pressure summary, assessments and progress notes showed staff had administered amlodipine without obtaining and documenting the resident's blood pressure at the time of administration or held the medication related to the physician ordered parameters:-11/14 to 11/17/25 no blood pressure was documented and Amlodipine was administered.-11/10 to 11/12/25 no blood pressure was documented and Amlodipine was administered. On 11/10 the MAR showed nursing staff had documented not applicable NA for weekly vital signs.-11/9/25 a blood pressure of 111/69 had been recorded at 7:05 a.m. by the night shift nurse and Amlodipine was administered by the day shift nurse.-11/8/25 no blood pressure was documented and Amlodipine was administered.-11/7/25 a blood pressure of 112/66 was documented at 11:13 a.m. and showed Amlodipine had been administered.-11/4-11/5/25 no blood pressure was documented and Amlodipine had been administered.-11/1-11/2/25 no blood pressure was documented and Amlodipine had been administeredThe review showed out of 17 opportunities Amlodipine had been administered 15 times without documentation of blood pressure at the time of administration, twice Amlodipine had been administered when blood pressure was outside of parameters and should have been held. Review of Resident #16's follow up Cardiology physician visit on 11/3/25 at 4:10 p.m. showed the resident had a past medical history of paroxysmal atrial fibrillation, coronary artery disease (CAD), hypertension, and hyperlipidemia. The medical necessity for cardiology was described as Follow up for cardiac med reconcile, titrating cardiac meds, lab follow up, following volume status, adjusting diuretics as needed, monitoring hemodynamic/symptoms during and post physical therapy, and increased risk for cardiac re-admission. The assessment for essential hypertension (HTN) showed the diagnosis was controlled on Norvasc 5 mg daily, asymptomatic, SBP less than 130, avoid hypotension, and monitor vital signs. The note instructed to maintain current plan of care, including regular assessment of vital signs, labs, and overall status. Review of Resident #16's care plan showed a focus revealing the resident had altered cardiovascular status related to (r/t) hypertension, CAD, (and) history of tachycardia. The associated interventions included instructions for staff to administer medications as ordered and monitor vital signs (and) notify the MD of significant abnormalities. An additional focus revealed the resident had hypertension and took BP medications. The interventions instructed staff to Give anti-hypertensive medications as ordered. Monitor of side effects such as orthostatic hypotension and increased heart rate (tachycardia), and effectiveness. An interview was conducted with Resident #16 on 11/18/25 at 9:40 a.m. The resident stated staff do not take blood pressure on a regular basis, not daily maybe once or twice a week. The resident stated they took blood pressure yesterday (day of medication administration) after telling them (pronoun) didn't feel good. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) who identified self as Resident #16's nurse, on 11/18/25 at 9:43 a.m. Staff B reported working the hall every couple of weeks but knew everyone on the hall. Staff B stated in regard to how often (pronoun) took Resident #16's blood pressure rarely. During an interview on 11/18/25 at 11:15 a.m. the Assistant Director of Nursing (ADON) stated vital signs are taken on admission, any change in condition, if skilled once a shift, if any medication (require), if blood pressure meds are taken and have parameters for blood pressure, if administering nitro take blood pressure, and obtain blood glucose before giving insulin. The ADON stated staff should de documenting blood pressure if there is a parameter, if there is a parameter the medication should have a pop-up box to put in the blood pressure, and believed the blood pressure documented in the pop-up box showed up on the MAR. Review of Resident #16's MAR was conducted and the ADON confirmed blood pressures were not documented with the administration of Norvasc. The ADON reviewed the order to monitor vital signs daily and stated if they aren't documented they weren't done. The ADON reviewed blood pressure summary and confirmed blood pressures were not done prior the administration of the resident's Amlodipine and stated the nurse had backfilled the blood pressure on 11/17 (after photo had been obtained). The ADON stated blood pressures should be taken immediately prior to the administration of the medication. Review of the policy - Administering Medications, revised April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. The policy included but was not limited to the following:-2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.-4. Medications are administered in accordance with prescriber orders, including and required time frame.-10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.-11. The following information is checked/verified for each resident prior to administering medications:o a. Allergies to medications; [NAME] b. Vital signs, if necessary.

Based on observations, record reviews and interviews the facility failed to notify and consult with the resident's physician on their known use of illicit drugs, related to the potential for medication contraindication for one resident (#4) out of eight residents sampled. Findings Included: On 10/07/2025 at 10:58 A.M. Resident #4 was observed in his wheelchair in the parking lot smoking. He said he goes to the west side of the parking lot for more privacy. He had a bottle of cologne on his lap and started spraying it on his body. Resident #4 said he was smoking marijuana (a psychoactive drug derived from the dried leaves, flowers, and stems of the Cannabis sativa or Cannabis indica plants, with effects Relaxation, Euphoria, Increased appetite, Altered perception, Impaired coordination, and Anxiety (in some users). Source:https://en.wikipedia.org/wiki/Cannabis. Resident #4 said some staff cared that he smoked and some staff did not. On 10/07/2025 at 2:00 pm. Resident #4 was observed in room [ROOM NUMBER] sitting in his wheelchair watching television. The room was noted with a strong smell of marijuana. Resident #4 said the smell in his room comes from him smoking marijuana outside. He said he tried to spray cologne on so the smell would not be so bad. Review of an admission record dated 10/07/2025 revealed Resident #4 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease without dyskinesia, without mention of fluctuations, chronic kidney disease, stage 3 unspecified, other seizures, cannabis abuse, uncomplicated. Review of a minimum data set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident #4 had moderate cognitive impairment. Review of physician's orders revealed the followingGabapentin Oral Tablet 1 milligram (Folic Acid) Give 1 tablet by mouth three times daily for nerve pain. Start date 05/01/2025Lacosamide Oral Tablet 200 milligram (Lacosamide) Give 1 tablet by mouth every 12 hours for seizure. Start date 04/16/2205Levetiracetam Oral Tablet 500 milligram (Levetiracetam) Give 3 tablet by mouth twice a day for seizures. Start date 04/16/2025Trazodone Hydrochloride (HCI) Oral Tablet 50 milligram (Trazodone HCI) Give 50 mg by mouth at bedtime for insomnia. start date 09/17/2025 Review of Resident #4 care plan revealed a focus showing resident #4 is a smoker date initiated on 4/14/2025 and revised on 07/23/2025Goals showed residents #4 will not suffer injury from unsafe smoking practices through the review date. Date initiated on 04/14/2025, revised on 06/17/2025Interventions showed to notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date initiated 04/17/2025. On 10/07/2025 at 11:06 a.m. an interview was conducted with Staff C, Certified Nursing Assistant, CNA. Staff C said Resident #4 always smells like marijuana after he comes back to the facility. She said staff, and most of the residents have complained about the smell to administration but nothing has been done about it. On 10/07/2025 at 11:59 a.m., an interview was conducted with Staff D, License Practical Nurse, LPN. Staff D said if she identifies one of her residents smoking marijuana, she immediately reports it to a supervisor. If the supervisor is not available, she reports the concern in a group chat to alert administration. Staff D said she does not notify the resident provider because once she reports the concern to a supervisor, it is up to them to handle the situation. Staff D said Resident #4 is very strong-willed and sometimes gets aggressive with staff. Staff D stated once he signs out on a leave of absence, then he is responsible for himself. Staff D said, We cannot control what he does once he signs out, even if he comes back to the facility smelling like marijuana. He goes outside on a leave of absence, which means he is his own person. Staff D said she reported the concerns regarding Resident #4 smoking marijuana to the supervisor before, and the supervisor addressed the issue with the resident. On 10/07/2025 at 12:20 p.m., an interview was conducted with Staff E, Registered Nurse, RN. Staff E said if a resident returned to the facility after a leave of absence smelling like marijuana, he would ask the resident about it. If the resident tells him no, they were not smoking an illegal substance, then there is nothing else he can do about it. Staff E said he was not allowed to search the resident even if they come back to the facility with a suspicious smell. He said the only thing he could do was to ask them if they smoked marijuana. Staff E stated Staff D had reported the concerns about Resident #4 smoking marijuana. He said when he questioned the resident about it, the resident told him he was not smoking marijuana. Staff E said Resident #4 did smell like marijuana, but there was nothing he could do if the resident tells him something different. Staff E said the only thing he could do was notify the provider, but he had not reached out to the Resident #4's provider about their concerns regarding drug use. Staff E said he thought Staff D had spoken to Resident #4's provider about the concern. On 10/07/2025 at 1:00 p.m., an interview was conducted with Staff F, Nurse Practitioner, NP. Staff F said she was the house provider, and she oversees all the residents at the facility. Staff F said her expectations were that residents should not do illicit drugs. She said if she is made aware that a resident was doing illicit drugs, she would have the staff report the concern to psych, because she would not want any interactions with the resident's medications. Staff F said the facility had not reported to her any concerns regarding current residents using illicit drugs. On 10/07/2025 1:56 p.m., an interview was conducted with the Medical Director (MD). He said if any resident at the facility was using illicit drugs, him and the resident provider needed to be informed. He said he was never informed concerning any residents at the facility using illicit drugs. The MD stated if he was informed, he would make sure the residents know it was against the facility and federal policy. The MD said, If any resident's room smelled like Marijuana or staff sees signs of residents smoking Marijuana, then they needed to notify the residents' provider so immediate action can be taken. On 10/07/2025 at 2:00 p.m., an interview was conducted with the Director of Nurses (DON) and the Nursing Home Administrator, NHA. The DON said if a resident smelled like marijuana but did not look impaired, there was nothing they could do about it. The NHA said Nurses should contact the resident's provider if the resident was impaired or smelled like they had smoked marijuana. Review of the facility policy titled, Notification of Change in Condition, Revision Date: 12/16/2020, Revealed Policy: The center to promptly notify the Patient/ Resident, the attending physician, and the Resident Representative when there is a change in the status or condition.

Based on observations, interviews, and record review, the facility failed to provide a safe, clean, and sanitary environment, in one common room and in two resident rooms (407 and 108) located in two halls (400 and 100) of six halls observed. Findings included: An observation of room [ROOM NUMBER] on 10/7/2025 at 9:24 A.M. revealed multiple light, dark gray and black spots of biogrowth on the back wall of the closet. The corners of the closet and the floor revealed dark accumulation of microorganisms. The floors were stained with brown and black substances. An observation of the Day Room revealed two air vents on the ceiling. There was white paint around each vent and underneath the paint was black areas observed coming through the peeling paint. The paint was covering areas of moisture/condensation. An interview was conducted on 10/7/2025 at 11:50 A.M. with Staff A, Housekeeping. Staff A said each room in the facility was deep cleaned at least once per month. She said if she saw bio-growth, she would spray it with [Name of Product]. She said that product kills the biogrowth on the walls and other surfaces. She said she did not know of any room that had biogrowth at the time. Staff A said the maintenance department takes care of the ceiling and vents cleaning. An interview on 10/7/2025 at 11:55 A.M. with Staff B, Laundry Aide revealed there had been biogrowth in the facility, which would be killed with [Name of Product]. Staff B stated if there was biogrowth on the ceilings, it is reported to maintenance. He said the maintenance department was responsible for removing bio-growth. He said he did not know if there was a checklist for the deep cleaning that was done once a month. An interview was conducted on 10/7/2025 at 12:08 P.M. with the Director of Maintenance (DOM). The DOM said he repaired the vents in the day room a few weeks ago. He said he cleaned and painted the area around the vent in the ceiling. He said he did not know why it looked black underneath the paint. The DOM said he did not know about the biogrowth in the closet of room [ROOM NUMBER]. He stated he could not check every room and relies on the staff to let him know about biogrowth found in the facility. The DOM said Room108 had not cleaned, and he did know why there was a note from housekeeping indicating the room was clean. An Interview with the Nursing Home Administrator (NHA) on 10/7/2025 at 12:56 P.M. revealed room [ROOM NUMBER] was his Angel Round room (A facility program assigning administrative staff resident rooms to monitor for concerns). The NHA stated he had not looked at the room in a few weeks. He said if biogrowth was found in resident areas, then maintenance was to be notified, and they should take care of it. The NHA said he did not know if there if there was a checklist for the deep cleaning that is done in resident rooms once a month. A review of a document titled, 5-Step Daily Room Cleaning, Revised 10/25/2016 showed: 3. Spot clean walls: vertical walls are not completely wiped down daily – but must be spot cleaned daily. On 10/7/2025 at 12:56 P.M. A request for a policy for removal of bio-growth was made. The NHA said the facility did not have a policy for removal of biogrowth. On 10/07/2025 at 10:58 A.M. Resident #4 was observed in his wheelchair in the parking lot smoking. He said he goes to the west side of the parking lot for more privacy. He had a bottle of cologne on his lap and started spraying it on his body. Resident #4 said he was smoking marijuana (a psychoactive drug derived from the dried leaves, flowers, and stems of the Cannabis sativa or Cannabis indica plants, with effects Relaxation, Euphoria, Increased appetite, Altered perception, Impaired coordination, and Anxiety (in some users). Source:https://en.wikipedia.org/wiki/Cannabis. Resident #4 said some staff cared that he smoked and some staff did not. On 10/07/2025 at 2:00 pm. Resident #4 was observed in room [ROOM NUMBER] sitting in his wheelchair watching television. The room was noted with a strong smell of marijuana. Resident #4 said the smell in his room comes from him smoking marijuana outside. He said he tried to spray cologne on so the smell would not be so bad. On 10/07/2025 at 11:06 a.m. an interview was conducted with Staff C, Certified Nursing Assistant, CNA. Staff C said Resident #4 always smells like marijuana after he comes back to the facility. She said staff, and most of the residents have complained about the smell to administration but nothing has been done about it. On 10/07/2025 at 11:59 a.m., an interview was conducted with Staff D, License Practical Nurse, LPN. Staff D said, We cannot control what he does once he signs out, even if he comes back to the facility smelling like marijuana. He goes outside on a leave of absence, which means he is his own person. Staff D said she reported the concerns regarding Resident #4 smoking marijuana to the supervisor before, and the supervisor addressed the issue with the resident. On 10/07/2025 at 12:20 p.m., an interview was conducted with Staff E, Registered Nurse, RN. Staff E said if a resident returned to the facility after a leave of absence smelling like marijuana, he would ask the resident about it. Staff E stated Staff D had reported the concerns about Resident #4 smoking marijuana. Staff E said Resident #4 did smell like marijuana, but there was nothing he could do if the resident tells him something different. On 10/07/2025 at 1:00 p.m., an interview was conducted with Staff F, Nurse Practitioner, NP. Staff F said the facility had not reported to her any concerns regarding current residents using illicit drugs. On 10/07/2025 1:56 p.m., an interview was conducted with the Medical Director (MD). The MD said, If any resident's room smelled like Marijuana or staff sees signs of residents smoking Marijuana, then they needed to notify the residents' provider so immediate action can be taken. On 10/07/2025 at 2:00 p.m., an interview was conducted with the Director of Nurses (DON) and the Nursing Home Administrator, NHA. The DON said if a resident smelled like marijuana but did not look impaired, there was nothing they could do about it. The NHA said Nurses should contact the resident's provider if the resident was impaired or smelled like they had smoked marijuana. The facility did not provide a policy on removal of odors.

Based on observations, record reviews, and interviews the facility failed to protect residents from neglect and verbal abuse by two staff members (A & B) for eight residents (#1, #2, #3, #4, #5, #6, #8, and #9) out of eight sampled for abuse and neglect. Findings included: On 6/9/25 at 10:00 a.m. Resident #1 was observed lying in bed and covered with blankets. The resident reported abusive and neglectful behavior had occurred last week, had been on menstrual cycle, and was left saturated with blood all day. The resident stated having had problems several times with Staff A Certified Nursing Assistant (CNA) and Staff B CNA being disrespectful, calling names, had talked about this resident's children, and talked about other residents and staff all the time. Resident #1 stated the staff members spoke about how fat they (other residents) were and how difficult it was to roll them. The resident stated the staff members behavior had been reported before, did not remember when, and did not know what the facility response was to the report. Resident #1 stated the staff members worked with the resident every day and spoke of others every day all the time. Review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnoses including but not limited to cerebral infarction due to unspecified occlusion or stenosis of right medial cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic post-traumatic stress disorder (PTSD), aphasia following cerebral infarction, and need for assistance with personal care. Review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE] showed the resident scored 13 of 15 for a Brief Interview of Mental Status (BIMS) indicating an intact cognition. The MDS showed the resident was dependent upon staff for toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene, sit to lying, and toilet transfers. The resident required substantial/maximal assistance for rolling left to right. The resident was frequently incontinent of urine and always incontinent with bowel. Review of Resident #1's care plan revealed the following: Resident has PTSD. Trigger for PTSD may become easily agitated when staff not providing care timely (and) become anxious from loud yelling from others. An intervention dated 5/20/24 instructed Provide CNA care timely. Resident #1 has an Activities of Daily Living (ADL) self-care performance deficit related to Cerebrovascular accident (CVA) with (w/) hemi, impaired balance, history of left humerus fracture, aphasia, dysphagia, bipolar disorder, major depressive disorder, generalized anxiety disorder, chronic PTSD, behaviors, (and) insomnia. The interventions included: 2 staff in the room while providing any care as the resident is totally dependent on staff and requires extensive (ext.) total assistance by 1 staff with personal hygiene and oral care (revised 6/20/24). An interview was conducted with the Nursing Home Administrator (NHA) on 6/9/25 at 1:36 p.m. The NHA stated on 5/29/25 Resident #1 had asked the Staffing Coordinator to assist her to the NHA office where she reported an incident had occurred with Staff A and B. Resident #1 stated she had put the call light on to be changed. The resident reported during care Staff A and Staff B were talking about residents and staff by name. The resident had asked to have brief changed, found out she was on her menstrual period and the staff members refused to wipe her. The NHA stated during the investigation other residents and staff had voiced same (similar) issues. The NHA stated both staff members were suspended then terminated. The NHA reported other residents voiced the following concerns regarding Staff A and Staff B. An interview was conducted with the NHA on 6/9/25 at 7:03 p.m. the NHA stated an unidentified CNA who had showered Resident #1 after reporting the incident on 5/29/25, reported there was blood in the resident's brief. On 6/9/25 at 10:14 a.m. Resident #2 was observed lying in a bariatric bed. The resident stated staff some staff were unprofessional, they do talk about other people, a couple of staff members whom this resident had not seen recently. The resident stated they were disrespectful regarding other residents. Review of Resident #2's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to morbid (severe) obesity due to excess calories, unspecified chronic obstructive pulmonary disease, and unspecified affecting left nondominant side hemiplegia. Review of Resident #2's quarterly Minimum Data Set, dated [DATE] revealed a 7 of 15 BIMS score, indicating a severe cognitive impairment. Review of the resident's care plan showed the resident required maximum to total assistance for bed mobility, personal hygiene, and incontinent toilet use. On 6/9/25 at 10:35 a.m. Resident #3 had stated Staff A and Staff B are rude and do not clean area well when changing her. The resident reported commenting to the staff members about doing it right the first time and they responded with rude comments. Review of Resident #3's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to morbid (severe) obesity due to excess calories, need for assistance with personal care, not elsewhere classified lymphedema, and unspecified neuromuscular dysfunction of bladder. Review of Resident #3s quarterly Minimum Data Set, dated [DATE] revealed a 15 of 15 BIMS score indicating an intact cognition. Review of the resident's Kardex (a guide to patient care details), revealed the resident required a bariatric bed with a low air loss mattress, required 2 staff members for turn and repositioning, was dependent on 2 staff for incontinent toileting, and staff were to converse with the resident while providing care. On 6/9/25 at 1:36 p.m. the NHA stated Resident #4 had reported Staff A and Staff B would care for her together and if they changed her once, that was it. The resident stated they made her feel bad when she soiled self. On 06/09/2025 at 10:05 a.m., Resident #4 stated the facility got rid of the girls that were not talking appropriately. The resident was not descriptive about what happened, just that they were gone and they no longer worked at the facility. When asked if she had been abused or neglected, she said, neglected. Resident #4 said, they would only change me once. Review of Resident #4's Annual Minimum Data Set (MDS) dated [DATE] revealed the resident was admitted on [DATE] and scored 12 of 15 on the Brief Interview of Mental Status (BIMS) indicating an intact cognition. The comprehensive assessment revealed the resident was dependent on staff for toileting hygiene, bathing/showering, lower body dressing, and required substantial/maximum assistance for personal hygiene. The MDS revealed the resident was always incontinent of bowel and bladder. On 6/9/25 at 1:36 p.m. the NHA stated Resident #5 had reported Staff A and Staff B did not get her out of bed when requested and they did not put her back correctly. She stated the resident, a bariatric patient liked the bed set up in a way the resident felt comfortable and that the staff members had made her feel like a burden. On 6/9/2025 at 11:09 a.m. Resident #5 was observed lying in bed. The resident stated staff were disrespectful, not abusive, giving an example as they ignore you when the call light is on. The resident stated the staff spoke about other residents. Review of Resident #5's admission Record revealed the resident was admitted on [DATE]. The record included diagnoses not limited to morbid (severe) obesity due to excess calories, body mass index (BMI) 50.0 to 59.9 adult, need for assistance with personal care, and unspecified systemic lupus erythematosus. On 6/9/25 at 1:36 p.m. the NHA stated Resident #6 had reported Staff A and Staff B did not clean him well and would leave bowel movement on buttocks. The resident had recalled an incident when the staff members left him in the shower room alone and when asked to be changed, they made him feel like a burden. The NHA stated Resident #6 was a double above-knee amputee and should be supervised in the shower. Review of Resident #6's Quarterly MDS dated [DATE] showed the resident was admitted on [DATE]. The assessment revealed the resident had scored 12 of 15 on the BIMS indicating an intact cognition and required partial to moderate assistance for toileting hygiene, shower/bathing, and lower body dressing. The MDS showed the resident was an above the knee bilateral amputee. On 6/9/25 at 1:36 p.m. the NHA stated Resident #8 reported both Staff A and Staff B antagonized him and other residents when they asked for assistance. On 6/9/25 at approximately 4:30 p.m. Resident #8 was observed sitting in wheelchair dressed in seasonally appropriate clothing. The resident reported the ability to do a lot for self. He stated the facility had a problem with a couple of girls but understood they were gone. He did not explain what the problem was. Review of Resident #8s Annual Minimum Data Set (MDS) dated [DATE] revealed the resident was admitted on [DATE] and had scored 13 of 15 on BIMS, indicating an intact cognition. The assessment revealed the resident was independent with toileting and personal hygiene, requiring supervision with shower/bathing. The active diagnoses showed morbid (severe) obesity due to excess calories. On 6/9/25 at 1:36 p.m. the NHA stated Resident #9 reported Staff A and Staff B had left him soiled in brief and told him to wait for the next shift. The resident stated the two staff members would shut off the call light, was quick to change him when soiled, and would talk about others when caring for him making him feel like he was not even in the room. Review of Resident #9's Annual MDS dated [DATE] revealed the resident was admitted on [DATE] and had scored 12 of 15 on BIMS assessment indicating an intact cognition. The annual assessment revealed the resident had range of motion limitations to bilateral upper and lower extremities, was dependent upon staff for toileting hygiene, showering, and lower body dressing, and required substantial/maximum assistance with upper body dressing and personal hygiene. The MDS showed the resident had an indwelling catheter and was always incontinent of bowel. The active diagnoses for the resident included morbid (severe) obesity due to excess calories, paraplegia, and Parkinson's disease. Review of the resident census showed Resident #1, #2, #3, #4, #5, #6, #8, and #9 resided on the same unit and specifically on the 200 and 300 hallways of the unit. During the interview on 6/9/25 at 1:36 p.m. the NHA stated the facility had asked other staff members similar questions asked of the residents regarding Staff A and Staff B. The NHA stated the following written staff statements were submitted: - Staff C, Licensed Practical Nurse (LPN) reported both Staff A and Staff B talked to residents in an unprofessional way, resident meal trays were left in front of them for about 45 minutes and (they) speak to the residents crazy. - Staff D, CNA reported when Staff A and Staff B work together they are rude to residents and how they talk to some residents was verbally aggressive or rude unprofessional. - Staff E, Medical Records/CNA reported Staff B did not want to care for difficult residents and Staff A did not want to care (named) resident, would refuse to go into the room to pass trays. When (Staff E) was working the floor Staff A and Staff B would disappear during meal and care times, they would complain about caring for Resident #1, talk bad about the resident, complain about how hard it was to care for the resident. Staff E reported they were very verbal about it, and spoke openly in front of everyone usually around the nursing station. An interview was conducted with Staff E on 6/9/25 at 2:28 p.m. Staff E stated Staff A and Staff B would refuse to care for some residents. Staff B would intentionally make a (named unsampled) resident wait for hours before getting the resident up. The staff member reported not informing anyone, there wasn't really anything to report. Staff E reported informing Staff B the resident was ready, and Staff B would say she would get to him. The staff member stated she didn't know if this behavior was reportable. The staff member stated there was hostility between the nurses, the CNAs, and Staff A and B, when they were told to do something they didn't get done, and it went on for a while. The staff member reported Staff A and B would work together with all their assigned patients and went room to room doing patient care, they had issues with Resident #1, and Resident #1 had issues with them. Resident #1 did not like them to be assigned to her, but they continued to assigned to the resident. Staff E stated it was out of our (CNAs) hands once it was reported. The NHA, who was present during this interview responded by shaking head acknowledging he was aware. An interview was conducted with Staff C, LPN on 6/9/25 at 2:45 p.m. The staff member clarified crazy (in written statement) meant they were occasions she would hear Staff A and B speak rudely to patients. Staff C remembered one incident where a resident had told Staff B she was like a lap dog and Staff B had responded to not ask her for anything if I'm a lap dog. She stated she wrote a statement on Staff B being rude but no one followed up with her regarding the statement. Staff C stated it was always hard to talk to Staff A and B. She stated she did talk to management, but the facility has never had steady management but did not feel anything got done. An interview was conducted with the NHA on 6/9/25 at 3:05 p.m. The NHA reported switching assignments for Staff A and B. They had called the compliance hotline they were pissed about being separated. The NHA stated they were aware of the working environment between Staff A and B and the unit but did not know about the issues with the residents at the time. An interview was conducted on 6/9/25 at 4:06 p.m. with Staff F, LPN/Unit Manager (UM). The staff member reported getting a complaint at 3 p.m. regarding a resident being full of feces, and Staff B had left before doing rounds with oncoming shift. Staff F LPN/ UM reported receiving complaints from different shifts about things not being done by Staff A and B. She stated sometimes the staff members could not be found when call lights were going off (like a Christmas tree down there) and nurses would come to her regarding the staff members. Staff F reported having reported constantly to the current NHA, and have informed the Director of Nursing (DON) and HR. An interview was conducted on 6/9/25 at 5:25 p.m. with Human Resources (HR). HR reported getting lots of things under door but denied having received anything regarding Staff A and B. Review of the policy and procedure, N-1265 - Abuse, Neglect, Exploitation & Misappropriation, revised 11/16/2022, documented the policy: 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/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. The policy defined the following: - Mental Abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. - Verbal Abuse may be considered a form of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of age ability to comprehend or disability. - Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to: - Failure to take precautionary measures to protect the health and safety of the resident. - Intentional lack of attention to physical needs including, but not limited to, toileting and bathing. Failure to provide services that result in harm to the resident, such as not turning a bedfast resident or leaving a resident in a soiled bed. - Failure or refusal to provide a service for the purpose of punishing or disciplining a resident, unless withholding of a service is being used as part of a documented integrated behavioral management program. Procedure: Acts of abuse directed against residents are absolutely prohibited. Such acts are cause for disciplinary action, including dismissal and possible criminal prosecution. Questions may arise as to what actions constitute abuse of a resident. Any action that may cause or causes actual physical, psychological or emotional harm, which is not caused by simple negligence, constitutes abuse.Acts such as teasing, humiliating, degrading, or intentionally ignoring a resident may constitute abuse and will be dealt with no less severely than acts causing physical harm. Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as caused by improper or excessive action. All actions in which employees engage with residents must have their legitimate goal, the healthful, proper, and humane care and treatment of the resident. 2. Training: Employees of the center will receive education and training on Resident Rights, Resident Abuse, and abuse Reporting during orientation and annually thereafter. Additional education and training will be provided as deemed necessary. Employee obligation: 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 events 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. 3. Prevention: The center is committed to the prevention of abuse, neglect, misappropriation of resident property, and exploitation. The following systems have been implemented: - Resident Council - Grievance/Concern program including posted information on the grievance official. - Sufficient numbers of staff to meet the needs of the residents. - Department Heads and supervisors that monitor staff to identify inappropriate behavior. - Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition or other non-verbal indication of abuse. - Posted information on how to contact appropriate State agencies. 4. Identification: All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Nursing/ designee. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Nursing will serve as the Abuse Coordinator. 5. Investigation: The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation. A Social Service representative may be offered in the role of resident advocate during any questioning of or interviewing of residents. Investigations will be accomplished in the following manner Preliminary Investigation: - Immediately upon an allegation of abuse or neglect, the suspect9s) shall be segregated from residents pending the investigation of the resident allegation. - The nurse or Director of Nursing/ designee shall perform and document a thorough nursing evaluation and notify the attending physician. - An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. This report should be filed as soon as possible in order to provide the most accurate information in a timely fashion, and submitted to the Abuse Coordinator. Investigation: The Abuse Coordinator and/or Director of Nursing shall take statements from the victim, the suspect9s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/ she shall also secure physical evidence. Upon completion of the investigation, a detailed report shall be prepared. 6. Protection: Any suspect(s), who is an employee or contract service provider, once he/she has (have) been identified, will be suspended pending investigation. - The resident will be evaluated for any signs of injury, including a physical exam and/ or psychosocial assessment, as appropriate. - Increased supervision of the alleged victim and residents. - Room or staffing changes, if necessary, to protect the resdient9s) form (sic) the alleged perpetrator. - Protection from retaliation. - Provide the resident with emotional support and counseling during and after the investigation, if needed. 7. Reporting/ Response: Any employee or contracted service provider 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 events 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 Nursing is the designated abuse coordinator. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notifications of Law Enforcement if a reasonable suspicion of crime has occurred.

Based on observation, record review and interview, the facility failed to ensure a functioning grievance process for two residents (#1 and #9 ) of ten residents sampled. Findings included: A review of a Complaint / Grievance Report, dated 05/22/2025, documented (Resident #1) communicated verbally to the Social Service Assistant (SSA) a concern: Resident #1 stated 2 CNA's (Certified Nursing Assistants) were having personal conversations when providing care. The form was signed by the Social Services Director (SSD) on 05/23/2025. The form had an area to document the concern type, treatment, Care, management of funds, behavior of other residents, missing items, violation of rights, and other. The latter area was blank. The form documented nursing was assigned the responsibility for the investigation. The findings of the investigation were documented: Staff were identified and were noted to have personal conversations while providing care to residents. The plan to resolve the complaint: Education to identified CNAs. Expected results of the actions taken: Verbal education provided to identified CNAs on not having personal conversations while providing care to residents. CNAs expressed understanding. The form was signed by (Staff F, Licensed Practical Nurse) ( LPN), Unit Manager (UM), 05/26/2025. The form documented the complaint was resolved. The form was blank to indicate if the resident was satisfied. The form documented the results and resolution steps were reported to the resident. A review of Resident #1's clinical chart showed an admission in 02/2023. Medical diagnoses included but not limited to hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side; generalized anxiety disorder; and post-traumatic stress disorder. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental status (BIMS) score of 13, which indicated the resident was cognitively intact. A review of the facility Grievance log from 05/01/2025 through the 06/092025, listed two complaints filed by Resident #1, dated 05/22/2025 and 05/29/2025. An interview was conducted on 06/09/2025 at 11:01 a.m. with Staff F, licensed Practical Nurse (LPN)/ Unit Manager (UM). She stated regarding Resident #1's complaint dated 5/22/2025, I was not aware of that one coming to me directly. When I did become aware, I spoke to the resident. I did give a statement to the CNAs. If it is the same situation that I was thinking about, those two CNAs were put on suspension. She stated the SSD came to her about the concern. Staff F stated she left the building and came back on the following week. She stated she found out about the concern on 05/26 at the morning meeting. Staff F said, I spoke to her (the resident) on 05/26 about the concern. On 06/09/2025 at 12:35 p.m., an interview was conducted with the SSD. He stated the 05/22 grievance for Resident #1 was communicated to the SSA. On 06/09/2025 at approximately 12:40 p.m., an interview was conducted with the SSA with the Nursing Home Administrator (NHA) in the room. The SSA stated Resident #1 had reported regarding two staff members, she did not like the behavior; the conversations they were having, their likes and dislikes for the residents. The SSA stated she relayed the concern to the Administrator In Training (AIT). The AIT put it on the grievance form. The SSA said I did not personally investigate. During the interview, the NHA said, the grievance would have gone to the unit manager. On 06/09/2025 at 2:22 p.m., an interview was conducted with the NHA regarding Resident #1's grievance dated 5/22. A request for documentation pertaining to an investigation for the grievance revealed there was no documentation. He stated there was nothing further. He confirmed he was the Abuse Coordinator. He stated he was out of the building from 05/22 and came back on 05/27. He stated the AIT was the assigned Abuse Coordinator in his absence. An interview was conducted on 06/09/2025 at approximately 1:36 p.m. with the NHA regarding the reportable investigation he had conducted for the allegation reported by Resident #1 on 05/29. The NHA said, Resident #1 had reported on 05/29/2025 she had a care concern about Staff A, CNA and Staff B, CNA. (Resident #1) reported them talking about residents and staff by name. At the time, she wanted her brief changed and she found out she was on her period. They refused to wipe her. That was the initial complaint. Both staff were suspended. The NHA said we did interviews with other residents and staff. Other residents had identified same issues. We chose people in the same assignment. An interview was conducted on 06/09/2025 at approximately 2:30 p.m. with the AIT, she stated she did not interview (Resident #1), and she did not investigate. She stated she did not do anything about the complaint. Subsequently, at 3:58 p.m. the AIT stated she helped the SSA fill out the grievance form for resident #1 for the 05/22. She stated it looked like (Staff F, LPN, UM) did the investigation. On 06/09/2025 at 1:26 p.m., an observation was conducted of Resident #1. She confirmed she had submitted a grievance to complain about two aides on 05/22. She stated no one came and talked to her about the concern. She stated she had not received a response from the facility about her grievance submitted on 5/22. A review of a complaint/ Grievance Report dated 05/28/2025 by (Staff G, CNA), documented a concern for treatment and care for Resident #9 showing: CNA reports that resident was covered in feces and he had been sitting for a while before anyone came to change him. The staff member assigned responsibility for the investigation was Staff F, LPN, UM. The investigation: This resident was found to be covered in feces. The Aide assigned to resident was (Staff B, CNA). She was educated about the importance of providing prompt care. Expectation showed: aide will work endeavor to ensure proper care. Written teachable moment was provided to aide, signed as completed 06/03/2025. The section to be completed on whether the grievance was reportable to the state agency was not marked with either a yes or no indication. A review of Resident #9's clinical chart documented an admission of 05/2023. His diagnosis list included but not limited to Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Morbid obesity, and muscle weakness. A review of a Brief Interview for Mental status, dated 08/16/2024, documented a score of 13, with a comment Intact cognitive response. A review of Resident #9's clinical chart, the Care Plan, documented a focus area: Resident #9 has an ADL (Activity of Daily Living) self-care performance deficit and at risk for decline. Interventions included: Toilet Use: The resident is totally dependent on staff for toileting . incontinent to bowel, initiated 04/04/2023. A review of Staff B, Certified Nursing Assistant's (CNA) personnel file was conducted with the Human Resource Director (HRD). Present in the file was a document, Teachable Moment, dated 05/29/2025 for Staff B, CNA, which documented a description of action: (Resident #9) was found to be covered in feces. Good practice is we check and change residents every 2 hours. Resident states he had been asking to be changed all morning, and he had not been changed. When the 3-11 p.m. aide came on duty, you were already out of the building. She didn't get to do bedside round (receive report) and upon entering the resident's room, found resident covered in feces. The form was not signed by any person as presenting the document or receiving the document. During the review of the Teachable Moment with the HRD, she stated she did not know about the form. She stated, teachable moments are nursing documents. The HRD stated, I assume it was nursing that wrote it up with the expectation of presenting. I cannot tell you who wrote it up. An interview conducted was conducted with the NHA On 06/09/2025 at 6:33 p.m. He stated residents should be changed, At least every two hours. When asked, if a resident alleges, he had been sitting in a bowel movement (BM) since 12:00 p.m., and not changed until between 3:00 and 3:30 p.m., if it was appropriate care, he stated, I would say it is not. It has the potential to be neglect. He stated the incident was not reported. He said, I went and talked to the resident. And he said, he went to the bathroom in his brief. He said the girls were busy on the floor; he has a boisterous voice; (Staff G, CNA) thought he was yelling; and she went in and changed him. The NHA stated he asked the resident if he felt like he was neglected, and he said no, and he did not know why someone had reported it. He confirmed the staff member assigned to Resident #9 on 05/28/2025 during the 7:00 a.m. to 3:00 p.m. shift was Staff B, CNA. A review of the Complaint/ Grievance policies and procedures, last revised on 10/24/2022, documented the policy: The Center will support each resident's right to voice a complain/ grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/ grievance and inform the resident of progress towards resolution. Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility Abuse Policy. The resident should have reasonable expectations of care and services, and center should address those expectations in a timely reasonable and consistent manner.

Based on observation, record review and interviews, the facility failed to ensure an allegation of neglect was reported to the appropriate Agencies for one (#9) of ten sampled residents. Findings included: A review of Resident #9's clinical chart documented an admission of 05/2023. His diagnosis list included but not limited to Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Morbid obesity, and muscle weakness. A review of a Brief Interview for Mental status, dated 08/16/2024, documented a score of 13, with a comment Intact cognitive response. A review of Resident #9's clinical chart, the Care Plan, documented a focus area: Resident #9 has an ADL (Activity of Daily Living) self-care performance deficit and at risk for decline. Interventions included: Toilet Use: The resident is totally dependent on staff for toileting . incontinent to bowel, initiated 04/04/2023. A review of Staff B, Certified Nursing Assistant's (CNA) personnel file was conducted with the Human Resource Director (HRD). Present in the file was a document, Teachable Moment, dated 05/29/2025 for Staff B, CNA, which documented a description of action: (Resident #9) was found to be covered in feces. Good practice is we check and change residents every 2 hours. Resident states he had been asking to be changed all morning, and he had not been changed. When the 3-11 p.m. aide came on duty, you were already out of the building. She didn't get to do bedside round (receive report) and upon entering the resident's room, found resident covered in feces. The form was not signed by any person as presenting the document or receiving the document. During the review of the Teachable Moment with the HRD, she stated she did not know about the form. She stated, teachable moments are nursing documents. The HRD stated, I assume it was nursing that wrote it up with the expectation of presenting. I cannot tell you who wrote it up. An interview conducted on 06/09/2025 at 6:15 p.m. with the NHA, while reviewing the Teachable moment for Staff B, he stated teachable moment was invalid. It was not signed; it was a worthless piece of paper that should not have been in the file. He said he did not know who had filled it out; after reading it he said he should have been in on it. On 06/09/2025 at approximately 6:20 p.m., an interview was conducted with Staff G, CNA. She recalled the concern with how she had found Resident #9. She said, I came in at 3:00 p.m.; I was assigned (the back hall where Resident #9 resides). I heard someone yelling. I thought it was (Resident #9), so, I went in and checked on him. It was between 3:00 and 3:30 p.m., it was the first thing I heard. He was covered in feces from the waist, some of it was on his thighs, it was like diarrhea. He told me he had been like that since noon. Some of the feces was dried on, some of it was not, I had to scrub him. The sheets were covered in it too. I changed everything. She stated normally there is report given during shift change, but at the time, there was no one to provide the report. She stated she shared the information with the nurse, Staff C, LPN and she went and got the Unit Manager, Staff F, LPN. Staff G stated she wrote a statement and gave it to the Unit Manager, Staff F. A review of a complaint/ Grievance Report dated 05/28/2025 by (Staff G, CNA), documented a concern for treatment and care for Resident #9 showing: CNA reports that resident was covered in feces and he had been sitting for a while before anyone came to change him. The staff member assigned responsibility for the investigation was Staff F, LPN, UM. The investigation: This resident was found to be covered in feces. The Aide assigned to resident was (Staff B, CNA). She was educated about the importance of providing prompt care. Expectation showed: aide will work endeavor to ensure proper care. Written teachable moment was provided to aide, signed as completed 06/03/2025. The section to be completed on whether the grievance was reportable to the state agency was not marked with either a yes or no indication. An interview conducted was conducted with the NHA On 06/09/2025 at 6:33 p.m. He stated residents should be changed, At least every two hours. When asked, if a resident alleges, he had been sitting in a bowel movement (BM) since 12:00 p.m., and not changed until between 3:00 and 3:30 p.m., if it was appropriate care, he stated, I would say it is not. It has the potential to be neglect. He stated the incident was not reported. He said, I went and talked to the resident. And he said, he went to the bathroom in his brief. He said the girls were busy on the floor; he has a boisterous voice; (Staff G, CNA) thought he was yelling; and she went in and changed him. The NHA stated he asked the resident if he felt like he was neglected, and he said no, and he did not know why someone had reported it. He confirmed the staff member assigned to Resident #9 on 05/28/2025 during the 7:00 a.m. to 3:00 p.m. shift was Staff B, CNA. The NHA stated the process for reporting an allegation was, I report it to our clinical team and the Regional Nurse Consultant, who is their Risk Manager. Then, I write up my initial findings, submit on the AIRS (AHCA Incident Reporting System) system; notify the Department of Children and Families, police, and any other parties necessary, and then. begin the investigation. The NHA confirmed this incident was not reported. Review of the policy and procedure, N-1265 - Abuse, Neglect, Exploitation & Misappropriation, revised 11/16/2022, documented the policy: 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/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. 7. Reporting/ Response: Any employee or contracted service provider 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 events 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 Nursing is the designated abuse coordinator. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notifications of Law Enforcement if a reasonable suspicion of crime has occurred.

Based on observation, interview and record review the facility failed to ensure residents who were assesed to need constatnt supervision during smoking received adequate supervision for nine (#10, #13, #8, #12, #14, #9, #11, #15 and #26) of 27 sampled residents. Findings included: Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke. However, for the safety of all residents and staff the center has promulgated a safe smoking policy. All residents who wish to smoke at the center will abide by the center's smoking policy. Residents electing to smoke will be provided a safe smoking assessment to determine and evaluate each resident's ability to safely smoke. Because violations of the smoking policy can lead to catastrophic consequences, the smoking policy will be vigorously applied without exception. Violations of the policy will result in remedial action based upon the nature of the infraction. Remedial includes but is not limited to warning, revocation of smoking privileges, police intervention, and / or discharge. This agreement represents your acknowledgement that the center has provided you a copy of the center's smoking policy and your agreement to abide by the terms set forth in the policy. I, undersigned, understand that these safety rules apply to me and the safety of the other residents and violations may result in subsequent education, warnings, and other remedial actions at the discretion of the Executive Director. 1. During an observation on 04/02/2025 at 11:24 a.m. Resident #10 self-propelled herself in her wheelchair into the building from outside. A cigarette lighter was observed in her lap. Resident #10 was observed propelling herself through the building to her room and onward to the end of the 300 hallway. Resident #10 stated she goes outside to smoke. Resident #10 stated she has to sign out LOA to in order to smoke. Resident #10 stated she has to go out to the sidewalk on the busy road. Resident #10 stated, The road was not safe, the cars are so fast, it is dangerous. Resident #10 stated she was allowed to go outside to the sidewalk to smoke from 8 a.m. to 8 p.m. Resident #10 stated she signs out either at the nursing station or the front desk. Resident #10 stated they cannot smoke in the parking lot. Resident #10 stated they are supposed to give their cigarettes and lighter to them (the facility), but she forgot about her lighter today. Resident #10 stated there were about 10 of us who go outside to smoke. 2. An observation on 04/03/2025 at 9:00 a.m. revealed Resident #13 self-propelling himself down the sidewalk. He was observed by a second surveyor to be crossing 4 lanes of traffic at the corner of the facility's lot. Three other residents were observed sitting on the sidewalk in front of the building beside the 6 lanes of traffic smoking. The traffic appeared to be speeding, by travelling at approximately 40-45 mph (miles per hour). Record review of the Admission Record showed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included but not limited to diabetes, absence of left and right leg above knee, muscle weakness, Chronic Obstructive Pulmonary Disease, Atrial fibrillation, hypertension, need for assistance for personal care, supraventricular tachycardia, and nicotine dependence. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. Review of the physician orders showed may go out on LOA on 12/11/2024. Review of the Smoking Evaluation for Resident #13 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the Care plan showed Resident #13 was a smoker, initiated on 10/18/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 10/18/2024; The resident was able to: (light own cigarette), has LOA to go out front to smoke as of 10/18/24 and revised on 03/25/2025. Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 11/08/2024. The resident requires a smoking apron while smoking as of 10/18/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #13 signed it on 10/18/2024. 3. During an observation on 04/02/2025 at 9:00 a.m. Resident #8 was observed exiting the building with his cigarettes in his lap. Review of Resident #8's Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease, diabetes, nicotine dependence. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J the resident was a tobacco user. Review of the physician orders for Resident #8 showed, may go out on LOA (Leave of Absence) as of 12/11/2024. Review of the Smoking Evaluation for Resident #8 as of 03/09/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the Care plan for Resident #8 showed the resident was a smoker, initiated on 11/08/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 11/08/2024; The resident was able to: (light own cigarette), has LOA to go out front to smoke as of 11/08/24 and revised on 03/25/2025. Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 11/08/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #8 signed it on 10/18/2024. 4. Record review of the Admission Record showed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included but not limited to nondisplaced supracondylar fracture, paraplegia, cervical spinal stenosis, need for assistance with personal care. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. Review of the physician orders for Resident #12 showed, may go out on LOA on 12/11/2024. Review of the Smoking Evaluation for Resident #12 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking Review of the Care plan for Resident #12 showed the resident was a smoker, initiated on 07/10/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 07/10/2024; Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 07/10/2024. Review of the record revealed Resident #12 had not signed the Smoking Agreement/Notice of Policy. The signed policy was requested and not provided. 5. Review of the Admission Record showed Resident #14 was admitted to the facility on [DATE] with diagnoses included but not limited to Congestive Heart Failure, hypertension. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. Review of the physician orders for Resident #14 showed, may go out on LOA on 12/11/2024. Review of the Smoking Evaluation for Resident #14 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the Care plan for Resident #14 showed the resident was a smoker, initiated on 05/01/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 05/01/2024; the resident requires supervision while smoking as of 05/01/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #14 signed it on 04/30/2024. 46498 6. On 4/02/2025 at 11:38 a.m. and on 4/3/2025 at 12:30 p.m., Resident #9 was observed sitting outside the driveway smoking a cigarette in a high back wheelchair. She was observed located on the driveway leading out into a busy three-lane highway where cars were observed entering and leaving out of the driveway. Resident #9 stated the staff at the facility told her that she has to smoke outside where she is located, because she is not allowed to smoke on the premises. She stated no one had told her where she could safely smoke. Review of the Admission Record showed Resident #9 was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease, unspecified, other abnormalities of gait and mobility, muscle weakness (generalized). Review of a Minimum Data Set, dated dated dated [DATE] Section C- Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #9 is cognitively intact. Review of Section J showed Resident #9 has shortness of breath or trouble breathing with exertion. Review of the Smoking Evaluation for Resident #9 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the care plan for Resident #9 showed a focus showing Resident #9 is a smoker, date initiated,1/7/2025. The goals showed Resident #9 will not suffer injury from unsafe smoking practices through the review date, date initiated 1/7/2025. Interventions showed to instruct residents about the facility policy on smoking: locations, times, safety concerns, dated initiated 1/7/2025. Review of the Admission Record for Resident #10 showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to generalized muscle weakness, need for assistance with personal care, chronic obstructive pulmonary disease, unspecified, and other abnormalities of gait and mobility Review of the Smoking Evaluation for Resident #10 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #10 showed a focus for smoking. Review of the care plan goals showed Resident #10 will not smoke without supervision through the review dated, date initiated 11/7/2024. Review of the intervention showed Resident #10 requires supervision while smoking. Date initiated 11/7/2024. 7. Review of the Admission Record for Resident #11 showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic venous hypertension (Idiopathic) with ulcer of left lower extremity, history of falling, cerebral infarction, unspecified, wheezing. Review of the Smoking Evaluation for Resident #11 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #11 showed a focus for smoking date initiated 3/25/2025. The goals showed Resident #11 will not suffer injury from unsafe smoking practices through the review date, date initiated 3/25/2025. interventions showed to instruct residents about the facility policy on smoking: locations, time, safety concerns. The resident can (light own cigarette) Has Leave of absence, LOA to go out front to smoke. 8. Review of the Admission Record for Resident #15 showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to encounter for orthopedic aftercare following surgical amputation, chronic obstructive pulmonary disease, unspecified, muscle weakness (generalized), other lack of coordination. Review of the Smoking Evaluation for Resident #15 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #15 showed a focus for smoking date initiated 10/21/2024. The goals showed Resident # 15 will not smoke without supervision through the review date 10/21/2024. The interventions showed the resident requires supervision while smoking, date, initiated 11/27/2024. On 4/3/2025 at 2:00 p.m., an interview was conducted with Staff D, the Administrator in Training, AIT. Staff D, AIT stated she did not really know much about the smoking situation so she would have to get someone else to discuss smoking. Staff D stated she came from a non-smoking facility, and she can see that residents smoking in the front next to the road can be a concern. Staff D stated she knew Activities keep track of the list of residents who smoke, and nursing does the smoking assessments. She stated the residents who sign out leave of absence (LOA), are the residents who do not want to smoke within the facility's time frames. Staff D stated they even have a hard time getting the LOA cards back from the residents who go outside, and they have a hard time keeping track of their smoking materials. On 4/3/2025 at 2:45 p.m. an interview was conducted with Staff A, The Support Director of Nurses, DON. Staff A stated that when a resident is admitted to the facility and the resident is identified as a smoker, nursing takes them out to do an assessment to see if the resident is a safe smoker or not. After the nursing assessment is completed, nursing notifies the Activity Director so she can go over the smoking policy with the resident and have them sign it during that time. She stated after the residents are provided with the smoking policy, they are placed in a smoking group according to smoking times. Residents that go out to smoke in front of the building have a leave of absence, LOA, order to go out. Staff A stated if a resident had an order and signs out LOA, they can go in front of the building or wherever they want. She stated the residents observed outside have an LOA order and they can go outside in front of the building to smoke. Staff A stated the facility's times for smoking was only for residents who require supervision while smoking. She stated if a resident had an LOA order, they could go out on their own. She stated she had not spoken to the residents about the safety concerns when smoking near the road, which could be a safety issue. She stated she had not asked any of the residents if they had any concerns about smoking next to the road in front of the building. She stated the assessments that show the residents needed constant supervision were completed wrong. Staff A said, It was just human error, she was just clicking off on the quarterly assessment trying to get them all caught up on. She stated residents who smoke should have a smoking assessment, a care plan and a signed smoking policy. 52156 An observation was made on 04/02/2025 at 12:55 p.m. revealing an unidentified resident on her way back inside to the facility from smoking. Further observation revealed three other residents were observed outside smoking on the sidewalk in front of the facility's parking lot. Review of the Leave of Absence (LOA) sign-out sheet revealed two of the four residents observed outside had filled the sign-out sheet with their sign-out time. Further review of the LOA sign-out sheet revealed documentation of a sign in time pre-filled, but the residents were observed on the sidewalk smoking. Resident #13 had a sign out time of 11:25 a.m. and a return time of 11:45a.m., but was observed on the sidewalk smoking at 1:02 p.m. Resident #14 had a sign out time of 8:30 a.m. and a return time of 12:50p.m., but was observed on the sidewalk smoking at 1:05 p.m. 9. An interview was conducted on 04/03/2025 at 10:55 a.m. with Resident #26. She stated smoking had become an issue. She stated ever since residents moved from another facility, they went from not having many smokers to having a lot of smokers. Resident #26 stated, They really needed to get a designated smoking aide. She said aides are pulled from the floor and caused residents to not get help if needed during the smoking times. Resident #26 stated she had been told that her aide was overseeing the smoking breaks, and she would be assisted when the aide returned. Review of the Admission Record showed Resident #26 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, type 2 diabetes, and contracture left hand. A review of the quarterly MDS (Minimum Data Set) revealed Resident #26 had a BIMS (Brief interview Mental Status) score of 14, indicating intact mental cognition. Review of the facility's policy, Smoking-Supervised, revised 02/07/2020 showed The Center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. Smoking is only allowed in designated areas and during designated times. The Center will have safety equipment available in designated smoking areas including: smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. Procedure: 1. Residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. 2. 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. 3. The Center will establish and post designated smoking areas and times. 4. During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. 5. The Center will retain and store matches, lighters, etc. for all residents. 6.All residents who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures. 7. Residents will be advised upon admission that violations of the smoking policy may result in revocation of smoking privileges, discharge, and/or being reported to law enforcement. 9. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based on observations, interviews, and facility record review, the facility failed to ensure sufficient staffing met the needs of the residents as evidenced by: 1. Resident interviews on untimely call light response for five residents (#5, #23, #24, #25 and #26) of six residents sampled, 2. Unresolved grievances related to call light response times for one resident (#5) of two residents reviewed for grievances. Findings Included: An interview was conducted on 04/02/2025 at 9:45 a.m. with Resident #23 and #24. Resident #24 stated that the staffing was often a problem. She stated staff often said they were Short-handed and didn't have time to assist her or she had to wait longer for assistance. Resident #24 stated she was often provided with incontinence care only one time during the first shift of the day. Resident #23 confirmed that she had brought up her concerns. He stated that he's an independent resident but had observed they took a long time to assist Resident #24. Record review revealed that Resident #23 was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, muscle weakness, and chronic pain syndrome. A review of Resident #23's quarterly MDS (Minimum Data Set) dated 02/21/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11, indicating intact mental cognition. A record review for Resident #24 revealed the resident was admitted to the facility on [DATE] with diagnoses hemiplegia and hemiparesis following unspecified cerebrovascular infarction affecting left non-dominant side, muscle wasting and atrophy, non-pressure chronic ulcer of the left heel and midfoot, and polyneuropathy. A review of Resident #24's comprehensive MDS (minimum Data Set) dated 03/04/2025 revealed the resident had a BIMS score of 12, indicating intact mental cognition. An interview was conducted on 04/02/2025 at 10:15 a.m., with Staff I, Licensed Practical Nurse (LPN). She stated staffing was constantly an issue, usually had more than 30 residents. Staff I, LPN stated that shift she had 34 residents. She stated she felt like she was constantly rushing and in a hurry to get everything done. Staff I, LPN stated she often felt like they didn't have the help that they needed to be able to properly take care of all of their residents. An interview was conducted on 04/02/2025 at 10:25 a.m., with Resident #25. Resident #25 stated that she was often told by a Certified Nursing Assistant (CNA) that she didn't have time to help her. She stated the CNA told her they had too many residents and were short staffed. Resident #25 stated she recently had a situation where she sat in the hallway for two hours after asking her CNA to help her back to bed. She stated that she has brought up the lack of response and the poor attitude of aides when they've been asked to assist her to the administration. A record review of Resident #25 revealed that she was admitted to the facility on [DATE] with diagnoses of systemic lupus erythematosus, type 2 diabetes, morbid severe obesity, and polyosteoarthritis. A review of Resident #25's quarterly MDS dated [DATE] revealed the resident to have a BIMS score of 13, indicating intact mental cognition. An interview was conducted on 04/02/2025 at 10:35 a.m., with Staff H, CNA. She stated that she had been with the facility for many years and staffing, Had gotten really bad. Staff H, CNA stated they often only had 4 or 5 CNAs taking all of the residents. Staff H, CNA stated certain sections had a lot of heavy acuity residents where it could be impossible to get everything done. Staff H, CNA stated residents complained about not getting their showers or incontinent care in the time that they wanted. Staff H, CNA stated they could only do their best and couldn't possibly get to each resident quickly when they wanted it. An interview was conducted on 04/02/2025 at 11:15 a.m. with Staff F, LPN. She stated that staffing in the facility was really bad. Staff F, LPN stated she's heard residents complain about staff response, but she felt they tried their best. Staff F, LPN stated she always had between 30-34 residents and often felt overwhelmed with the number of residents she had. She stated she frequently had to stay an hour or more past her shift trying to finish her work. An interview was conducted on 04/02/2025 at 10:55a.m. with Resident #26. Resident #26 stated depending on who was working she got her call light answered in, Okay timing. and stated specifically on 3-11 p.m. shift the staffing seemed to be short because staff were always slower to answer the call lights. A record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, type 2 diabetes, and contracture left hand. A review of the quarterly MDS dated [DATE] revealed that Resident #26 received a BIMS score of 14, indicating intact mental cognition. An observation was made on 04/02/2025 at 11:16 a.m. A bathroom alarm was on and it was observed that Staff K, unit manager, was sitting at the nurse's station. Further observations revealed Staff M, CNA, was walking down the other hallway, looked at the room with the call light on, and continued walking. Another staff member, on their way out the unit, asked Staff M CNA if it was her resident. Staff M, CNA, responded that it was not, but she would find the CNA who was assigned to that room. An interview was conducted on 04/03/2025 at 11:55am with Resident #5. Resident #5 revealed her grievance, about call lights had not been addressed and no one ever followed up with her. She felt there was still an issue with staff not answering the call light in a timely manner and receiving the care she needed when she used it. Resident #5 stated that day she returned from an appointment and asked the CNA to assist her back in to bed, as she had been in her wheelchair for a prolonged period of time. She stated the CNA told her she wouldn't assist her back into bed because the lunch trays were arriving soon. She stated she felt staffing had always been the same and believes there is a care issue. Resident #5 stated she's not sure if it's the number of staff or if it was specific aides that didn't want to do the work. A record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease without dyskinesia, type 2 diabetes, and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. A review of Resident #5's quarterly MDS revealed the resident to have a BIMS score of 08, indicating moderately impaired cognition. An interview was conducted on 04/03/2025 at 2:06 p.m. with Staff J, CNA. She stated that staffing can be bad depending on the day. Staff J, CNA revealed the days when there were low staffing, it made it difficult to get all of her resident care done. She stated that staffing is especially difficult during the 3-11 shift. Staff J, CNA stated during the day if they were short staffed, they had the extra aides like restorative or central supply to help. She stated if the 3-11 shift is short staffed, they don't have, the extra hands. Staff J, CNA stated that if they have 1 or 2 call offs, they wouldn't have the extra hands to help if they need it. An Interview was conducted at 04/03/2025 at 2:39 p.m., with Staff D, Administrator in Training (AIT). The Staff D, AIT was aware of the issues with the call lights. She stated that the facility completed call light audits as well as educated the staff on anyone being able to answer the call light. Staff D, AIT stated call lights were still being looked at in the Quality Assurance Performance Improvement (QAPI) meetings. She stated they hadn't been doing audits long enough to do any tracking or trending. Staff D, AIT stated she was not aware of a staffing problem, as she felt they met the numbers. She stated they are actively trying to hire more staff, especially for the 3-11 shift where she knew they had needs. 2. On 4/2/25 at 9:58 a.m., an observation of the 300-hall revealed room [ROOM NUMBER] had an active call light. Staff G, Certified Nursing Assistant (CNA) was observed in the 300- hall while the call light was on. Staff F, Licensed Practical Nurse (LPN) were observed in the 300- hall while the call light was on. Further observations revealed a housekeeping staff at the door, across from the room with the call light on. At 10:05 a.m., Staff K, LPN/Unit Manager (UM) was observed sitting at the nurse's station and walked over to room [ROOM NUMBER] to answer the call light. Observations of the 300-hall revealed the three staff were still present in the area where the call light was on. 50570 On 4/2/25 at 3:05 p.m., an interview was conducted with the resident council president who stated, Evening shift aids disappear off the floor, except for a few of them. She stated that sometimes staff tell her there's only three nurses, and she needs to wait. She stated that sometimes there are three CNA's for the whole floor, when there's supposed to be more. The resident council president stated staff tell her they are short staffed. Regarding call light concerns, she felt, It's work ethic, not a staffing issue. She stated at the last resident council meeting, they were informed by the administrator that call light audits were being conducted. She stated the staff conducting call light audits told her, The longest wait was 30 minutes. The resident council president stated, Staff don't take anything we say seriously. It's like a joke. On 4/3/25 at 11:35 a.m., an interview was conducted with Staff D, Administrator in Training (AIT) about the manager on duty (MOD) program implemented on 3/22/25. She stated MOD is on weekends and they have a, To do list, to include call light audits. She stated room rounds are conducted Monday through Friday to include call light audits. She stated room rounds were something the facility was already doing but was updated around February 2025. She stated the expectation for call light audits during the week is 12 rooms and 10 rooms on the weekends. The AIT stated, Call light response has been pretty good. She stated if they take longer, It's because they were providing care to another resident. Staff D, AIT stated anyone can answer the call light and this has been discussed in town hall meetings. Staff D, AIT stated they don't have an expectation of how quickly staff should respond to call lights. She stated, Respond as timely as you can. She stated the if a staff member answered a call light and it's not within their scope, they should leave the call light on and get the appropriate person. She stated they are in their third week of call light audits. Staff D, AIT stated she's monitoring rounds and conducts follow-up with residents. She stated the resident council president told her the call light response is improving, and she's received the same feedback from other residents. A review of the facility's grievance log revealed two grievances related to call lights in January and March 2025. On 4/3/25 at 12:02 p.m., an interview was conducted with the Social Services Director (SSD). She stated currently upper management staff were conducting room rounds, to include call light response audits. The SSD stated these staff have assigned rooms. She stated call light responses are observed every morning during room rounds. The SSD stated the room rounds are conducted each shift. She stated room rounds have been helpful, so they are aware of the residents' issues. She stated they found responses to call lights varies, because of staff and shift. She stated room rounds and the MOD conducted call light audits for different rooms and times of day. She stated MOD audits on weekends have helped improve call light concerns. She said the room rounds conducted Monday through Friday have demonstrated improvements in call light concerns. The SSD stated she's received feedback from residents that the call light response has improved. On 4/3/25 at 12:17 p.m., an interview with the SSD revealed grievances are discussed during morning meetings. She stated concerns from resident council meetings are communicated by the activities director, or their assistant, at morning meetings. She stated any outstanding grievances are also discussed. The SSD stated recent concerns from the resident council meetings include the CNA's response to call lights. On 4/3/25 at 12:38 p.m., an interview was conducted with Staff E, Staffing Coordinator/CNA. She stated staffing is according to the patients per day (PPD). She stated the typical ratio is 10-12 residents for one CNA. She stated for nursing, it's two nurses per unit for a total of four nurses. She stated they don't exceed 40 residents for one nurse. Staff E, Staffing Coordinator/CNA stated one nurse typically has 25 to 31 residents. She stated if there was a staff call out, they send text messages first to see who can come in. Staff E, Staffing Coordinator/CNA, stated if no one can came in, and it's a nurse call out, then one of the unit managers, wound care nurse, Assistant Director of Nursing (ADON) or Director of Nursing (DON) will take over. She stated if it's a CNA call out, they have staff in other departments such as, restorative aid, activities staff, medical records, or central supply, that have their CNA certification. She stated for the staff, such as restorative aid or activities, that are covering as a CNA are not expected to complete both roles. Staff E, Staffing Coordinator/CNA stated she looked at the daily census to re-assess and adjust staffing. She stated she uses the bed board to determine how many residents a CNA and nurse will have. She confirmed she takes into consideration the residents' needs when determining the staffing ratio. She stated on weekends there are more CNAs on the floor, therefore they have less residents. She stated CNAs on weekends typically have 9-10 residents, instead of 12. She stated if there are staffing concerns from residents, those concerns would go to the SSD. She stated concerns directly from staff would come to her, then she would go to the Director of Nursing (DON) to adjust assignments or do room changes. She stated when she came to the facility in December 2024, she brought it to the DON's attention about adjusting assignments. She stated numbers are different now. Staff E, Staffing Coordinator/CNA, stated that CNAs now have a whole unit with a hall partner, instead of having room assignments in multiple units. Regarding resident smoke breaks, she stated everyone has special duties which is indicated on the daily assignment sheet. She stated staff assigned to resident smoke breaks are rotated daily. She stated it's typically a CNA, but anyone could do it. She stated when a CNA leaves the unit to go the resident smoke break, They work it out on the floor. She stated the CNA is expected to let their hall partner or someone know they are stepping off the floor. She stated smoke breaks are 25 minutes, with two smoke breaks per shift. On 4/3/25 at 3:22 p.m., Staff C, Registered Nurse (RN), Regional Director of Clinical Services stated the facility does not have a staffing policy. A review of the facility's policy titled, Complaint/Grievance, with an effective date of 11/30/2014 and a revision date of 10/24/2022, revealed the following, . The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution. Further review of the grievance under procedure revealed the following, .8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request.

Based on observations, interviews, and record review, the facility failed to have a system in place to enable accurate reconciliation and accounting for all controlled medications for 4 out of 6 sampled medication carts. Findings included: An observation was conducted on 04/02/2025 at 10:20 a.m. with Staff L, Licensed Practical Nurse (LPN) for the 500 hallway medication cart. Staff L, LPN was observed placing one Medication Monitoring / Control Records log into the 500 hallway narcotic book. The Shift Change Controlled Substance Inventory Count Sheet showed there were 25 cards and 1 bottle of liquid in the narcotic drawer. Staff L counted the cards as well as the bottle of liquid controlled substance, and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drugs/cards were compared to the individual Medication Monitoring / Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 500 hallway showed the following residents on 04/02/2025 had narcotics added to the medication cart, without a second nurse verifying the medications. Resident #22 had Temazepam added to the cart, Resident #21 had Oxycodone and Lyrica added to the cart, and Resident #20 had Percocet added to the cart. Each resident had a completed narcotics card and a second nurse signature was missing as verification. None of the narcotic cards revealed the strength of each medication. An observation was conducted on 04/02/2025 at 10:20 a.m. with Staff L, LPN for the 600 hallway medication cart. Staff L, LPN was observed placing three Medication Monitoring / Control Records logs and three individual controlled drug cards into the 600 hallway narcotic book and narcotic drawer. The Shift Change Controlled Substance Inventory Count Sheet showed there were 25 cards in the narcotic drawer. Staff L counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drugs/cards were compared to the individual Medication Monitoring/Control Records logs and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 600 hallway showed on 04/02/2025 the following residents had narcotics added to the medication cart without a second nurse verifying the medications. Resident #19 had Zolpidem added to the cart, and Resident #18 had Morphine and Oxycodone added to the cart. None of the narcotic cards revealed the strength of each medication. Staff L, LPN stated she had education regarding narcotics/medication administration. Staff L stated the education included they were to have double signatures for the narcotic medications when the medications arrived from the pharmacy. Staff L stated when a narcotic was discontinued or the card was empty they were to have two nurses sign the sheet and the card, and the medication was to be taken to the Director of Nursing (DON) office. An observation was conducted on 04/02/2025 at 10:47 a.m. with Staff M, LPN for the 400 hallway medication cart. The Shift Change Controlled Substance Inventory Count Sheet showed there were 31 individual controlled drug cards in the 400 hallway cart. Staff M counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drug cards were compared to the individual Medication Monitoring/Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 400 hallway showed the following residents had narcotics added to the medication cart on 04/02/2025 without a second nurse verifying the medications. Resident #17 had Norco added to the cart. The medication strength was not documented for the medication. Staff M, LPN stated they had education on narcotic counts and counting the narcotic cards with two nurses at shift change. Staff M stated two nurse had to sign when medications come in (from the pharmacy). Staff M stated if a narcotic card was empty or discontinued two nurses had to sign off and the card goes to the DON's office. An observation was conducted on 04/02/2025 at 11:15 a.m. with Staff F, LPN for the 100 hallway medication cart. The Shift Change Controlled Substance Inventory Count Sheet showed there were 44 individual controlled drug cards in the 100 hallway cart. Staff I counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drug cards were compared to the individual Medication Monitoring /Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 100 hallway showed the following residents had narcotics added to the medication cart on 03/31/20255 without a second nurse verifying the medications. Resident #16 had Ativan added to the cart, Resident #11 had Morphine added to the cart, and Resident #7 had Oxycodone added to the cart. The medication strength for the narcotics was not documented on the card. Staff F stated she had education regarding narcotic administration which included two nurses verifying the medications from the pharmacy. She stated two nurses do the narcotic count at shift change. She stated two nurses have to sign and verify the discontinuation of medications. Review of the Education Sign In sheets for Receiving Narcotics and Documentation on 02/13/2025 and 02/18/2025 showed the following: All narcotics received must be received by two nurses. They are added to the narcotic flowsheet by resident names, medication, and how many cards. When giving prn (as needed) pain medication you sign out of narcotic book and in medical record software. If the narcotic order is changed in frequency, put order change sticker on the card. If the narcotic is discontinued bring to DON for destruction. The four nurses observed on 04/02/2025 were on the Education In-service attendance record for 02/13/25. An interview was conducted on 04/03/2025 at 9:56 a.m. with Staff C, Regional Registered Nurse (RRN), Staff A, support DON, and Staff B, Interim DON regarding narcotic administration education. Staff C stated due to an incident they started education on proper narcotic management and re-education. They identified opportunities within the program that the count sheets were not being filled out properly and they were hard to follow. They started re-education on shift-to-shift count, completion of the actual count forms (Medication Monitoring / Control Records), accepting medication (narcotics), taking discontinued medications and empty cards to the DON. Staff C stated they implemented audits to make sure the flow sheet Shift Change Controlled Substance Inventory Count Sheet was documented properly with adding narcotics (plus), deleting narcotics (minus), and second signatures documented. Staff C stated they implemented audits on documentation of delivery slips. Staff C stated they identified opportunities within the building which included documentation of prn's (medications), and low inventory. They were filling out the sheet Shift Change Controlled Substance Inventory Count Sheet daily instead of a continual flow. Prior administration changed it to a daily form, and did not see it as a possible problem. Staff C stated they did audits daily for 2 weeks, twice a week for 2 weeks and were to perform weekly for 4 weeks and monthly for 2 months. Staff A stated they reviewed the Shift Change Controlled Substance Inventory Count Sheet on the audits they were performing. Staff C verified the residents that were added to the Shift Change Controlled Substance Inventory Count Sheet did not have two nurse verification. Staff A stated the surveyors reviewed the Shift Change Controlled Substance Inventory Count Sheet on the off two-week audit. Staff B stated they educated the nurses when the narcotics come into the building from the pharmacy and the bags are sealed. The sealed container can be signed by one nurse and when the bag is opened, two nurses must sign and validate the contents. Staff B stated the nurses were educated to initial on both the individual narcotic Medication Monitoring / Control Records and delivery slip inside the bag. Staff B stated on the Shift Change Controlled Substance Inventory Count Sheet the nurse was to add the resident name and drug to the sheet including the quantity of the narcotics. The second nurse was to initial for validation of the medication. Staff B stated a second nurse was also to initial validation if a card was zero with the resident name, drug name, and then removed from the total number of cards found in the narcotic drawer. One nurse signs and the second nurse initials as a witness. Staff B stated the nursing staff was educated to follow this process. Staff A, Staff B, and Staff C verified the Shift Change Controlled Substance Inventory Count Sheet lacked the second signature. After interview with Staff A, Staff B, Staff C, an observation on 04/03/2025 at 10:30 a.m. was performed with Staff B, Interim DON of the narcotic books. The following number of Medication Monitoring / Control Records were not initialed /validated by a second nurse. 100 hallway 17 out of 35 or 49% 200 hallway 9 out of 25 or 36% 300 hallway 11 out of 22 or 50% 400 hallway 19 out of 29 or 66% 500 hallway 17 out of 22 or 77% 600 hallway 10 out of 22 or 45% During an interview on 04/03/25 at 10:47 a.m. with Staff C, RRN she stated they had an ADHOC meeting on 02/10/2025. Staff C stated they were not following the process for counting cards and comparing to the physical card count. Staff C stated they reviewed the current policies and procedures. Staff C stated they educated the nurses to follow policy and procedure. Staff C stated they also did a three day look back. They had a second ADHOC on 02/20/2025. Staff C stated the Unit Managers (UM) were given the task to perform weekly audits and the DON auditing was started. The UM's were auditing daily for 2 weeks, and then biweekly for 2 weeks they were to progress to weekly for 4 weeks and then monthly for 2 months. Staff C stated the UM's were supposed to be looking at the Shift Change Controlled Substance Inventory Count Sheet. Staff C stated the UM audits included Controlled substance count is correct? Documentation on the Medication Administration Record (MAR) reflects what is signed out on the Shift Change Controlled Substance Inventory Count Sheet. Staff C stated she did not know how many residents were sampled for the audits. Staff C stated they had an ADHOC on 02/27/2025 and reviewed the audits and the process was being followed. Staff C stated they had no issues or concerns noted in Quality Review. Updates were added to the new hire orientation for nurses. Staff C stated we will have to go back to ADHOC. Staff C stated we will have to look at the policies again and re-audit based on the policy. Staff C stated the QA process did not work. Staff C stated we will have an ADHOC today. Staff C stated they reviewed their policy and it does not say they are to have two nurses initial on the individual narcotic Medication Monitoring / Control Records. Staff C stated they over did it and did not follow the policy / procedure. Staff C stated they will re-educate the nurses. Review of the facility's policy, Acceptance of Controlled Drugs, revised on 02/17/2025 showed the following: To ensure controlled drugs are properly accounted for in accordance with federal regulations. Procedure: Controlled drugs will be delivered to the facility by the pharmacy in a sealed, tamper proof container. One nurse will electronically sign for the container. Receiving nurse should inspect integrity of the sealed container and not accept a container that may have been opened or tampered with. The container will remain sealed until second nurse is available to open and validate the contents. 2 nurses will open their controlled drug container and reconcile the pharmacy manifest to the controlled drugs sign the manifest. The manifest is placed in the medication room. Controlled medications are then placed into the medication carts by nurses. If discrepancies are found during reconciliation, notify the director of nursing immediately and the pharmacy within 24 hours. Discrepancies may include but are not limited to: missing controlled drugs, incorrect quantities, damaged containers or seals, tote is open or there is evidence of tampering. The Medication Monitoring Control Record from pharmacy will be placed in the Narcotic Book. The Shift Change Control Substance Inventory Control Sheet will identify the addition of the new control drug. It will be kept with the medication monitoring control record in the narcotic book. Review of the facility's policy, Controlled Drug Count, revised 02/19/2025, showed the following: This policy outlines the process for counting and documentation of controlled substances chain of custody from off going nurse to oncoming nurse and additional steps to take if a discrepancy is discovered. Procedure 3. The two nurses to count the number of Medication Monitoring Control Records and boxes / card / etc. A. verify that the number of individual boxes / card / etc. matches the number on the Shift Change Controlled Substance Inventory Count Sheet. Review of the facility's policy, Controlled Drug Disposal, revised 02/19/2025, showed the following: To ensure controlled drugs are disposed of and records maintained to Federal and State Laws and regulations to the director of nursing and the consultant pharmacist. Discontinued Controlled Drugs Discontinued controlled drugs are controlled drugs that have been discontinued, or resident has been discharged . Nurse to remove the control drug from the medication cart along with the Medication Monitoring Control Record. Controlled drug to be given to the director of nursing. Director of nursing to verify the controlled drug and that the amount remaining with a second nurse. Director of Nursing and a second nurse sign the Medication Monitoring Control Record to verify removal. Director of Nursing and a second nurse to document that controlled drug on the pharmacy Electronic Drug Destruction Log.

Based on observations, interviews, and record review, the facility failed to establish and implement a Quality Assurance and Performance Improvement Program (QAPI) that enabled accurate reconciliation and accounting for all controlled medications for 4 out of 6 sampled medication carts. Findings included: Review of the facility's policy, QAPI Goals, 2025 QAPI Plan, not dated, showed the following: At Aspire at Seminole we are committed to focusing on clinical care, quality of life and resident choice. On behalf of those we serve, we are committed to using QAPI to improve our performance and practices and to assure wee meet and exceed regulatory requirements and standards. Scope: Aspire at Seminole's QAPI program encompasses all areas that impact quality of care, quality of life, resident choice and care transition with participation from all disciplines. Patient-Driven Care: all patient care is patient-driven to ensure that residents are properly cared for and are a part of their care planning and drive their outcomes. Performance Improvement Projects (PIPs): The QAPI team will review data and benchmarks and determine if gaps or patterns exist in our systems that could result in quality problems or if there are any opportunities to make improvements. I'm seeking care Potential PIPs are identified by the QAPI committee. QAPI team along with the PIP lead is responsible for developing the PIP charter and for assembling the PIP team. The PIP team members will be identified based on the problem, including interdisciplinary members, residents or family members that can bring value and contribute for the opportunity to be assessed and represent staff across all three shifts if needed. PIP results, outcomes are status are reported by the project lead to the monthly Q API committee by submitting an updated performance improvement plan. Performance Improvement Plans will include goals, actions, responsible party, target dates and status / outcome. Completed Performance Improvement Plans will be filed in the QAPI notebook and will be monitored periodically to assure achievements are being sustained. If an issue arises within the center needs immediate attention, and Ad Hoc QAPI meeting will be put into place to review the concern and put immediate action into place to ensure proper quality of care for residents. Systematic Analysis: The PIP Team will analyze the problem area by conducting a root cause analysis, identify solutions and develop a performance improvement plan to be implemented. An observation was conducted on 04/02/2025 at 10:20 a.m. with Staff L, Licensed Practical Nurse (LPN) for the 500 hallway medication cart. Staff L, LPN was observed placing one Medication Monitoring / Control Records log into the 500 hallway narcotic book. The Shift Change Controlled Substance Inventory Count Sheet showed there were 25 cards and 1 bottle of liquid in the narcotic drawer. Staff L counted the cards as well as the bottle of liquid controlled substance, and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drugs/cards were compared to the individual Medication Monitoring / Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 500 hallway showed the following residents on 04/02/2025 had narcotics added to the medication cart, without a second nurse verifying the medications. Resident #22 had Temazepam added to the cart, Resident #21 had Oxycodone and Lyrica added to the cart, and Resident #20 had Percocet added to the cart. Each resident had a completed narcotics card and a second nurse signature was missing as verification. None of the narcotic cards revealed the strength of each medication. An observation was conducted on 04/02/2025 at 10:20 a.m. with Staff L, LPN for the 600 hallway medication cart. Staff L, LPN was observed placing three Medication Monitoring / Control Records logs and three individual controlled drug cards into the 600 hallway narcotic book and narcotic drawer. The Shift Change Controlled Substance Inventory Count Sheet showed there were 25 cards in the narcotic drawer. Staff L counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drugs/cards were compared to the individual Medication Monitoring/Control Records logs and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 600 hallway showed on 04/02/2025 the following residents had narcotics added to the medication cart without a second nurse verifying the medications. Resident #19 had Zolpidem added to the cart, and Resident #18 had Morphine and Oxycodone added to the cart. None of the narcotic cards revealed the strength of each medication. Staff L, LPN stated she had education regarding narcotics/medication administration. Staff L stated the education included they were to have double signatures for the narcotic medications when the medications arrived from the pharmacy. Staff L stated when a narcotic was discontinued or the card was empty they were to have two nurses sign the sheet and the card, and the medication was to be taken to the Director of Nursing (DON) office. An observation was conducted on 04/02/2025 at 10:47 a.m. with Staff M, LPN for the 400 hallway medication cart. The Shift Change Controlled Substance Inventory Count Sheet showed there were 31 individual controlled drug cards in the 400 hallway cart. Staff M counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drug cards were compared to the individual Medication Monitoring/Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 400 hallway showed the following residents had narcotics added to the medication cart on 04/02/2025 without a second nurse verifying the medications. Resident #17 had Norco added to the cart. The medication strength was not documented for the medication. Staff M, LPN stated they had education on narcotic counts and counting the narcotic cards with two nurses at shift change. Staff M stated two nurse had to sign when medications come in (from the pharmacy). Staff M stated if a narcotic card was empty or discontinued two nurses had to sign off and the card goes to the DON's office. An observation was conducted on 04/02/2025 at 11:15 a.m. with Staff F, LPN for the 100 hallway medication cart. The Shift Change Controlled Substance Inventory Count Sheet showed there were 44 individual controlled drug cards in the 100 hallway cart. Staff I counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drug cards were compared to the individual Medication Monitoring /Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 100 hallway showed the following residents had narcotics added to the medication cart on 03/31/20255 without a second nurse verifying the medications. Resident #16 had Ativan added to the cart, Resident #11 had Morphine added to the cart, and Resident #7 had Oxycodone added to the cart. The medication strength for the narcotics was not documented on the card. Staff F stated she had education regarding narcotic administration which included two nurses verifying the medications from the pharmacy. She stated two nurses do the narcotic count at shift change. She stated two nurses have to sign and verify the discontinuation of medications. Review of the Education Sign In sheets for Receiving Narcotics and Documentation on 02/13/2025 and 02/18/2025 showed the following: All narcotics received must be received by two nurses. They are added to the narcotic flowsheet by resident names, medication, and how many cards. When giving prn (as needed) pain medication you sign out of narcotic book and in medical record software. If the narcotic order is changed in frequency, put order change sticker on the card. If the narcotic is discontinued bring to DON for destruction. The four nurses observed on 04/02/2025 were on the Education In-service attendance record for 02/13/25. An interview was conducted on 04/03/2025 at 9:56 a.m. with Staff C, Regional Registered Nurse (RRN), Staff A, support DON, and Staff B, Interim DON regarding narcotic administration education. Staff C stated due to an incident they started education on proper narcotic management and re-education. They identified opportunities within the program that the count sheets were not being filled out properly and they were hard to follow. They started re-education on shift-to-shift count, completion of the actual count forms (Medication Monitoring / Control Records), accepting medication (narcotics), taking discontinued medications and empty cards to the DON. Staff C stated they implemented audits to make sure the flow sheet Shift Change Controlled Substance Inventory Count Sheet was documented properly with adding narcotics (plus), deleting narcotics (minus), and second signatures documented. Staff C stated they implemented audits on documentation of delivery slips. Staff C stated they identified opportunities within the building which included documentation of prn's (medications), and low inventory. They were filling out the sheet Shift Change Controlled Substance Inventory Count Sheet daily instead of a continual flow. Prior administration changed it to a daily form, and did not see it as a possible problem. Staff C stated they did audits daily for 2 weeks, twice a week for 2 weeks and were to perform weekly for 4 weeks and monthly for 2 months. Staff A stated they reviewed the Shift Change Controlled Substance Inventory Count Sheet on the audits they were performing. Staff C verified the residents that were added to the Shift Change Controlled Substance Inventory Count Sheet did not have two nurse verification. Staff A stated the surveyors reviewed the Shift Change Controlled Substance Inventory Count Sheet on the off two-week audit. Staff B stated they educated the nurses when the narcotics come into the building from the pharmacy and the bags are sealed. The sealed container can be signed by one nurse and when the bag is opened, two nurses must sign and validate the contents. Staff B stated the nurses were educated to initial on both the individual narcotic Medication Monitoring / Control Records and delivery slip inside the bag. Staff B stated on the Shift Change Controlled Substance Inventory Count Sheet the nurse was to add the resident name and drug to the sheet including the quantity of the narcotics. The second nurse was to initial for validation of the medication. Staff B stated a second nurse was also to initial validation if a card was zero with the resident name, drug name, and then removed from the total number of cards found in the narcotic drawer. One nurse signs and the second nurse initials as a witness. Staff B stated the nursing staff was educated to follow this process. Staff A, Staff B, and Staff C verified the Shift Change Controlled Substance Inventory Count Sheet lacked the second signature. After interview with Staff A, Staff B, Staff C, an observation on 04/03/2025 at 10:30 a.m. was performed with Staff B, Interim DON of the narcotic books. The following number of Medication Monitoring / Control Records were not initialed /validated by a second nurse. 100 hallway 17 out of 35 or 49% 200 hallway 9 out of 25 or 36% 300 hallway 11 out of 22 or 50% 400 hallway 19 out of 29 or 66% 500 hallway 17 out of 22 or 77% 600 hallway 10 out of 22 or 45% During an interview on 04/03/25 at 10:47 a.m. with Staff C, RRN she stated they had an ADHOC meeting on 02/10/2025. Staff C stated they were not following the process for counting cards and comparing to the physical card count. Staff C stated they reviewed the current policies and procedures. Staff C stated they educated the nurses to follow policy and procedure. Staff C stated they also did a three day look back. They had a second ADHOC on 02/20/2025. Staff C stated the Unit Managers (UM) were given the task to perform weekly audits and the DON auditing was started. The UM's were auditing daily for 2 weeks, and then biweekly for 2 weeks they were to progress to weekly for 4 weeks and then monthly for 2 months. Staff C stated the UM's were supposed to be looking at the Shift Change Controlled Substance Inventory Count Sheet. Staff C stated the UM audits included Controlled substance count is correct? Documentation on the Medication Administration Record (MAR) reflects what is signed out on the Shift Change Controlled Substance Inventory Count Sheet. Staff C stated she did not know how many residents were sampled for the audits. Staff C stated they had an ADHOC on 02/27/2025 and reviewed the audits and the process was being followed. Staff C stated they had no issues or concerns noted in Quality Review. Updates were added to the new hire orientation for nurses. Staff C stated we will have to go back to ADHOC. Staff C stated we will have to look at the policies again and re-audit based on the policy. Staff C stated the QA process did not work. Staff C stated we will have an ADHOC today. Staff C stated they reviewed their policy and it does not say they are to have two nurses initial on the individual narcotic Medication Monitoring / Control Records. Staff C stated they over did it and did not follow the policy / procedure. Staff C stated they will re-educate the nurses.

Based on observation, interview and record review the facility failed to abide by their smoking policy of ensuring residents are provided a safe, designated smoking area for nine (#10, #13, #8, #12, #14, #9, #11, #15 and #26) of 27 sampled residents. Findings included: Review of the facility's policy, Smoking-Supervised, revised 02/07/2020 showed the Center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. Smoking is only allowed in designated areas and during designated times. The Center will have safety equipment available in designated smoking areas including: smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. Procedure: 1. Residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. 2. 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. 3. The Center will establish and post designated smoking areas and times. 4. During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. 5. The Center will retain and store matches, lighters, etc. for all residents. 6.All residents who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures. 7. Residents will be advised upon admission that violations of the smoking policy may result in revocation of smoking privileges, discharge, and/or being reported to law enforcement. 9. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke. However, for the safety of all residents and staff the center has promulgated a safe smoking policy. All residents who wish to smoke at the center will abide by the center's smoking policy. Residents electing to smoke will be provided a safe smoking assessment to determine and evaluate each resident's ability to safely smoke. Because violations of the smoking policy can lead to catastrophic consequences, the smoking policy will be vigorously applied without exception. Violations of the policy will result in remedial action based upon the nature of the infraction. Remedial includes but is not limited to warning, revocation of smoking privileges, police intervention, and / or discharge. This agreement represents your acknowledgement that the center has provided you a copy of the center's smoking policy and your agreement to abide by the terms set forth in the policy. I, undersigned, understand that these safety rules apply to me and the safety of the other residents and violations may result in subsequent education, warnings, and other remedial actions at the discretion of the Executive Director. 1. During an observation on 04/02/2025 at 11:24 a.m. Resident #10 self-propelled herself in her wheelchair into the building from outside. A cigarette lighter was observed in her lap. Resident #10 was observed propelling herself through the building to her room and onward to the end of the 300 hallway. Resident #10 stated she goes outside to smoke. Resident #10 stated she has to sign out LOA to in order to smoke. Resident #10 stated she has to go out to the sidewalk on the busy road. Resident #10 stated, The road was not safe, the cars are so fast, it is dangerous. Resident #10 stated she was allowed to go outside to the sidewalk to smoke from 8 a.m. to 8 p.m. Resident #10 stated she signs out either at the nursing station or the front desk. Resident #10 stated they cannot smoke in the parking lot. Resident #10 stated they are supposed to give their cigarettes and lighter to them (the facility), but she forgot about her lighter today. Resident #10 stated there were about 10 of us who go outside to smoke. 2. An observation on 04/03/2025 at 9:00 a.m. revealed Resident #13 self-propelling himself down the sidewalk. He was observed by a second surveyor to be crossing 4 lanes of traffic at the corner of the facility's lot. Three other residents were observed sitting on the sidewalk in front of the building beside the 6 lanes of traffic smoking. The traffic appeared to be speeding, by travelling at approximately 40-45 mph (miles per hour). Record review of the Admission Record showed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included but not limited to diabetes, absence of left and right leg above knee, muscle weakness, Chronic Obstructive Pulmonary Disease, Atrial fibrillation, hypertension, need for assistance for personal care, supraventricular tachycardia, and nicotine dependence. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. Review of the physician orders showed may go out on LOA on 12/11/2024. Review of the Smoking Evaluation for Resident #13 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the Care plan showed Resident #13 was a smoker, initiated on 10/18/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 10/18/2024; The resident was able to: (light own cigarette), has LOA to go out front to smoke as of 10/18/24 and revised on 03/25/2025. Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 11/08/2024. The resident requires a smoking apron while smoking as of 10/18/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #13 signed it on 10/18/2024. 3. During an observation on 04/02/2025 at 9:00 a.m. Resident #8 was observed exiting the building with his cigarettes in his lap. Review of Resident #8's Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease, diabetes, nicotine dependence. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J the resident was a tobacco user. Review of the physician orders for Resident #8 showed, may go out on LOA (Leave of Absence) as of 12/11/2024. Review of the Smoking Evaluation for Resident #8 as of 03/09/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the Care plan for Resident #8 showed the resident was a smoker, initiated on 11/08/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 11/08/2024; The resident was able to: (light own cigarette), has LOA to go out front to smoke as of 11/08/24 and revised on 03/25/2025. Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 11/08/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #8 signed it on 10/18/2024. 4. Record review of the Admission Record showed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included but not limited to nondisplaced supracondylar fracture, paraplegia, cervical spinal stenosis, need for assistance with personal care. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. Review of the physician orders for Resident #12 showed, may go out on LOA on 12/11/2024. Review of the Smoking Evaluation for Resident #12 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking Review of the Care plan for Resident #12 showed the resident was a smoker, initiated on 07/10/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 07/10/2024; Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 07/10/2024. Review of the record revealed Resident #12 had not signed the Smoking Agreement/Notice of Policy. The signed policy was requested and not provided. 5. Review of the Admission Record showed Resident #14 was admitted to the facility on [DATE] with diagnoses included but not limited to Congestive Heart Failure, hypertension. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. Review of the physician orders for Resident #14 showed, may go out on LOA on 12/11/2024. Review of the Smoking Evaluation for Resident #14 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the Care plan for Resident #14 showed the resident was a smoker, initiated on 05/01/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 05/01/2024; the resident requires supervision while smoking as of 05/01/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #14 signed it on 04/30/2024. 46498 6. On 4/02/2025 at 11:38 a.m. and on 4/3/2025 at 12:30 p.m., Resident #9 was observed sitting outside the driveway smoking a cigarette in a high back wheelchair. She was observed located on the driveway leading out into a busy three-lane highway where cars were observed entering and leaving out of the driveway. Resident #9 stated the staff at the facility told her that she has to smoke outside where she is located, because she is not allowed to smoke on the premises. She stated no one had told her where she could safely smoke. Review of the Admission Record showed Resident #9 was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease, unspecified, other abnormalities of gait and mobility, muscle weakness (generalized). Review of a Minimum Data Set, dated dated dated [DATE] Section C- Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #9 is cognitively intact. Review of Section J showed Resident #9 has shortness of breath or trouble breathing with exertion. Review of the Smoking Evaluation for Resident #9 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the care plan for Resident #9 showed a focus showing Resident #9 is a smoker, date initiated,1/7/2025. The goals showed Resident #9 will not suffer injury from unsafe smoking practices through the review date, date initiated 1/7/2025. Interventions showed to instruct residents about the facility policy on smoking: locations, times, safety concerns, dated initiated 1/7/2025. Review of the Admission Record for Resident #10 showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to generalized muscle weakness, need for assistance with personal care, chronic obstructive pulmonary disease, unspecified, and other abnormalities of gait and mobility Review of the Smoking Evaluation for Resident #10 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #10 showed a focus for smoking. Review of the care plan goals showed Resident #10 will not smoke without supervision through the review dated, date initiated 11/7/2024. Review of the intervention showed Resident #10 requires supervision while smoking. Date initiated 11/7/2024. 7. Review of the Admission Record for Resident #11 showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic venous hypertension (Idiopathic) with ulcer of left lower extremity, history of falling, cerebral infarction, unspecified, wheezing. Review of the Smoking Evaluation for Resident #11 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #11 showed a focus for smoking date initiated 3/25/2025. The goals showed Resident #11 will not suffer injury from unsafe smoking practices through the review date, date initiated 3/25/2025. interventions showed to instruct residents about the facility policy on smoking: locations, time, safety concerns. The resident can (light own cigarette) Has Leave of absence, LOA to go out front to smoke. 8. Review of the Admission Record for Resident #15 showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to encounter for orthopedic aftercare following surgical amputation, chronic obstructive pulmonary disease, unspecified, muscle weakness (generalized), other lack of coordination. Review of the Smoking Evaluation for Resident #15 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #15 showed a focus for smoking date initiated 10/21/2024. The goals showed Resident # 15 will not smoke without supervision through the review date 10/21/2024. The interventions showed the resident requires supervision while smoking, date, initiated 11/27/2024. On 4/3/2025 at 2:00 p.m., an interview was conducted with Staff D, the Administrator in Training, AIT. Staff D, AIT stated she did not really know much about the smoking situation so she would have to get someone else to discuss smoking. Staff D stated she came from a non-smoking facility, and she can see that residents smoking in the front next to the road can be a concern. Staff D stated she knew Activities keep track of the list of residents who smoke, and nursing does the smoking assessments. She stated the residents who sign out leave of absence (LOA), are the residents who do not want to smoke within the facility's time frames. Staff D stated they even have a hard time getting the LOA cards back from the residents who go outside, and they have a hard time keeping track of their smoking materials. On 4/3/2025 at 2:45 p.m. an interview was conducted with Staff A, The Support Director of Nurses, DON. Staff A stated that when a resident is admitted to the facility and the resident is identified as a smoker, nursing takes them out to do an assessment to see if the resident is a safe smoker or not. After the nursing assessment is completed, nursing notifies the Activity Director so she can go over the smoking policy with the resident and have them sign it during that time. She stated after the residents are provided with the smoking policy, they are placed in a smoking group according to smoking times. Residents that go out to smoke in front of the building have a leave of absence, LOA, order to go out. Staff A stated if a resident had an order and signs out LOA, they can go in front of the building or wherever they want. She stated the residents observed outside have an LOA order and they can go outside in front of the building to smoke. Staff A stated the facility's times for smoking was only for residents who require supervision while smoking. She stated if a resident had an LOA order, they could go out on their own. She stated she had not spoken to the residents about the safety concerns when smoking near the road, which could be a safety issue. She stated she had not asked any of the residents if they had any concerns about smoking next to the road in front of the building. She stated the assessments that show the residents needed constant supervision were completed wrong. Staff A said, It was just human error, she was just clicking off on the quarterly assessment trying to get them all caught up on. She stated residents who smoke should have a smoking assessment, a care plan and a signed smoking policy. 52156 An observation was made on 04/02/2025 at 12:55 p.m. revealing an unidentified resident on her way back inside to the facility from smoking. Further observation revealed three other residents were observed outside smoking on the sidewalk in front of the facility's parking lot. Review of the Leave of Absence (LOA) sign-out sheet revealed two of the four residents observed outside had filled the sign-out sheet with their sign-out time. Further review of the LOA sign-out sheet revealed documentation of a sign in time pre-filled, but the residents were observed on the sidewalk smoking. Resident #13 had a sign out time of 11:25 a.m. and a return time of 11:45a.m., but was observed on the sidewalk smoking at 1:02 p.m. Resident #14 had a sign out time of 8:30 a.m. and a return time of 12:50p.m., but was observed on the sidewalk smoking at 1:05 p.m. 9. An interview was conducted on 04/03/2025 at 10:55 a.m. with Resident #26. She stated smoking had become an issue. She stated ever since residents moved from another facility, they went from not having many smokers to having a lot of smokers. Resident #26 stated, They really needed to get a designated smoking aide. She said aides are pulled from the floor and caused residents to not get help if needed during the smoking times. Resident #26 stated she had been told that her aide was overseeing the smoking breaks, and she would be assisted when the aide returned. Review of the Admission Record showed Resident #26 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, type 2 diabetes, and contracture left hand. A review of the quarterly MDS (Minimum Data Set) revealed Resident #26 had a BIMS (Brief interview Mental Status) score of 14, indicating intact mental cognition.

Based on record review and interview, the facility failed to ensure a transfer notice was provided to the resident and the resident representative for one (Resident #3) of three residents sampled for emergency transfers. Findings included: Review of Resident #3's admission Record showed he was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Review of paperwork dated 02/02/2025 at 2:38 PM showed the Psychiatric Advanced Registered Nurse Practitioner (ARNP) completed involuntary examination documents for Resident #3 for schizoaffective disorder, resident's inability to determine whether examination is necessary, and a substantial likelihood that without care or treatment the individual will cause serious bodily harm to self or others. The ARNP documented the patient presented with psychosis, significant agitation, aggression and threatening of staff. Resident threw his food tray at a staff member and smeared feces all over his room. Resident was refusing all care or any psychopharmacological interventions. At the time of this event, the facility was unable to meet the resident's needs and presented as a danger to self or others. Resident #3 required a higher level of care for stabilization and safety. Review of a Behavior Note dated 2/2/2025 at 2:47 PM showed Resident #3 was insulting staff, threw his tray with his plate on the floor, and almost injured a staff member. Review of a Situation, Background, Assessment, and Recommendation (SBAR) Summary for Providers dated 02/02/2025 at 4:29 PM showed the primary care provider recommended Resident #3 be transferred to the hospital for an involuntary examination. Review of the medical record showed no evidence of a written Nursing Home Transfer and Discharge Notice being provided to Resident # 3 and his representative for the emergency transfer on 02/02/2025. On 4/3/2025 at 10:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated their process for emergency transfers was to receive an order to send the resident out from the physician, complete a transfer form and change in condition, and notify the resident's responsible party about the transfer. The DON reported the resident's responsible party would also receive a copy of the transfer notice. The DON reviewed Resident #3's medical record and confirmed the written Transfer and Discharge Notice for the 02/02/2025 event could not be located. On 4/3/2025 at 11:05 AM, an interview was conducted with the Social Service Director (SSD). The SSD stated she started working at the facility on 2/18/2025, after the emergency transfer for Resident #3 on 02/02/2025. She stated when a resident was sent out to the hospital there should be a Transfer and Discharge Notice given, a physician order, and the resident responsible party should be notified. She stated the transfer/discharge forms were placed in her inbox, and she kept a record of the notices in a binder in her office. She stated when she looked in her binder, she did not have a Transfer and Discharge Notice for Resident #3. She confirmed Resident #3's Transfer and Discharge Notice could not be located.

Based on interview and record review, the facility failed to investigate an injury of unknown origin that resulted in a transfer to a higher level of care for one (#1) of one resident out of ten residents reviewed. Findings Included: A review of Resident #1's Admission Record showed an original admitted [DATE] with a readmitted [DATE] with the following diagnoses: Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side Other abnormal of gait and mobility Need for assistance with personal care Difficulty in walking, not elsewhere classified. Muscle weakness (generalized) Muscle wasting and atrophy, not elsewhere classified, unspecified site A review of Resident #1's care plan dated [DATE] showed a Focus area: ADL (Activity of Daily Living)/ self-care performance deficit related to hemiparesis, weakness, dementia, schizoaffective disorder- depressive type, major depressive disorder, insomnia, incontinence, muscle wasting and atrophy, lumbar spondylosis impaired mobility. Interventions include but are not limited to: Bed Mobility: The resident requires moderate to max assistance by one staff to turn and reposition in bed frequently and as necessary. (revised on [DATE]) Transfer: The resident requires total assistance by two staff to move between surfaces and as necessary. (revised on [DATE]) On [DATE] at 2:23 p.m., an interview was conducted with Staff H, Registered Nurse (RN). Staff H stated Resident #1 was assigned to her on [DATE]. Staff H stated Resident #1 told her he was dropped when getting out of bed earlier. Staff H stated the resident told her this information while his daughter was in the room. Staff H stated the resident told her he fell from his bed to the wheelchair. Staff H stated she was in shock because no one told her. Staff H stated she immediately interviewed the resident and did a full head to toe assessment with vital signs. Staff H stated she then talked to the two Certified Nursing Assistants (CNA) responsible for his transport from the bed to the wheelchair and both denied he fell . Staff H, RN could not name the two CNAs but would recognize their faces. Staff H stated she filled out an incident report and immediately notified the nurse practitioner and the Director of Nursing. Staff H stated the daughter was at his bedside the whole time and was witness to the resident's statement of the events. Staff H stated earlier Resident #1 requested to eat his dinner out of bed that evening. Staff H stated she requested the CNA assigned to the resident to assist with his request. Staff H stated she was finishing her medication administration when Resident #1's daughter approached her at the nurses' station and stated the resident wanted to return to bed due to pain. Staff H stated she did not see the daughter initially enter the facility. Staff H stated the resident was transferred to the wheelchair ten to fifteen minutes prior to his request to return back to bed. Staff H approached Resident #1 in the TV room and offered pain medication but stated he wanted to return to bed. Staff H stated she personally returned the resident back to his bed with his assigned CNA via a mechanical lift. Staff H stated the resident appeared more comfortable once he returned to his bed but was unable to straighten both his legs. Staff H stated she gave Resident #1 [Acetaminophen] and stated the resident had received stronger pain medication earlier and it was too soon to receive another dose. Staff H notified the nurse practitioner regarding the resident's increased pain and the daughter's concern to have the resident transferred to the hospital for further evaluation. On [DATE] at 3:03 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she received a call from Staff H on the night Resident #1 went to the hospital after his claim of a fall. The DON stated the nurse in her incident report stated the resident told her he fell while transferring to his wheelchair with two CNAs. The DON stated the CNAs were not interviewed by her but went by the incident report filled out by Staff H. The DON stated Resident #1 should be transferred via mechanical lift by two nursing staff. The DON could not state who the two CNAs were or confirm how the resident was transferred to the wheelchair. The DON stated the resident had a fall on [DATE] in which x-rays and pain medication were ordered. The DON stated the resident was normally confused and stated she thought the resident was confused on [DATE] as the fall he experienced was on [DATE]. The DON stated falls were discussed the following day during the interdisciplinary (IDT) team meeting. The DON stated the resident had expired at the hospital. On [DATE] at 3:45 p.m., an interview was conducted with Staff I, CNA. Staff I stated Staff H asked her to get Resident #1 out of bed into his wheelchair. Staff I stated she used a [sit to stand] to transfer the resident with the assistance of Staff J, CNA. Staff I stated Resident #1 acted scared of the sit and stand but did good transferring to wheelchair. Staff I stated she brought the resident to the TV room. Staff I stated she saw the resident's daughter with him. Staff I stated the resident was complaining of pain all day. Staff I stated he was out of bed for 10 minutes before Staff H asked for assistance to return the resident back to bed. Staff I stated the resident did not fall when she assisted resident initially out of bed. On [DATE] at 4:00 p.m., an interview was conducted with Staff J. She stated she did not assist getting Resident #1 out of bed but simply held the wheelchair steady while Staff I transferred the resident to the wheelchair from a standing position. Staff J stated the resident was able to weight bear and Staff IF stood the resident up and transferred him into the wheelchair in a stand and pivot motion. Staff J stated, all I know was he was in a lot of pain all day. On [DATE] at 4:14 p.m., an interview was conducted with Staff F, Director of Clinical Services (DCS), Staff E, Regional [NAME] President of Operations (VPO) and the DON. Staff F, DCS stated in a change of condition such as a fall, the priority is the resident. Staff F stated the resident should initially be assessed head to toe for any injuries. The physician and family representative should be notified. Staff F stated during morning IDT rounds, any incident(s) were reviewed. If there were any questions, we would potentially get more interviews to close the loop of the concern. Staff F stated if the resident went to a higher level of care, a root cause analysis would involve interviewing the staff. Staff E, VPO stated the Admissions department would follow up with a resident that was transferred to a higher level of care. Staff E was unable to state the outcome of Resident #1 but went to the Admissions department, returned, and stated Resident #1 had expired the following day. A review of Resident #1's hospital record dated [DATE] showed a history and physical of Resident #1: [AGE] year-old male presents today with apparent pain to bilateral lower extremities. It was noted today that patient does not want to extend either knee and seems agitated with any attempts to passively extend. Seems to complain of pain of lower extremities but patient has difficulty relating history due to history of dementia. A review of Resident #1's re-evaluation dated [DATE] and timed at 22:00 (10:00 a.m.) showed a reevaluation status notation: [AGE] year-old presents today with apparent pain to bilateral extremities their hematoma suggestive of possible injury. Reevaluation status: bilateral knee fractures. A review of Resident #1's radiological results of left and right knee showed the following: Left knee: Impacted proximal fibular metaphyseal fracture of indeterminate age. Left knee: Nondisplaced proximal tibial metaphyseal fracture of indeterminate age. Right knee: Acute comminuted proximal tibial metaphyseal fracture. Right knee: Age indeterminate proximal fibular metaphyseal fracture. A review of the facility's policy titled, Florida Adverse Incident Reporting, revised [DATE] showed the following policy statement: The Facility will be in compliance with State Adverse incident reporting requirements. The Administrator and/ or designated risk manager are responsible for the state reporting. Adverse incident reports will be submitted as required by state regulations for events meeting reporting criteria. The policy's procedure includes but is not limited to: 1. The facility will file an adverse incident report for events meeting reporting criteria. 2. The purposes of reporting to the agency under this requirement, the term adverse incident means: a) An event over which the facility personnel could exercise control and which is associated in whole or in part with the facilities intervention, rather than the condition for which such intervention occurred, and which results in one of the following: 1) Death 2) Brain or spinal damage 3) Permanent disfigurement 4) Fracture of dislocation of bones or joints 5) A limitation of neurological, physical, or sensory function 6) Any condition that required medical attention to which the resident has not given his or her consent, including failure to honor advanced directives 7) Any condition that requires the transfer of the resident, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the resident's condition prior to the adverse incident; or, 8) An event that is reported to law enforcement or its personnel for investigation

Based on observations, interviews, and record review, the facility failed to 1. provide treatment and services in accordance with physician orders for one (#9) out of three residents reviewed; and 2. failed to ensure call lights were answered within a timely manner for four (#5, #6, #7, and #8) of ten sampled residents. Findings Included: 1. Review of the Admission Record showed Resident #9 was admitted to the facility on [DATE] with diagnoses to include acute osteomyelitis, chronic ulcer of the right heel and midfoot, peripheral vascular disease, and type 2 diabetes mellitus with foot ulcer. Review of Resident #9's Medication Administration Record for November 2024 showed the following: -Cleanse left Achilles with [antimicrobial wound cleanser] 0.125% solution, apply nickel thick [topical enzyme medication] and cover with dry dressing every day shift for arterial wound, completion of wound care was not documented on 11/3, 11/4, 11/5, 11/6, and 11/9/2024. -Cleanse left anterior lower leg with [antimicrobial wound cleanser] 0.125%, apply nickel thick [topical enzyme medication] and cover with dry dressing every day shift for arterial wound, completion of wound was not documented on 11/3, 11/4, 11/5, 11/6 and 11/9/2024. - Cleanse left dorsal foot with [antimicrobial wound cleanser] 0.125%, cover with nickel thick [topical enzyme medication] and dry dressing every day shift for arterial wound, completion of wound care was not documented on 11/3, 11/5, 11/6 and 11/9/2024. -Cleanse left great toe with NS apply Betadine leave open to air (OTA) every day shift for arterial wound, completion of wound care was not documented on 11/3, 11/5, 11/6 and 11/9/2024. -Cleanse left temple with NS, pat dry apply silver sulfadiazine and leave OTA daily every night shift for wound care, completion of wound care was not documented on 11/14. -Silva sulfadiazine external cream 1% apply to left temple topically every night for infectious wound cleanse wound with [antimicrobial wound cleanser] leave OTA, completion of wound care was not documented on 11/14/2024. -Cleanse left great toe with NS apply Betadine leave OTA every day shift for arterial wound, completion of wound care was not documented on 11/22 and 11/24/2024. -Cleanse left Achilles with Normal Saline (NS), pat dry, apply nickel thick [topical enzyme medication], cover with silver (Ag+) alginate and cover with dry dressing every day shift for arterial wound, completion of wound care was not documented on 11/22 and 11/24/2024. On 11/25/24 at 1:20 P.M., Resident #9 was observed lying in bed, after obtaining permission, Staff K, Certified Nursing Assistant (CNA) assisted with exposing the dressing on his left lower extremity. The dressing was dated 7A-7P, 11/23. Review of Resident #9's care plan focus showed, diabetic ulcer on the left lateral foot, initiated 9/18/24, interventions included administer treatment as ordered. During an interview on 11/25/2024 at 3:30 P.M., the Director of Nursing said the facility's expectation was that dressings were to be dated and initialed by the nurse. Review of a facility's policy and procedure, titled Clinical Guideline Skin and Wound, effective date 4/1/2017 showed Overview: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/ prevention of pressure injury. Process: .develop individualized goals and interventions Review of facility's policy and procedure, titled Physician Orders, effective date 11/30/2024 showed Policy: The center will ensure that physician orders are appropriately and timely documented in the medical record. 20536 2. On 11/25/2024 during the 7-3 shift, the facility was toured and the following call light observations were made: On 11/25/2024 at 9:26 a.m., Resident #5's call light above the room door was observed on. There were various staff walking by the room to include Certified Nursing Assistants, Nurses, and Housekeeping staff. At 9:34 a.m., a staff member went into the room to answer the light. It was noted the call light was on for at least eight minutes without staff responding to it. On 11/25/2024 at 10:00 a.m., an interview with Resident #5 revealed call lights were routinely answered late and there were times it took over thirty minutes before someone answered. She also revealed there were times when staff came in just to turn off the light and would leave without finding out what she needed. She revealed this happened during the days, nights, and weekends. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed, Cognition - Brief Interview for Mental Status (BIMS) score was 10 of 15 which indicated the resident had moderate cognitive impairment. On 11/25/2024 at 10:20 a.m., Resident #6's call light above the room door was observed on. There were various staff walking by the room to include Certified Nursing Assistants, Nurses, and Housekeeping staff. At 10:28 a.m., a staff member went into the room to answer the light. It was noted the call light was on for at least eight minutes without staff responding to it. On 11/25/2024 at 10:40 a.m. Resident #6 was interviewed with relation to call light response times. She confirmed her light was just answered untimely and it happened a lot. She revealed there were times when her call light was not answered for over twenty minutes. She had mentioned this to staff but there had not been any changes. Review of the current Quarterly MDS assessment dated [DATE] showed, Cognition - BIMS score - 12 of 15 which indicated the resident had moderate cognitive impairment. On 11/25/2024 at 12:20 p.m., Resident #7's call light above the room door was observed on. There were various staff walking by the room to include Certified Nursing Assistants, Nurses, and Housekeeping staff. At 12:32 p.m., a staff member went into the room to answer the light. It was noted the call light was on for at least twelve minutes without staff responding to it. On 11/25/2024 at 1:30 p.m., an interview with Resident #7 was attempted. She was noted with cognition deficits, but was able to answer simple questions related to her call light response times. She confirmed she used the call light and there were times staff do not answer the lights for over thirty minutes. She had reported this concern to staff (unnamed) in the past. Review of the current Quarterly MDS assessment dated [DATE] showed, Cognition - BIMS score was 9 of 15, which indicated the resident had moderate cognitive impairment. On 11/25/2024 at 11:50 a.m., Resident #8's call light above the room door was observed on. There were various staff walking by the room to include Certified Nursing Assistants, Nurses, and Housekeeping staff. At 12:06 p.m., a staff member went into the room to answer the light. It was noted the call light was on for at least sixteen minutes without staff responding to it. On 11/25/2024 at 1:00 p.m., an interview with Resident #8 revealed she had made complaints related to staff call light response times. She revealed there had been times the call light had not been answered for over one hour. She revealed this happened during the nights mostly, but there were times during the days when the call light had not been answered timely. Review of the current Annual MDS assessment dated [DATE] showed, Cognition - BIMS score was 11 of 15, which indicated the resident had moderate cognitive impairment. On 11/25/2024 at 12:00 p.m., an interview with the 100/200/300 Unit Manager confirmed that all residents, while they were in their room either in a chair or in bed, were to have the call light placed within their reach. She further revealed that all staff were qualified to answer a call light initially. The Unit Manager revealed the expectation was for staff to answer the call light as soon as possible. The Unit Manager was asked if answering call lights ranging from eight minutes to sixteen minutes was an expectation. She revealed that the lights should be answered in a manner that was more timely. On 11/25/2024 at 12:45 p.m. - 1:10 p.m., Staff A and Staff C, Certified Nursing Assistants (CNAs), and Staff B, Registered Nurse (RN) revealed all residents while in their rooms were placed with a call light within their reach. Staff A, C, and B revealed that call lights were to be answered as soon as they saw the light on and to be answered as soon as possible. Staff A and Staff C revealed when they answered call lights, they were to go in the room and find out what the resident needed and then to assist that resident, rather than just go in the room to turn off the light and leave the room. Staff A, B, and C also revealed sometimes during the shift, things could be busy and it could take some time to answer the light. However, they said any staff member could walk to the room to at least find out what was needed initially. On 11/25/2024 at 5:00 p.m., an interview with the Staff E, Regional [NAME] President of Operations, and Staff F, Director of Clinical Services revealed call lights were to be answered as soon as possible but there could be some parts of the day when they staff were busy like during meal pass, and lights could take a little longer to answer. Both Staff E and F confirmed call light response times ranging from eight minutes to sixteen minutes was not timely. Staff were routinely trained and inserviced on the importance of answering call lights right away. The Nursing Home Administrator of record was not available for interview during the time of the survey. Staff E revealed the facility did not have a specific policy and procedure related to call light response times.

Based on observation, record review, and interviews, the facility failed to ensure adequate nail care and consistent shower services for one (Resident #1) of three residents sampled for Activity of Daily Living services. Findings included: A review of Resident #1's clinical chart, documented an initial admission of 05/2022; readmission of 03/2024. Medical Diagnoses included: Metabolic Encephalopathy; Hyperosmolality and Hyponatremia; Aphasia; chronic kidney disease; contracture of muscle right hand, diabetes insipidus . On 09/16/2024 at 1:08 p.m., a phone interview was conducted with Resident #1's family member. She stated she communicated with (Resident #1) daily by way of video chat. She stated his appearance was unclean at times and his fingernails are long and unclean. On 09/16/2024 at approximately 1:30 p.m., Resident #1 was observed in his room, sitting in his wheelchair at bedside. He agreed to answer questions. He showed the surveyor his hands. Resident #1 was observed to have a closed right hand, which he pulled open to show his nails. The skin on the right hand was observed to be dry and scaly in appearance. His fingernails were observed to be longer in length, approximately 1/4 inch beyond the nail bed, darker yellowish discolor in appearance and uneven. When asked if he would like his nails to be cut, he nodded yes. On 09/16/2024 at approximately 1:40 p.m., Staff A, Licensed Practical Nurse (LPN) was interviewed. She said she was familiar with Resident #1, and stated, For nails, we have a podiatrist that comes in weekly. That is Social Services responsibility for scheduling the residents. I do not deal with the nails. Shower sheets are in the books. Certified Nursing Assistants (CNAs) fill them out. There is a shower schedule. A review of the shower schedule in the book reflected Resident #1's room to be scheduled for two times per week, Monday and Thursdays during the 7:00 a.m. to 3:00 p.m. shift. On 09/16/2024 at 1:59 p.m., the Social Service Director (SSD) was interviewed. She stated for male residents, the CNAs or Nurses would cut the residents fingernails. She said, for the toenails, the facility has a podiatrist group. For diabetic residents, the podiatrist would have to see the resident. She stated at this time, there had been a transition to a new podiatrist group, (name of company). She stated she had a list of residents that are to be seen by them. She stated she would put a resident on the list if she was told to by the CNAs or nursing staff. On 09/16/2024 at 2:25 p.m. the SSD was re-interviewed, she provided documentation of podiatrist visits for the facility. Resident #1 was documented to have been seen for his feet on 07/01/2024. She confirmed there was no documentation of the resident being seen for his fingernails. Review of the list of residents scheduled to be seen on 09/30/2024 by the podiatrist revealed no presence of Resident #1's name. The SSD stated the residents on the list were for foot care services. She stated the podiatrist service company had been changed. Services by the former company were completed in 07/2024. No podiatrist services in 08/2024 due to the transition, and the current list of persons were to receive care on 09/30/2024. When asked if the podiatrist provided fingernail cutting service to Resident #1, she stated she would have to review with the Director of Nursing (DON). An interview was conducted on 09/16/2024 at 2:34 with the DON. For Resident #1, she stated, we can clip them; nursing can clip them; CNAs can file them. He is a diabetic. They have to be very careful with him. The DON stated there was not specific place for documentation of the nail care. For the shower sheets for Resident #1, the DON said she did not see any shower sheets for the last 30 days for Resident #1, she said she knew the resident had got a shower the other day, she could not remember which day. She stated she knew the resident refused on occasion. She confirmed staff should document refusal of shower. The process, she confirmed that the aides are to fill out a shower sheet and then the nurses sign off to review if the resident had any new areas of skin conditions. A review of a blank shower sheet presented by the DON, titled, Skin Monitoring: Comprehensive CNA shower review, documented: Perform a visual assessment of resident's skin when giving the resident a shower. Report abnormal looking skin (as described below) to the charge nurse immediately. Forward any problems to your prospective unit managers for review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph abnormalities by number. The form was observed to have a visual assessment area with a body diagram to show locations of abnormalities on the skin. Further review of the form reflected an area: Does the resident need fingernails/toenails cut? With a yes or no box to mark. The form had an area for the CNA to sign and the Charge nurse to sign, an area to document the Charge nurse's assessment, and interventions. A review of Resident #1's Care Plan, focus area: (Resident #1) has an ADL (activities of daily living) self-care performance deficit . initiated 08/31/2023. The goal of the plan: The resident will maintain current level of function in ADLs through the review date. The interventions included: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse, initiated 08/31/2023. Bathing/Showering: The resident requires supervision/ touching assistance by staff with bathing/ showering as scheduled and as necessary, initiated 08/31/2023. On 09/16/2024 at 2:50 p.m., Resident #1 was observed with the DON. Resident #1 allowed the DON to review his hands. The DON was observed to state, I am going to come down and cut those for you.

Based on observation, record review, and interview, the facility failed to ensure a dignified existence was provided to one resident (#16) out of eight residents sampled. Findings included: During an observation made on 05/20/2024 at 2:51 p.m. Resident #16 was observed scooting around on the floor in her room with staff surrounding her. The resident scooted from her room into the middle of the hallway in front of other residents and staff. During an observation made on 05/22/2024 at 10:30 a.m., in the activities room, Resident #16 was observed in a corner separated from other residents in the activities room while an activities program was being conducted with other residents. She was observed sleeping with a blanket over her whole body, reclined back in the chair's lowest position and her feet positioned upward. Review of an Admission Record, dated 05/23/2024, showed Resident #16 was admitted originally on 05/18/2022 and readmitted on [DATE] with diagnoses to include senile degeneration of brain, not elsewhere classified, chronic obstructive pulmonary disease, unspecified, bipolar disorder, current episode mixed, severe, with psychotic features. Review of a Minimum Data Set (MDS), Assessment Reference Date/Target Date 02/19/2024, showed a Brief Interview for Mental Status (BIMS) score of 03 which indicated Resident #16 was severely impaired. Review of Resident #16's care plan, initiated 05/19/2022 and revised on 05/202024, showed a focus area as the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs r/t (related to) cognitive deficits, and the resident had a history of falls, dementia, bipolar disorder, anxiety disorder, cataracts. The care plan goals documented, [Resident #16] will maintain involvement in cognitive stimulation, social activities as desired through review date. Date initiated 05/19/2022 and revised on 10/30/2024. The target date for this goal was 06/02/2024. The interventions for this care plan included to ensure 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. Date initiated: 05/19/2022. On 05/20/2024 at 3:00 p.m. an interview was conducted with Staff A, License Practical Nurse (LPN). She stated Resident #16 was care planned to put herself on the floor. She said she would assist the resident off the floor in a few minutes. On 05/22/2024 at 11:00 a.m. an interview was conducted with the Activities Director. She stated that she was used to Resident #16 being placed in the activity room so she could watch her during activities. She said the resident was sleeping. She was not able to recall who placed the resident in the activity room. On 05/22/2024 at 11:00 a.m. an interview was conducted with the Director of Nursing (DON). She stated Resident #16 should not have been left in the activity room the way she was. She would have expected her staff to put the resident back in her bed. She further stated staff should not allow the resident to scoot out in the hallway. Someone should have assisted her off the floor. On 05/22/2024 at 3:00 p.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated the way Resident #16 was found in the activity room was unacceptable. She said someone should have put the resident in her bed if she was asleep.

Based on observation, record review and interview, the facility failed to ensure a reasonable accommodation of resident needs for one resident (#44) out of eight sampled residents related to having an appropriate bed to sleep in. Finding included: During an observation made on 5/20/2024 at 12:00 pm. Resident #44 was observed lying down in bed with his feet hanging off the edge of the bed mattress. He was observed dressed in his night gown. He said his legs were too long for his bed and the staff at the facility had known about it for a long time, but had not done anything about it. During an observation on 5/22/2024 at 8:00 a.m. Resident #44 was observed lying down in bed with his head slightly elevated and his feet hanging off the edge of his bed. He said he would like to have another bed because he was not able to fit on his bed. Review of an Admission Record, dated 5/22/2024, showed Resident #44 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to difficulty in walking, not elsewhere classified, schizoaffective disorder, depressive type, depression, unspecified. Review of a Minimum Date Set (MDS) with an Assessment Reference Date of 4/26/2024 showed a Brief Interview for Mental Status (BIMS) score of 06, which indicated the resident was severely cognitive impaired. During an interview on 5/20/2024 at 3:00 p.m. with Staff B, Certified Nursing Assistant (CNA), she stated she worked at the facility for six years. She said Resident #44 has had the air mattress he was on for a long time. The mattress was not a good fit for him because his legs were too long. He had complained about it, but nothing had been done. During an interview on 5/23/2024 at 8:11 am. with the Assisted Director of Nursing (ADON), she stated she worked as the ADON since February 26, 2024. She said she reviewed Resident #44's chart and noticed that he had a wound, but it was resolved. She stated she really did not know why he still had an air mattress because it should have been switched out for a regular mattress. She did not think the resident's mattress was a problem because she had not had anyone complain to her about it. During an interview on 5/23/2024 at 8:11 a.m. with the Director of Nursing (DON), she stated the facility process was on admission, if a resident had a wound, then the Admission Coordinator would notify the interdisciplinary team that special equipment was needed for the resident, for example an air mattress. She stated, When I reviewed [Resident #44's] record he did not currently have a wound, so there is no purpose for him to have an air mattress at this time. We do not measure residents when providing them with a mattress. My expectation is that staff notify us if a resident bed is too small, or they can put the information on the maintenance log so we can review it there. We saw the resident's mattress today and we will remove it immediately and replace it with a mattress appropriate for him. She said I would have expected the CNA to report this information to her. During an interview on 5/23/2024 at 3:11 p.m. with the Regional Nurse Consultant, she said they did not have a policy regarding mattress sizing or accommodation of needs related residents' beds. This situation was a standard of care. The CNA should have notified their nurse, or the concern should have been logged in the maintenance logbook. They were always told to tell someone if they identify an issue with their residents. Photographic evidence obtained.

Based on interviews and record review, the facility did not ensure personal hygiene needs related to bathing were being met for 2 residents (#1 and #2) of 3 residents reviewed for ADLs (activities of daily living). Findings included: 1. Review of the MDS for Resident #1, dated 1/9/2019, Section C, Cognitive Patterns, revealed a BIMS (brief interview for mental status) score of 15, indicating Resident #1 was cognitively intact. Review of Section G, Functional Status, G0120. Bathing, showed 3. Physical help in part of bathing activity, and 2. one person physical assist. The Care Plan review dated 10/12/2018 showed a Focus: The resident has an ADL self-care performance deficit and at risk for decline r/t (related to) (diagnoses). Interventions included Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated/refuses to use shower shower chair. Bathing/Showering: The resident requires assistance of: dependent x 1-2 people. The CNA (Certified Nursing Assistant) Kardex was reviewed and revealed Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated/refuses to use shower shower chair. Bathing/Showering: The resident requires assistance of: dependent x 1-2 people. At 12:24 p.m. on 3/7/2019 an interview with Resident #1 was conducted. She said she is supposed to be getting bed baths three times a week, and they're not getting done. On her shower days, they tell her they are too busy. She said she smells and feels unclean. She said she used to be a nurse, and she feels ugly and dirty here. She began crying. She also said the aides don't want to give her a bath. She said she is lucky if she gets one or two a week. She said she has special equipment for washing her hair in the bathroom but nobody wants to use it to wash her hair. Her hair smells. She said she doesn't know why they can't use the hoyer to take her in the bathroom. Staff say they're too busy. Resident #1 said the Social Worker, DON (Director of Nursing), and Administrator know about it, but they don't do anything about it. There isn't enough staff here. Shower sheets were requested for the month of (MONTH) 2019, and were not provided. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #2's MDS section C, Cognitive Patterns, dated 2/3/2019, showed a BIMS score of 15, indicating Resident #2 was cognitively intact. Section G, Functional Status was also reviewed and revealed G0201. Bathing 4. Total Dependence with 2. 1 person physical assistance. Review of the CNA Kardex showed Bathing/Showering: The resident is totally dependent on 1-2 staff to bathe/shower. At 2:48 p.m. on 3/7/2019 in an interview with Resident #2, he said he is supposed to be getting three showers a week, and he gets one to two. He said the aides tell him the hoyer pad is missing, or there aren't enough staff. He bought his own hoyer pad. He said the DON knows and she is working on it. Shower sheets for the months of (MONTH) and (MONTH) were requested and were not provided. At 8:54 a.m. on 3/8/2019 an interview was conducted with the DON. She said they do not have shower sheets. Staff were filling them out and throwing them away every month. The facility just became aware of it and started a PIP (performance improvement plan) last week.

Based on observations, record review, interview, and policy review, the facility did not ensure residents received care and treatment to promote healing of pressure ulcers for three residents (#2, #5, and #6) of 3 residents reviewed for wound care. Findings included: 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #2's MDS assessment date 2/3/2019 Section M, Skin Conditions, showed A. Resident has a pressure ulcer/injury, a scar over a bony prominence, or a non removable dressing/device. M0300. Current Number of Unhealed Pressure Ulcers/Injuries at each stage. C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling. Enter Number -2. Number of these stage 3 pressure ulcers that were present upon admission/entry or reentry. Enter number-2. physician's orders [REDACTED]. 1/25/2019 Iodosorb gel Cleanse right medial foot and right lat foot with NS (normal saline), apply Iodosorb gel and 4x4 and gauze wrap once daily At 9:55 a.m. on 3/7/2019 in an interview with Resident #2, he said nobody wants to do his wound; sometimes he won't get it treated for [REDACTED]. He has to ask them to do it or it won't get done. They don't have a wound care nurse. On 3/7/2019 at 11:07 a.m., a wound care observation was conducted with Staff B, RN, and the Physician's Assistant (PA). The PA gathered supplies, gauze 4x4's, saline, and scissors and brought them to the resident's room where she placed them on a foam plate on the resident's bed. The PA cleaned the wounds on the lateral and medial right foot with saline. Then she measured the wounds and left the room. Both wounds were clean and odor-free, with a beefy red, moist wound bed. They were a little smaller than a quarter in size, with a depth of approximately 2 cm (centimeters). There was scant serosanguainous (blood tinged) drainage present. Staff B, RN, put on a pair of gloves and cleaned the bed side table with a bleach wipe. Then she took a towel and wiped the table dry with it. She placed the supplies she had gathered from the treatment cart on a foam plate on the bed side table. Then Staff B put on a pair of gloves to prepare the supplies. She opened the gauze wrap. She placed gauze 4x4's in a cup of saline she had opened. Then she cleaned the right lateral outer pressure sore with the saline soaked gauze from the inside to the outside of the wound. She disposed of the soiled gauze in the trash can at the bed side. Then Staff B removed her gloves and placed them in the trash can as well. Staff B put on a new pair of gloves. She did not perform hand hygiene. She removed another gauze from the saline and cleaned the right inner foot wound from the inside out. She disposed of her gloves and the gauze in the trash can. Next, Staff B put on a new pair of gloves without performing hand hygiene. Then she opened the Iodosorb gel and squeezed some of its contents onto a tongue depressor. She used the tongue depressor to apply the Iodosorb to the wound bed of the right lateral foot. Then she squeezed more Iodosorb onto the same tongue depressor and applied it to the wound bed as well. She repeated the process a third time, covering the entire wound bed. Staff B disposed of the tongue depressor in the trash can. Next, Staff B applied a gauze 4x4 to the wound bed and covered it with a border/[MEDICATION NAME] (Vitale) dressing. Then Staff B wrapped Resident #2's right foot with rolled gauze. Staff B removed the backing from another Vitale dressing and applied it over the right medial wound, which was partially exposed beneath the rolled gauze, to secure the dressing. Staff B did not put any of the Iodosorb on the right medial foot wound prior to applying the gauze and dressing. She removed her gloves and disposed of them in the trash can. Then she put on a new pair of gloves. She picked up a foam contracture boot that was lying on the floor, and put it on the Resident #2's right foot, securing it with Velcro straps. Then she picked up a catheter bag that had fallen to the floor during the treatment when the resident had muscle spasms, and placed it between his feet on the footrest of his motorized wheel chair. She removed her gloves and washed her hands in the sink. Then she returned the Iodosorb tube to a plastic bag and placed it in the treatment cart, along with some unused aluminum foil she had placed on the bed side table. Then she disposed of the remaining opened saline, gauze, wrappers and foam plates in the trash can. Staff B left the biohazardous waste in the trash can and exited the room. In an interview with Staff B, RN on 3/7/2019 at 11:37 a.m., she confirmed she did not put Iodosorb on the right inner foot wound, and she said only saline. 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Record review was conducted of the MDS assessment dated [DATE], and showed the following information: Section M, Skin Conditions, M0300 Number of Unhealed pressure ulcers at each stage: 1. number of stage 2 pressure ulcers -one. 2. Number of Stage 2 pressure ulcers that were present on admission-one. Review of the billing record dated 2/1/19 showed Resident #5 was not in the facility after 2/1/2019. The admission record showed she returned on 2/7/2019. Review of the physician's orders [REDACTED]. The 1/24/2019 physician's orders [REDACTED]. The TAR (treatment administration record) for (MONTH) and (MONTH) 2019 were reviewed, and showed the only treatments signed in (MONTH) were on the 23rd and the 25th. The (MONTH) treatments had been signed on (MONTH) 5, 6, and 7. No other treatments were signed and no other treatment records were provided. On 3/7/2019 at 9:39 a.m., a wound care observation was conducted with the Unit Manager on the SSU nursing unit and the wound care PA. The Unit Manager washed her hands in the bathroom sink and put on a pair of gloves. The PA put on a pair of gloves. The Unit Manager assisted Resident #5 to turn to the right side and held her there while the PA assessed the wound on the left buttock. There was no dressing present. The left buttock wound was the size of a dime and red, with granulation (connective) tissue present. The pressure sore was without drainage, and there was no odor. The PA cleaned the left buttock wound with gauze and saline. She disposed of the used gauze in the trash can near the bed. Then she switched places with the Unit Manager, positioning Resident #5 for the treatment. The Unit Manager removed her gloves and put on a new pair. She did not perform hand hygiene. She removed a hydrogel dressing from a foam plate she had placed on the bed side table and placed it over the left buttock pressure sore. Then she replaced the brief the resident was wearing. The PA removed her gloves and washed her hands in the sink. The Unit Manager remained in the room after requesting assistance to reapply Resident #5's pants. 3. Review of the MDS (Minimum Data Set) for Resident #6, assessment Section M, skin conditions, dated 1/22/2019 showed M0210. Unhealed Pressure Ulcers/Injuries, coded '0', no. Admission data collection 1/15/2019 no open areas, c/o pain to the coccyx. Review of the Admission/Readmission Data Collection, dated 2/18/2019, showed a pressure ulcer of the coccyx with pink and yellow slough present. Review of the Skin Evaluation dated 2/25/2019 revealed the open area on the coccyx was identified as redness. No further wound assessment with the onset, treatments,description, or measurements was present in the medical record from the date of admission until the Wound Care Consultant assessed the wounds on 2/28/2019. Review of the PA (Physician Assistant)'s assessment on 2/28/2019 revealed the following: (page 8) Description: Pressure ulcer of the sacral region, unstageable. Wound #4 Sacrum Cleanse with with Saline, Apply Santyl to wound bed, Cover wound with Bordered Gauze. (page 12) Wound Progress: Wound #4 status is open. The wound is currently classified as Unstageable/Unclassified with an etiology (cause) of pressure ulcer and is located on the sacrum. The wound measures 7 cm length x (by) 9.5 cm width, 52.229 cm 2 area. The wound margin is distinct with the outline attached to the wound base. There is none present, amount of drainage noted. There is small (1-33%) pink granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including adherent slough. The PA's wound assessment dated [DATE] was also reviewed and showed the following information: (page 6) Description: Pressure ulcer of sacral region, unstageable. Wound Cleansing and dressings: Wound #4 Sacrum: Cleanse wound with saline. Apply Santyl to wound bed. Cover wound with bordered gauze. (page 10) Wound progress: Wound #4 status is open. The wound is currently classified as Unstageable/Unclassified wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 7.5 cm length x 9 cm width, 53.01 cm 2 area. There is a small amount of serous drainage noted. The wound margin is distinct with the outline attached to the wound base. There is a large (67-100%) amount of necrotic tissue within the wound bed including adherent slough. The Care Plan dated 2/7/2019 was also reviewed and the following information was discovered: Focus: The resident has pressure injury to his coccyx/sacrum r/t (related to) decreased mobility, incontinence. Goal: The resident's pressure injury will show signs of healing and have minimal risk of infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Monitor/document/report PRN (as needed) any changes in skin status. A review of the physician's orders [REDACTED]. 2/6/2019 cleanse buttocks with NS and apply Calcium alginate and a CDC (clean dry dressing) QD (every day) and prn (as needed). 2/20/2019 coccyx wound- clean with NS, apply Santyl and dry dressing daily and prn. 2/28/2019 sacrum- cleanse with NS, apply santyl and foam dressing daily The TARs (Treatment Administration Records) were reviewed along with nurse's notes. There were no signed treatments for the month of (MONTH) 2019, and the only treatments signed in (MONTH) 2019 were on (MONTH) 6 and and 7. The nurse's notes dated 2/6/2019 showed a buttock wound was found and the ARNP (Advanced Registered Nurse Practitioner) ordered a treatment. A nurse's noted dated 2/22/2019 showed a wound on the sacral area was cleaned with normal saline and a gauze pad with the date and time was applied. In an interview with the RN (Registered Nurse) Unit Manager on the SSU nursing unit, at 1:13 p.m. on 3/8/2019 she said the wound on Resident #6's buttocks started at the facility before he went to the hospital. At 1:29 p.m. on 3/8/2019 an observation during wound care was conducted with the SSU nursing unit Unit Manager, RN. The Unit Manager removed supplies from the treatment cart. She took a pair of scissors from the treatment cart drawer and used them to cut strips of tape. She marked the tape with the date and her initials. Then she placed Santyl ointment in a medicine cup, and placed it on a foam plate along with a tongue depressor, Bordered gauze, a cup of normal saline, skin prep, and gauze 4x4s. She also placed a red biohazard bag on top of the treatment cart. Then she removed some gloves from a box and brought the supplies into Resident #6's bedroom. She set them on the bedside table on top of the foam plate. She went into the bathroom and washed her hands in the sink and dried them with paper towels. She put on a pair of gloves and removed foam boots from Resident #6's feet. Then she removed his socks. Next, she applied skin prep to Resident #6's right heel. Then she applied another skin prep to Resident #6's left heel. After removing her gloves, the Unit Manager washed her hands in the bathroom sink, and dried them with paper towels. Then she put on another pair of gloves. She used the bed controller to raise the bed. She went to the door way and asked for assistance to reposition Resident #6. Staff G, RN, assisted with pulling Resident #6 up in the bed. Next, the Unit Manager reapplied Resident #6's socks and foam boots to his feet. She removed the gloves and washed her hands in the sink and dried them with a paper towel. She put on a new pair of gloves. Then she opened the bordered gauze dressing and used a felt tipped marker to mark it with the date. The she opened the gauze 4x4's. After instructing Resident #6 to turn to his left side, the Unit Manager removed the dressing from his coccyx .The dressing had scant yellow-brown drainage, and no odor. When she realized she had forgotten the biohazard bag, she disposed of the dressing in the trash can at the bedside. The wound was on Resident #6's coccyx and right buttock, with irregular, well-defined borders. The wound covered Resident #6's coccyx, and the inner portion of his right buttock. It was about 3 inches by 3 inches in size. There was 100% yellow slough present. The Unit Manager did not remove her gloves or perform hand hygiene prior to proceeding to clean the wound with saline and gauze. After cleaning the wound, the Unit Manager disposed of the gauze in the trash can. Then she used a dry gauze 4x4 to pat the wound dry. Next, she used the tongue depressor to apply Santyl to the wound bed. Then she placed a gauze 4x4 on the wound and applied the Bordered gauze. After that, she removed the gloves and disposed of them in the trash can along with the remaining supplies. Then she washed her hands in the sink and dried them with paper towels. At 3:31 p.m. on 3/8/2019, an interview was conducted with the DON (Director of Nursing). She said the facility did a full house audit last week on the MARS (Medication Administration Records) and TARS (Treatment Administration Records) and started working on a PIP (performance improvement plan). She said one of the nurses had mentioned in passing that she didn't realize the transcription process, and they realized the transcription process might be a problem, so they did a full house audit. She also stated that staff should wash their hands when going from dirty to clean. On 3/8/2019 at 5:15 p.m., in a follow up interview with the DON, she confirmed the (MONTH) TAR wound care had not been signed except for on the 6th and 7th. She repeated the facility had done a full house audit last week, and she said, yes, she was aware there was a problem. Polices and Procedures dated 12/6/2017 review showed the following: Subject: Dressing Change Policy: A clean dressing will be applied by a nurse to a wound as ordered to promote healing. Procedure: Place supplies on prepped work surface Perform hand hygiene Apply gloves Remove and dispose of soiled dressing Remove gloves Perform hand hygiene Apply gloves Evaluate wound for type, color, amount of drainage Cleanse wound as ordered, dispose of gauze Remove gloves and perform hand hygiene Apply treatment as ordered and clean dressing Discard gloves and perform hand hygiene

Based on interviews, record review, review of time punch cards and posted staffing board assignments, observations, and policy review, the facility did not ensure that sufficient staff was available to provide personal hygiene needs for 2 residents (#1 and #2) of 3 residents reviewed for ADLs (activities of daily living), and that pressure ulcer treatments were provided timely to three residents (#2, #5, and #6) of 3 residents reviewed for wound care. Findings included: On 3/7/2019 at 6:30 a.m. an interview was conducted with Resident #10. She said on (MONTH) 22 and 23 they were short staffed. There was one aide on the night shift for this unit, so they called an aide from SSU, the other nursing unit, to come help. Staff C, CNA was the only aide. Nobody was gotten up. On the 23rd, there were two aides on night shift. Nobody was gotten up. That was Saturday and Sunday. At 6:46 a.m. on 3/7/2019, an interview was conducted with Staff C, CNA. She said yes, she was the only CNA last Saturday. It was the 24th. She showed the surveyor a photo on her cell phone which showed the staffing board with 2 nurses and 2 CNAs. ***Photographic evidence was taken*** She said the nurse had the assignment sheet with herself, and agency, agency, agency on it under CNA assignments. An aid from SSU, the other unit, came to help. They had 62 patients, so they each had 31 apiece. She said they couldn't get anybody up with just 2 of them. On 3/7/2019 at 7:03 a.m., an interview was conducted with Staff D, CNA. She said staffing varies. She said yes, she has had more than 20 in her assignment. The last time was last week, on Friday night. There were 3 aides. It was 22 apiece. She said they couldn't get residents up. They are short staffed a lot on weekends, Fridays, Saturdays, Sundays, and Mondays. Time punches were reviewed for CNAs for 2/24/2019. There were only three CNAs who had punched in on the 11-7 shift. The census was ninety-nine, indicating the CNAs had 33 residents each in their assignment. On 3/8/2019 at 9:17 a.m. an interview was conducted with the acting Staffing Coordinator, Staff F, CNA. She said the facility does not have a staffing coordinator and she has been filling in for the last 2 days, maybe 3. When we fill those out (staffing calculation) we go by the sign in sheet. She confirmed there were only 3 CNAs who clocked in on the 11-7 shift on the 24th. An observation of the assignment on the staffing board for the SSU nursing unit was conducted on 3/8/2019 at 9:56 a.m. The Unit Manager was assigned to the 400/600-601 assignment. ***Photographic evidence was taken*** On 3/8/2019 at 10:27 a.m an observation on the GNR nursing unit staffing board showed the Unit Manager had an assignment on the 200 hall and 300 odd. ***Photographic evidence was taken*** In an interview with the DON at 11:34 a.m. on 3/8/2019, she said they are working more than usual. There is a turnover after a new Director comes on board. There is a culture change, and we have a lot of prn who aren't committed and we can't make them work. She said a lot of people resist, and since patient care comes first, if she finds lack of quality care she has to write someone up. Last week that occurred, so the person she wrote up called off for the next 3 shifts after. The DON said if the facility has to move someone from staffing to care, or activities to care, then that's what they will do because the care has to come first. We can't do activities without the care being provided. So I will shut them down if necessary or go give showers myself or whatever else I have to do to ensure the care is being provided. She said they are working on having a job fair, and until then they are working on a contract with another agency. In a follow up interview with the DON on 3/8/2019 at 11:58 a.m. she said one nurse stayed over and worked as a CNA the whole shift (of the 24th of February). She said another nurse scheduled for that shift was put on the floor because she was recently a CNA. She said they had more nurses but they needed more CNAs so that for the census the numbers were ok. She said they will have to see if there's a way for secondary positions to be clocked into, so if the nurse comes in as a CNA, then she can clock in that way. On 3/8/2019 at 1:17 p.m. an observation was conducted of the staffing assignment board on the GNR nursing unit. Staff E, CNA, restorative was assigned to rooms 100-108 even. ***Photographic evidence was taken*** On 3/8/2019 at 1:27 p.m. an interview was conducted with Staff E, CNA restorative. She said she works 7-3, and she is actually the restorative aide here. She said nobody was doing restorative today. She said another aide who is restorative is also on an assignment today. On 3/8/2019 at 3:37 p.m. in an interview with the DON, she said the facility has restorative aides, but they are not always in restorative daily. She confirmed there was no restorative today. At 5:26 p.m. on 3/8/2019, an observation of the staffing board on the SSU nursing unit revealed there were only 2 CNAs caring for for 36 residents. ***photographic evidence was taken*** At 12:24 p.m. on 3/7/2019, an interview with Resident #1 was conducted. She said she is supposed to be getting bed baths three times a week, and they're not getting done. On her shower days they tell her they are too busy. She said she smells and feels unclean. She said she used to be a nurse, and she feels ugly and dirty here. She began crying. She also said the aides don't want to give her a bath. She said she is lucky if she gets one or two a week. She said she has special equipment for washing her hair in the bathroom but nobody wants to use it to wash her hair. Her hair smells. She said she doesn't know why they can't use the hoyer to take her in the bathroom. Staff say they're too busy. Resident #1 said the Social Worker, DON (Director of Nursing), and Administrator know about it, but they don't do anything about it. There isn't enough staff here. Review of the MDS dated [DATE], Section C, Cognitive Patterns revealed a BIMS (brief interview for mental status) score of 15, indicating Resident #1 was cognitively intact. Review of Section G, Functional Status, G0120. Bathing, showed 3. Physical help in part of bathing activity, and 2. 2. one person physical assist. The Care Plan review dated 10/12/2018 showed a Focus: The resident has an ADL self-care performance deficit and at risk for decline r/t (related to) (diagnoses). Interventions included Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated/refuses to use shower shower chair. Bathing/Showering: The resident requires assistance of: dependent x 1-2 people. The CNA (Certified Nursing Assistant) Kardex was reviewed and revealed Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated/refuses to use shower shower chair. Bathing/Showering: The resident requires assistance of: dependent x 1-2 people. Shower sheets were requested for the month of (MONTH) 2019, and were not provided. At 2:48 p.m. on 3/7/2019, in an interview with Resident #2, he said he is supposed to be getting three showers a week, and he gets one to two. He said the aides tell him the hoyer pad is missing, or there aren't enough staff. He bought his own hoyer pad. He said the DON knows and she is working on it. Review of Resident #2's MDS section C, Cognitive Patterns, dated 2/3/2019 showed a BIMS score of 15, indicating Resident #2 was cognitively intact. Section G, Functional Status was also reviewed and revealed G0201. Bathing 4. Total Dependence with 2. 1 person physical assistance. Review of the CNA Kardex showed Bathing/Showering: The resident is totally dependent on 1-2 staff to bathe/shower. Shower sheets for the months of (MONTH) and (MONTH) were requested and were not provided. At 8:54 a.m. on 3/8/2019 an interview was conducted with the DON. She said they do not have shower sheets. Staff were filling them out and throwing them away every month. The facility just became aware of it and started a performance improvement plan last week. At 9:55 a.m. on 3/720/19 in an interview with Resident #2, he said nobody wants to do his wound; sometimes he won't get it treated for [REDACTED]. He has to ask them to do it or it won't get done. They don't have a wound care nurse. Review of Resident #2's MDS assessment dated [DATE] Section M, Skin Conditions, showed A. Resident has a pressure ulcer/injury, a scar over a bony prominence, or a non removable dressing/device. M0300. Current Number of Unhealed Pressure Ulcers/Injuries at each stage. C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling. Enter Number -2. Number of these stage 3 pressure ulcers that were present upon admission/entry or reentry. Enter number-2. physician's orders [REDACTED]. 1/25/2019 Iodosorb gel Cleanse right medial foot and right lat foot with NS (normal saline), apply Iodosorb gel and 4x4 and gauze wrap once daily. Record review was conducted of the MDS assessment dated [DATE] for Resident #5, which showed the following information: Section M, Skin Conditions, M0300 Number of Unhealed pressure ulcers at each stage: 1. number of stage 2 pressure ulcers -one. 2. Number of Stage 2 pressure ulcers that were present on admission-one. A review of the physician's orders [REDACTED]. The 1/ 9 physician's orders [REDACTED]. The TAR (treatment administration record) for (MONTH) and (MONTH) 2019 were reviewed, and showed the only treatments signed in (MONTH) were on the 23rd and the 25th. The (MONTH) treatments had been signed on (MONTH) 5, 6, and 7. No other treatments were signed and no other treatment records were provided. A record review conducted for Resident #6 found the Admission Data Collection, dated 1/15/2019, revealed no open areas, c/o pain to the coccyx. Review of the MDS assessment Section M, skin conditions, dated 1/22/2019 showed M0210. Unhealed Pressure Ulcers/Injuries, coded '0', no. Review of the Admission/Readmission Data Collection dated 2/18/2019 showed a pressure ulcer of the coccyx with pink and yellow slough present. Review of the Skin Evaluation dated 2/25/2019 revealed the open area on the coccyx was identified as redness. No further wound assessment with the onset, treatments,description, or measurements was present in the medical record from the date of admission until the Wound Care Consultant assessed the wounds on 2/28/2019. In an interview with the RN (Registered Nurse) Unit Manager on the SSU nursing unit, at 1:13 p.m. on 3/8/2019 she said the wound on Resident #6's buttocks started at the facility before he went to the hospital. The Care Plan dated 2/7/2019 was also reviewed and the following information was discovered: Focus: The resident has pressure injury to his coccyx/sacrum r/t (related to) decreased mobility, incontinence. Goal: The resident's pressure injury will show signs of healing and have minimal risk of infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Monitor/document/report PRN (as needed) any changes in skin status. Review of physician's orders [REDACTED]. 2/6/2019 cleanse buttocks with NS and apply Calcium alginate and a CDC (clean dry dressing) QD (every day) and prn (as needed). 2/20/2019 coccyx wound- clean with NS, apply Santyl and dry dressing daily and prn. 2/28/2019 sacrum- cleanse with NS, apply santyl and foam dressing daily The TARs were reviewed along with nurse's notes. There were no signed treatments for the month of (MONTH) 2019, and the only treatments signed in (MONTH) 2019 were on (MONTH) 6 and and 7. The nurse's notes dated 2/6/2019 showed a buttock wound was found and the ARNP (Advanced Registered Nurse Practitioner) ordered a treatment. A nurse's noted dated 2/22/2019 showed a a wound on the sacral area was cleaned with normal saline and a gauze pad with the date and time was applied. On 3/8/2019 at 5:15 p.m. in a follow up interview with the DON, she confirmed the (MONTH) TAR had not been signed except for on the 6th and 7th. She repeated the facility had done a full house audit last week, and she said, yes, she was aware there is a problem. A policy for staffing was requested and was not provided.

Based on staff interview, record and policy review, the facility failed to ensure that one (#53) of three residents sampled related to falls was transferred in accordance with the resident's care plan and facility policy. This resulted in a fall with injury; the resident sustained [REDACTED]. Findings included: During a review of the nurses' progress notes, an entry dated 11/14/2015 at 11:30 a.m. documented that at around 10:30 a.m. the aide told the nurse that the resident said that she fell from the machine (a lift used to transfer a resident who is unable to stand and move from bed to chair and back) yesterday while being transferred back to bed. The nurse went to the room to perform an assessment and found the resident's left hip and thigh warm and tender to touch. She noted a small discoloration or skin pigmentation at the site. The nurse notified the nursing supervisor and the physician who ordered a hip and femur x-ray. The resident's daughter was aware of the situation. A further note at 2:35 p.m. on 11/14/2015 showed that the resident did have a left hip fracture. The nurse notified the physician who gave the order for the resident to be transferred to the hospital. She also notified the daughter and nursing supervisor. The resident was sent out to the hospital later that day. Review of the Hospital Medical record for Resident #53 showed she was admitted on [DATE] with a displaced intertrocanteric fracture of her left femur. She had an open reduction and internal fixation, left hip, with intramedullary nail fixation on 11/15/2015 to repair the fracture. Resident #53 was admitted to the facility from the hospital on [DATE] with a [DIAGNOSES REDACTED]. The resident was documented as Spanish speaking only. She had a medical history that included: peptic ulcer disease, rheumatoid arthritis and osteoporosis (a weakening of the bone). Review of the Admission Data Collection form dated 7/8/2015 showed the resident was alert and oriented to person and place. A Fall Risk Assessment was completed with a score or 10 which placed the resident at risk for fall (10 or higher deems resident at risk). It showed that the resident had 1-2 falls in the past three months, was chair bound and unable to stand. The interventions to prevent falls included: frequent staff monitoring at night, visual and verbal reminders to use the call bell and bilateral quarter side rails as enablers to promote independence. A quarterly Data Collection form done on 09/29/2015 showed a fall risk score of six. This evaluation documented the resident as unable to stand, ambulatory and having had no fall in the past three months. A Minimum Data Set (MDS) report was completed on 07/15/2015. The Brief Interview for Mental Status (BIMS) revealed a score of 12 out of 15. This indicated that the resident had a mild cognitive impairment. She was coded as requiring extensive assistance of two staff for bed mobility, transfers and toileting. The MDS also coded the resident as having had a fall in the month prior to admission, no other falls in the previous six months and no fracture related to the fall. The MDS quarterly review completed on 10/15/2015 showed a BIMS score of 14 which indicated the resident was cognitively intact. She continued to need extensive, two person assistance for bed mobility, transfers and toileting, as well as having had no falls since admission. A Fall Prevention care plan was initiated on 07/22/2015 with a target date of 10/22/2015 and reviewed with a new target date of 01/16/2016. The resident was deemed at risk for falls related to cognitive status and unsteady gait. Goals included: will have no falls within the next 90 days, will show improvement in gait, number of falls will decrease within the next 90 days, and will not experience injury from fall(s). Interventions included: complete fall risk on admission and quarterly, assess resident's ability to follow directions, assure clear pathways in room, call bell within reach, ½ rails for mobility and safe turning and mechanical lift. An Activities of Daily Living (ADL) care plan was initiated and reviewed with the Fall Prevention care plan. Interventions included: Transfer: Assist the resident to transfer from/to bed-chair-toilet-wheelchair, resident requires mechanical lift-assist of two, therapy evaluation and treatment as needed. Interviews were conducted with random nursing staff on 12/02/2015. At 10:44 a.m., Nurse D said that if a person is transferred with a lift, 2 staff must be there. He said that he has not seen less than two staff using a lift and he offers to help when he can. Aide E was interviewed at 10:52 a.m. and said that if using a lift to transfer, there must be two staff members to use the lift. She said that she had never transferred a resident with a lift by herself. At 11:15 a.m. Nurse F said that she is familiar with the lift policy which is to always use two staff when transferring. Aide G was interviewed at 11:20 a.m. and confirmed that she uses lifts and that she must have another staff person assist her. She said that she has never had anyone fall while using the lift and that the nurses assist if an aide isn't available. On 11/18/2015 at 12:15 p.m. Staff Development RN and Unit Manager (UM) said that the resident was lowered to the floor in the transfer lift as the aide was getting her up. The UM indicated that she did not fall out of the lift sling. Nurse A assessed the resident who had no complaint of pain. An investigation was done and inservices with aides were conducted. No suspension. The aide panicked because she wanted to ensure the resident was up and out of bed before the daughter came in. The Investigate report was reviewed with the Nursing Home Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON)/Staff Development RN and a Regional Nurse Consultant on 12/02/2015 at 2:30 p.m. The report was completed on 11/16/2015 and documented the incident as a fall due to a hook on the lift sling coming loose from the lift bar. There were no written statements contained in the report. Aide B was interviewed on 12/02/2015 at 3:00 p.m. She has a heavy accent and asked that questions be asked slowly. Her comprehension was good and at times she had to search for the correct word. She said that she was taking care of the resident on 11/13/2015 day until the assigned person arrived. She had cared for her previously and had given her bed baths as part of the care. She said that the resident and her roommate were both Spanish speaking and liked having her care for them. She added that the resident did speak English and preferred to use her native language. The aide said that the resident asked to return to bed because her back and legs were hurting. Aide B said she asked another aide to assist her. She said the aide told her she was busy but would come later. Aide B said that the resident begged her twice more to put her in bed because she was in pain. She said that she panicked because she was afraid the daughter would yell at her when she arrived if the resident wasn't back in bed. The resident was in a wheelchair with the transfer lift sling under her. She said that when she lifted the resident, the resident said she felt like she was slipping and became afraid. The aide was afraid the resident would slip out of the sling. Aide B said that she couldn't get the resident back to the chair so she slowly lowered her to the floor, put pillows under her head and ran to get the nurse. After Nurse A checked the resident, they put the resident in bed and the nurse continued to check the resident. Aide B noticed that the resident had a purple bruise on her thigh and pointed this out to Nurse A. Aide B said that she had not seen that bruise when she had bathed the resident other times. She said that she knew she shouldn't have tried to transfer the resident alone and would never do that again. Nurse A was not able to be contacted for an interview. The Director of Nursing (DON), Assistant Director of Nursing (ADON)/Staff Development RN and a Regional Nurse Consultant (the facility consultant was at another survey) on 12/02/2015 at 3:30 p.m. were interviewed and confirmed that there was no documentation in the record that was written at the time of the incident. In an interview at 3:30 p.m. on 12/02/2015, the ADON said that the incident was not considered a fall since the aide had lowered the resident gently to the floor. She said that she had interviewed the aide and told her that it was better to be yelled at by the daughter than to place the resident at risk. She told the aide that she should always ask a nurse to help if another aide is not available at the time of transfer. After the interview of Aide B, the facility provided her written statement which was in Spanish. Staff C was called to translate the statement. The written statement contained information that the resident had told Aide B that earlier that day (11/13/2015), she (the resident) had been dropped. The DON and ADON confirmed that they had not read the statement and had no knowledge of this information. There was no documentation of the alleged fall in the resident's record and no listing on the Accident/Incident monthly log. The ADON said that she had done an in-service about lifting and transferring with the staff. A review of the facility's Policies and Procedures-Lifting and Moving Residents-Effective Date 11/30/2014 found the procedure included: 1. Assess the resident's condition and mobility. (Determine if the resident has been designated as a 2 or 4 person lift.) 2. Get help if at all in doubt about your ability to move the resident alone. Use resident transfer equipment as required. (Do not attempt to lift any resident alone that has been designated as a 2 or 4 person lift Use a mechanical lift to transfer a resident who cannot stand from the bed to the wheelchair. Note: two staff members must be present when transferring a resident with a mechanical transfer lift. At 4:50 p.m. on 12/02/2015, the UM was interviewed. He said that he heard the aide calling for help and went into the room with Nurse A who assessed the resident. After the resident was placed in bed, he spoke with Aide B about the incident and told her to get him or a nurse if another aide wasn't available. He said that he was in his office when the incident occurred. His office is next to the resident's room and he said he would have heard if she had been dropped to the floor. He was not aware of a previous fall.

Based upon interview, observation and record review, the facility did not ensure that the resident was free from a fall hazard for one (#1) out of four sampled residents. Not ensuring that the resident is free of accident hazards lead to a fall resulting in a left leg fracture requiring hospitalization . Findings include: As per the resident #1's face sheet, dated 12/18/12, the admitted was 12/18/12; DOB was 5/11/32; age 80. As per the resident's Admission Form, dated 12/18/12, the resident had the [DIAGNOSES REDACTED]. The timeline of events for the 12/31/12 fall were, according to the Skilled Nursing Notes dated 12/31/12 at 4:10 a.m., the following: the assigned Aide was performing routine care that required the bottom sheet of her linen changed. The resident was located on her left side; the aide raised the resident's right leg to assist the resident in positioning; and, the resident over swung her leg over her body which resulted in the resident rolling out of the bed onto her knees. The Hoyer was used to place the resident back in to the bed. No visible injuries were noted and the resident complaint of left knee discomfort when placed in the bed. According to the resident's December MAR the resident was medicated for Oxycodone 5mg 1 tablet, by mouth on 12/31/12, no time was listed. The back of the MAR, nurses notes or other did not list assessment type notes regarding the pain, e.g.the location, severity, nonpharmaceutical measures for pain, consistency or whether or not the pain medication was effective for the 12/31/12 date. On 2/1/13 at 1:40 p.m., the DON mentioned that the assigned nurse, "could have done better with the pain charting." According to the Skilled Nurses Notes, the resident did say she had pain on 12/31/12 at 2:00 p.m. and at 5:30 a.m. The resident was administered Oxycodone 5mg as per Doctor's Orders. As per nurses' notes, no arm pain was reported (as the complaint indicates) as per the resident's nurse's notes and other charting. According to the nursing progress notes assessment checklist, dated 12/31/12, the resident was not in pain, she was alert and oriented X3 and her emotional status was pleasant. A Doctor's Order, dated 12/31/12 at 4:55 p.m., read x-ray to left knee and hip. A Doctor's Order, dated 12/31/12 with no time listed, read x-ray to left knee and hip & cervical, thorax and lumbar back. On 2/1/13 at 1:00 p.m., the Unit Manager (Ms. Bones) mentioned that she wrote the untimed order right after the timed order as a replacement to the timed (4:55 p.m.) order; because she wanted to be thorough and also obtain an x-ray of the back. According to the Skilled Nursing Notes, dated 12/31/12 at 5:30 a.m., the following was noted: the resident mentioned that her left knee was bothering her before the incident. And, that the nurse was unclear as to when the knee pain began. According to the Skilled Nursing Notes, dated 12/31/12 at 6:30 a.m., the following was noted: A voicemail call was placed to the daughter concerning the incident; and, that the nurse informed the family that the resident is safe and well. According to the Nursing Notes, dated 12/31/12 at 10:00 a.m., the following was noted: Mobilex portable x-ray technician mentioned that the resident's body mass was too large for the x-ray to be reliable; and, the Doctor was called to notify. On 2/1/13 at 1:06 p.m., the unit manager mentioned that the facility was waiting for another technician to show up and re-evaluate whether or not the portable x-ray was able to be done. The Doctor was called at 10:00 a.m.; the Doctor returned the call at 1:35 p.m., a three & 1/2 hour lag period for communication. On 2/1/13 the Unit Manager mentioned that there is no protocol as to when to recall the Doctor regarding time. According to the Skilled Nursing Notes, dated 12/31/12 at 1:35 p.m., the following was noted: the Doctor called back and stated to keep monitoring the resident; and if the pain worsens to send the resident to the ER; and, the facility can secure outpatient x-ray on Wednesday 1/2/13. According to the Skilled Nursing Notes and the Nurses Notes, both dated and timed on 12/31/12 at 2:00 p.m., the following was noted: normal vital signs listed; resident medicated for pain. The location, intensity, duration, etc., of the pain was not listed. MD called; x-ray waiting; and, resident's daughter at bedside. According to the Skilled Nursing Notes, dated 12/31/12 with no time listed, the following was noted: Report given to daughter; daughter requested that resident be sent to ER; daughter mentioned, "My mother is having a stroke." Resident immediately evaluated with equal pupils and equal grip & pedal strength. A report was given to the ER nurse at Northside hospital. According to the Skilled Nursing Notes, dated 12/31/12 at 6:00 p.m., the following was noted: resident was admitted to the hospital. A local hospital report, dated 12/31 at 3:33 p.m., page 6 of 9, indicated: comminuted displaced distal left femoral fracture; marked arthritic changes at the medial and lateral knee joint compartments... (This indicates a fracture in which the bone has broken into pieces and has moved out of place.) On 1/24/13 at 2:03 p.m., the resident was not considered a fall risk because she did not meet the fall criteria; therefore, no Fall Care Plan was noted. The resident scored a 5 on the risk for Falls Assessment, dated 12/18/12. The Fall Risk Assessment was completed upon admission. According to the DON and the Falls Assessment Grid, a score of 10 or greater would indicate that the resident was at risk for falls. The facility had a Falling Stars Program Policy, dated 1/1/07 which stated: "A resident with a score of 10 or more on the fall risk assessment is considered at risk for falls." On 1/24/13 at 1:56 p.m., the DON mentioned that the aide was suspended on the day of the resident's fall which was on 12/31/12. The nurse was suspended also on 12/31/12. The DON also mentioned at this time that she provided an immediate Plan of Correction through in-servicing. The in-service records were reviewed. The nurses and aids were in-serviced. The in-services were completed by 1/4/13. In-servicing records indicate that a 4-point-plan-of-correction was implemented immediately regarding resident #1 as well as other residents at risk. The DON conducted most of the in-services; the unit managers conducted most of the follow-ups. On 2/1/13 at 11:43 a.m., the assigned Aide that was with the resident when the resident fell was interviewed. The aide mentioned the following: "the facility did have the resident listed as a 2-person-assist on the Kardex; however, it was common knowledge (not written knowledge) that the reason the resident was a 2-person-assist was because the resident felt that the staff was talking about her; therefore, the 2-person-assist requirement was not for safety; the 2-person-assist was to protect the facility against the resident's paranoia; the facility wanted the resident to be a 2-person-assist for the paranoia behavior reason. The Aide mentioned that since she had a good relationship with the resident that she was not concerned with any accusations directed at her from the resident. So, the aide continued to change the resident's bed sheets without assistance. The aide mentioned that she was fired from the facility because she did not use the 2-person-assist method. The aide mentioned that the resident had a little bit of pain right after the incident. The aid mentioned that each aide has about 18 residents at night; there were about 55 residents for three aides; and, the staffing was adequate regarding no one called-off of work that night; the facility does a good job with teaching/training." On 2/1/13 at 1:30 p.m., the Unit Manager was asked to provide a Behavioral Care Plan. The Unit Manager mentioned that the resident did not have behavioral issues. According to the skilled progress notes, dated 12/31/13, the resident was listed without behavioral issues. According to the resident's face sheet, dated 12/18/12 and according to the Admission Form, dated 12/18/12, there was no paranoia/behavior [DIAGNOSES REDACTED]. According to the Admission Care Plan, dated 12/18/12, the resident was listed as bed mobility with assist X2 persons.

Based on record review, observations, facility policy, and resident and staff interviews, the facility failed to meet the needs of residents by neglecting to provide necessary supervision and/or prompt and thorough response to a door alarm for two (#8 and 2) of four residents reviewed for accidents. These actions related to the elopement with injury of a frail elderly resident (#8) and to a fall down the front entry stairway of another frail elderly resident (#2); both of whom were assessed with [REDACTED]. These actions resulted in findings of Immediate Jeopardy, which was removed on [DATE], and the severity and scope was reduced to a D. Findings include: 1. On [DATE], a nurse's note (timed 10:00 a.m.), in the medical record of Resident #8 indicated that an antibiotic was administered without difficulty. Two episodes of crying were also noted along with the resident self-propelling in wheelchair and being rude to staff and roommate. An ordered pain medication was noted as also being given for complaint of pain. The 11:00 a.m. note indicated that the ordered pain medication appeared to be effective for left hip pain. The 12:30 p.m. note indicated that she was anxious, crying, and asking if they had seen her rings. It was noted that the anti-anxiety medication had been given at 12:00 p.m. Also noted that she was wheeling herself around saying "I'm going home;" that she refused lunch and took jacket out of the closet and tried to place it at the nursing station. It was noted that she was re-directed to her room. The 1:30 p.m. noted indicated that she was observed lying in parking lot on left side with leg bent and arms bent at sides; and complained of pain in extremities. A small abrasion to forehead was noted; along with 911 being dispatched and her being taken to hospital; and a message being left for her daughter. On [DATE], the final nurse's note (timed at 10:00 a.m.) indicated that the hospital was called and that the resident had been admitted on [DATE] with a [DIAGNOSES REDACTED]. The hospital's Discharge Summary (with the listed date of discharge of [DATE]) listed the resident's attending physician as the signing physician of that document. The initial admitting [DIAGNOSES REDACTED]. She was noted to have been admitted to the hospital. Also noted was that she had a history of [REDACTED]. Additional testing (via MRI) and neurology consult indicated that she was status [REDACTED]. "Neurology felt there was no further need for any intervention and the patient was subsequently discharged ." The physician noted discussing the discharge with the daughter, and due to her active attempts to elope, it was felt that she would most benefit from going to another facility with a secured unit. [AGE] year old Resident #8 was admitted to the facility on [DATE] per the medical record facesheet (noted as revised on [DATE]). The initial Minimum Data Set (MDS), with an assessment reference date of [DATE], indicated that she could answer the assessment questions but only scored 6 out of 15 in the section related to memory. She was noted with inattention and disorganized thoughts and some indicators of depression. Related to activities of daily living, she was coded as requiring limited assistance of one to dress, toilet, walk, and locomotion. Additionally, she was coded as unsteady in balance and as using a walker and a wheelchair for walking/locomotion. The MDS also coded her as having had a history of [REDACTED]. Included in this initial MDS's Care Area Assessment (CAA) Summaries was information regarding her having impaired communication related to her impaired cognition; and noted that she loses her train of thought a lot and may not fully understand what is being said to her. Additionally, the Falls CAA noted that she was at risk for falls due to history of a fall at home, where she sustained a laceration on the back of her head. Complications were noted to include: having impaired cognition due to advancing dementia; having poor safety awareness and making frequent attempts to get up on her own; having impaired balance while standing, turning and transferring; and being on an anti-depressant and a pain medication (due to shoulder pain and a long history of [MEDICAL CONDITION] arthritis). The Pain CAA noted (in part) "She is able to participate in therapy, feed herself, participates in her ADLs (activities of daily living) and wheels herself in the wheel chair readily. She does exhibit restlessness and attempts frequently to get up by herself. She is able to communicate need for pain med (medication) to the nurses." The ,[DATE] comprehensive care plan for Resident #8 was dated [DATE] (with a care plan meeting documented as being held on [DATE]); and covered various assessed concerns/problems. Included in the problems (among others) was her being at risk for falls; having mood symptoms of frequent crying episodes, restlessness and becoming easily annoyed at times; and having impaired cognition and communication related to dementia. The falls care plan included many approaches, several of which included keeping her in area where staff could monitor, low bed, and bed and chair alarm. On [DATE], a care plan problem was added regarding her being at risk for elopement related to exit-seeking behaviors and [DIAGNOSES REDACTED]. A problem regarding low activity level had been revised on [DATE] and indicated that she had cognitive impairment; impaired long/short term memory and decision-making skills; impaired attention span, frequent episodes of crying and " looking for her car/husband/children; " states I have to go get my husband, "I am going home;" easily agitated; can be verbally aggressive; not always easy to re-direct; frequent episodes of being very angry; and verbally rude towards others. These care plan problems had been added in conjunction with an "Elopement Risk Assessment" done on [DATE] by the Skilled Sub-Acute Nursing (SSU) Manager. Prior to the [DATE] fall with injury, nursing and other medical practitioner notes in Resident #8's medical record indicated an increase in mood/behavior problems in ,[DATE] as follows: a. The [DATE] "Geriatric Behavioral Management Assessment" note (written by an Advanced Registered Nurse Practitioner for the practitioner that had been seeing the resident in the facility since at least [DATE]) noted that [MEDICATION NAME] (an anti-depressant, also known as [MEDICATION NAME]) had been increased to 150 mg (milligram) on [DATE] and that they would continue to monitor. The [DIAGNOSES REDACTED]." b. The nurses' notes between [DATE] and [DATE] noted behavior monitoring related to the [MEDICATION NAME] increase to 150 mg (milligram). At times she was noted as being more cooperative and pleasant; and at other times she was noted to be crying without reason and needing redirection to her room and caution to not ambulate without assistance. c. On [DATE], the nurse's note (timed at 3:00 p.m.) indicated that the physician had been notified that the resident had episode of agitation and increased confusion, anger, paranoia, crying, which lasted approximately 2 ? hours; and then was calmer, more cooperative. She was noted as being given an ordered pain medication at onset for chronic back pain and appeared effective. Also noted was that blood work was due to be drawn [DATE]. The 5:00 p.m. note indicated she was propelling herself with wheelchair around the unit-denied pain or discomfort, no shortness of breath, no crying and behavioral issues at that time--continued to monitor. Additionally an Elopement Risk Assessment was found to have been done on that same day, due to exit-seeking behavior. The use of a wanderguard was care planned (and noted to be monitored by nursing) and included multiple approaches. Several of these included: re-direct resident from doors and exit PRN (as needed); use diversion when exit seeking; increased 1:1 monitoring if indicated; and personal wander prevention device. d. On [DATE], the nurse's note (timed at 11:00 a.m.) noted that the attending physician's Physician Assistant (PA) was asked if he had examined her today. The resident's episodes of agitation/anxiety/crying were explained/discussed, along with the recent increase in the anti-depressant, [MEDICATION NAME]. (The PA's note of that day noted that the [MEDICATION NAME] was to continue and that psychological consult (on [DATE]) suggested a named anti-psychotic medication; and indicated to re-check labs.) The nurse ' s note indicate that the PA was to discuss further with the physicians for who he worked-one of the physician ' s wanted the anti-psychotic medication begun, while the other adamantly was against its use. The nurse's note also indicated that she became suspicious of the nurse when applying lotion to her toes; stating that the nurse wanted her to slip and fall. She was noted as being anxious and starting to cry. The nurse attempted to reassure her and that the facility did not want her to fall and that they cared about her. She was noted as saying "No you don't." It was also noted that they were awaiting laboratory and urinalysis results. The 9:00 p.m. note indicated that she was alert, anxious and upset about staying at the facility; yelling and trying to get out of bed three times, with staff re-directing her. She refused to stay in bed, verbalizing that she wanted to go home and be out of this place. Staff explained that it was late and nobody would be able to pick her up to take her home. Offered pain medication for complaint of back pain-resident refused to take it and threw it on the floor. e. On [DATE], the nurse's note (timed at 1:20 a.m.) noted resident very upset that she now was a long term care placement; and did not want to stay. Stated: "I feel alone." She was noted as resting quietly at that time without further complaint. Also on [DATE] (untimed), the facility faxed to the physician with a question on the anti-psychotic and about laboratory work that was done, with culture and sensitivity results still pending. The physician replied do NOT give the named antipsychotic medication. f. On [DATE], the 4:,[DATE]:00 p.m. nurse's note indicated episodes of crying and wandering around the unit via wheelchair, stating "I'm going home." She was also noted to try to get out of the exit door; and had been returned to room several times and assisted to the bathroom. The 8:00 p.m. note indicated that HS care given; call bell noted within reach and bed alarm on. g. On [DATE], the nurse's note (timed at 2:00 a.m.) indicated resting quietly in bed-no episodes of crying this shift and no complaints of pain or discomfort. The 8 a.m. note indicated morning care given; and that she was sitting in her wheelchair in her room and wandering around unit in the wheelchair-quiet. Then the 2:00 p.m. note indicated after noon she started crying and being angry. The 4:,[DATE]:00 p.m. note indicated that she was less confused and not crying; that she talked with her husband by phone and was less agitated. h. On [DATE], the nurse's note (timed at 3:00 a.m.) indicated that she rested on/off during the night with eyes closed; and that a wanderguard in place due to exit-seeking behavior. The 9:30 a.m. note indicated that she was pleasant, cooperative and ate a good breakfast. Noted too was that she had not made any attempts to get out of bed unassisted-low bed, sensor bad in bed, wanderguard due to poor safety awareness. The 10:30 a.m. note indicated that she was propelling herself in the wheelchair; crying, looking for rings. The rings were locked in the medication cart-she had removed and placed them under pillow. The 10:30 a.m. note indicated that the results from the urine analysis culture and sensitivity test had been received and report faxed to the physician. Also that something for mood be prescribed for "crying jags, ^ (increased) anxiety, verbal abuse to staff and others, etc." Additionally a psychological evaluation was requested to determine competency. The 2 p.m. note indicated that she was attempting to exit doors-monitor and attempting to re-direct, distract, engage in activity. The 3:45 p.m. note indicated that a fax order for the psychological evaluation was received, along with an order for [REDACTED]. Regarding the above-mentioned fall with injury, the facility provided reports dated [DATE] and [DATE], which had been written by the Director of Nurses (DON). The reports indicated that Resident #8 went outside and the door alarm went off. A maintenance staff member (who had been using the nearby men's room) heard the alarm and went outside to look for who set off the alarm. He did not see anyone, so he silenced the alarm. It was noted that the staff member said he looked outside but did not look around the building for anyone, as he did not think that they would travel that fast. It was noted that the resident had gone around the corner and was on the ground moments later. When the resident was found, she was over the curb with the wheel chair on top of her body. The only obvious injury was an abrasion to the forehead. The resident was transferred to the hospital for evaluation and treatment; and was ultimately placed in a more secure locked environment. The [DATE] report indicated (in the section for description of corrective or proactive action(s) taken) that all staff in-serviced on the importance of looking beyond the entryway and around corners when the door alarm goes off. (However, review of the [DATE] training attendance sign-in sheets determined that only 73 of 132 staff were re-trained.) Also, the resident was noted as being transferred to a more secure environment for safety. On [DATE] at 6:19 p.m., the DON verified the above information, and indicated that the resident had gone to the ambulance entrance (located off of the 600 hall)-it was alarmed for when a wanderguard passed it and the alarm went off. The DON indicated that the resident was out there only a couple minutes-someone saw her outside and said she had tumbled over. The Maintenance Assistant (Employee #3) heard and looked but she had evidently gone off to the right around the side-and he did not go around the corner and look. On [DATE] at 10:10 a.m., the Maintenance Assistant (Employee #3) indicated that he heard the alarm while using the bathroom; and that it had been sounding several minutes. (He thought it was under 5 minutes by the time he got out of the bathroom). According to him, no other staff person had responded at that point. He looked up and down the hallway, then went through the double glass doors into the adjacent lobby and then to the double doors to the exit (next to which the wanderguard keypad was mounted. He said he went to the keypad and shut off the alarm; then took a step out of the door onto the 1-step up entry porch (located under a drive-through portico). He then looked left and right and did not see anyone so went back inside. This front walking surface (which was a one step-up from ground level porch area) stretched approximately 30 feet in each direction (or about 10 paces each way to either end of the building); and was adjacent to a driveway that ran in front of it (which was used as an ambulance entrance). He verified that he merely stepped out and checked in both directions and did not walk to either end of the porch to look into the parking lots that were on either side of the building. This main entrance faces a busy street, but the driveways run at an angle from the street toward this particular ambulance entrance way. When the Maintenance Assistant went back inside the building, within minutes a resident (Resident #14), who was in the 600 hall dining room, was yelling out about a resident having fallen outside. When he saw the fallen resident, she was at the second parking spot in the western lot right next to the building; and had fallen over the cement parking bumper. The 2nd parking spot was observed to be visible about 2 to 3 paces from the front entrance. However, it could not be seen if one stood at that doorway and looked in that direction. The Maintenance Assistant verified that the alarm was set off only by the wanderguard mechanism worn by various residents (either on their arm, leg or chair). When the person with a wanderguard hit the sensor area, then the alarm sounded. This was observed to be a loud whooping sound, as well as a voiced message that sounded over the public address system " Door alarm, 600 hall. " Both sounds continue until the alarm was turned off. Regarding the above 600 hall exit door, this entrance/exit portico area was observed to face a highly trafficked 7-lane city street. From the exit door, it was approximately 35 paces (or 105 feet) to that street (when walking straight ahead and through an area of curb-surrounded bushes. Two paved driveways ran through this portico entrance area. The West driveway to the street measured approximately 53 paces (or 160 feet); and the East driveway measured approximately 51 paces (or 153 feet). On [DATE] at 1:40 p.m., the witnessing resident (Resident #14) was interviewed. Resident #14 said that she had been sitting at the dining room window and saw Resident #8 wheeling down the sidewalk from the portico area. The left wheel of Resident #8's chair had slipped off the sidewalk and she had fallen down and rolled over the parking bumper. Resident #14 yelled and went out into the hallway and saw the Maintenance Assistant (Employee #3) and yelled for him. Resident #14 said he and other staff responded to her call for help right away. She did not recall one way or the other hearing the alarm sounding. On [DATE] at 2:55 p.m., the SSU Manager (Employee #1) indicated that from the time of admission the resident had periodic agitation, crying, wandering-behavior was up and down and seemed to escalate after lunch. Staff had been talking with the physicians and PA involved; laboratory work was done and the resident was on an antibiotic at time of the incident. She indicated that this resident was one for whom staff tried to redirect, calm and, as necessary, keep near to them -- e.g. 1:1 at times, or put by nursing station. The Unit Manager said she would even be brought into her office and she would sit there with the Unit Manager. The Unit Manager said she was on duty the day of the fall outside, but did not see the resident at the time. She indicated that the Maintenance Assistant (Employee #3) had responded to the wanderguard alarm going off; and that Resident #14 had called out about seeing her fall outside. On [DATE] at 3:15 p.m., a Nurse (Employee #2) indicated she was on the floor the day of the resident's fall. The LPN indicated that they tried to do informal 1:1 supervision with her so she would be with others and be distracted. On the day of the fall, she had been with an Aide, who was called to help in another resident's room. She heard that the Aide had then positioned the resident by the nursing station, which was common to do for that resident and some others. The Nurse indicated that she remembered seeing the resident earlier in the day, but did not hear the wanderguard alarm sounding because she was in another resident's room at the time. She got a call that the resident was in the parking lot and was told that the resident had flipped over the parking bumper barrier-she thinks that the wheelchair was to the side (and not on top of the resident) when she observed the resident. She also added that the resident in latter days of her stay was more agitated/upset; and that staff tried to figure out how to keep her comfortable. The LPN said she had given the resident an anti-anxiety medication that day (which was ordered to be given as needed for agitation; and noted on medication records as having been given at 12:00 p.m. with the medication effectiveness noted as being "- poor"). The Nurse also relayed that the resident was at that time on an antibiotic. Per the Nurse, every time she saw the physician or PA, she talked with them about the resident. The physician seeing her did not agree on using [MEDICATION NAME] (an anti-psychotic medication)-one wanted the anti-psychotic started and the other was against it and wrote an order to not use it. On [DATE] at 9:40 a.m., the Assistant Director of Nurses (ADON), who also served as the facility's Staff Developer for training, indicated that the expectation regarding the sounding wanderguard alarm was that ALL staff would respond to the area of the alert, except if unable to do so because of providing care to a resident. She indicated that the alarm was not to be turned off (at the keypad next to the alarming door) until the "trigger" was found (i.e. who/what caused the alarm to go off). She further indicated that the alarm continuing to sound brings additional staff that might be needed (e.g. if the resident would be injured and the 1st responder needing to stay with the resident while others obtained further help; or if more staff would be needed for a search etc.). She had no explanation for why this had not occurred in the case of Resident #8. The ADON indicated that all staff were trained upon hire during orientation; and provided a "Blue Ribbon Orientation Checklist" which indicated that newly hired staff received "Safety 101" training during orientation. This training included missing resident at a glance and elopement guide training. The ADON also indicated that the staff annually attended mandatory in-services. Sheets of attendees for the last annual (on "Education Report by Course" forms) for the time period of [DATE] through [DATE]) included the "Silverchair Learning Systems" course "Missing Resident/Elopement"; and had 97 attendees. The attendees included the Maintenance Assistant (Employee #3) as well as 96 others. The course included definition of elopement, 6 risk factors for elopement, discussion of who may wander and why, and discussion of management of wandering. Included in the information was the question "What is elopement and what are the risk factors?" followed by "Elopement is unsupervised or unassisted flight from the facility. The resident did NOT elope if he/she was identified leaving the facility and was redirected back into the facility (the care plan worked!)." Also included in the course information was the question " If you think that a resident is missing, you should try to find them quickly by yourself so nobody else will find out." The correct answer was "False," with the additional information "If a resident is thought to be missing, the elopement procedure should be initiated which included all staff." Additionally: "The person in charge of the search will assign staff members to look in certain areas." The exterior search techniques stated: "Exterior of the Building within 10 feet - search all rooms using the interior search technique. Look under and behind all plant life - trees, shrubs, etc." The exterior ground of the facility information included: "Search the Parking Lot(s) - Physically look under and inside all vehicles on the property, look on all sides of the vehicle" and went on to describe searches of culverts/ditches, retention ponds and dumpsters. These training policies were not implemented in the case of Resident #8, in that she was unmonitored to the extent that she left the facility unsupervised and unassisted (sustaining a fall with injury); and in that there was a lack of staff responding in a timely manner to the sounding alarm, as well as a lack of a thorough search by Employee #3 who did respond to the alarm. 2. A review of Resident #2's medical record revealed a nurse's note, dated [DATE] 2:50 p.m., that documented the resident was observed on the ground outside of the building in front of steps laying flat on her back with her feet closest to the steps. The resident was able to verbally communicate with staff and her hand grips were equal. She complained of left leg discomfort and was unable to straighten her left leg without pain. There was a hematoma to her forehead. 911 was called as was the resident's physician and her responsible party and the resident was transferred to the hospital. The physician's hospital note, dated [DATE], documented the resident was admitted to the hospital with [REDACTED]. A report completed by the facility Director of Nursing (DON) on [DATE], documented the events surrounding the fall as follows: The Resident was found on the ground outside the facility on the front of the steps leading to the building. She was flat on her back with her feet facing the steps. She complained of left leg discomfort, hematoma was observed on her forehead and two skin tears on her right lower extremities. The Physician was called and ordered the resident to be transferred to hospital for evaluation and treatment. An investigation completed by the facilities' (DON) on [DATE], documented the analysis of the fall: The resident would go outside three to four times each day. She would sit by the front door and watch visitors and sun herself. This day she apparently opened the gate at the top of the front entrance and fell down the four stairs. After examination at the hospital she had sustained a large hematoma on the forehead and a fractured femur. The DON documented the corrective action to be that the resident would no longer go outside unattended. From ,[DATE] to [DATE], observations were made of the main entrance at the west side of the building where the resident fell . It revealed two hollow metal tubular gates with an opening in the middle. The gates were approximately waist high and ended approximately two feet from the ground. The two gates met in the middle at the top of four stairs and did not have a latching mechanism but would close on their own if left open. When walking up the steps the gate would be pushed toward the building to open, and when walking down the steps the gate would pulled toward the building to open. A sidewalk extended to the south down the porch to a parking lot. The side walk was fenced on one side (the side away from the building) until approximately the end of what would be the 400 Hall where it opened into a parking lot. Another similarly-fenced sidewalk extended toward the north of the building; and continued to encircle the north portion of the building and part of the eastern side-ending in a service alley/lot located approximately where 200 Hall ended. [AGE] year old Resident #2 was admitted to the facility initially [DATE], per the medical record facesheet dated as revised [DATE]. Nursing admission notes documented that she was most recently readmitted on [DATE], after hospitalization for a [MEDICAL CONDITION] she sustained after falling out of her wheel chair. The Quarterly Minimum Data Set (MDS) completed, prior to the fall on [DATE], noted that resident sometimes understands others, has impaired vision, is able to see large print and has corrective lenses. Her mental status was documented as having problems with short and long term memory. She was able to recall the location of her room and staff names and faces but her cognitive skills for daily decision making were moderately impaired, defined as poor decisions requiring cue and supervision. The resident required extensive assistance with transferring and walking in her room. Walking in corridor and locomotion (resident used wheel chair) on unit was documented as requiring limited assistance. Fall history was noted in the last month as well as a fall in the last two to six months. Nursing care plans that were active at the time of the resident's fall were reviewed. They included problems for fall risk, elopement, cognitive impairment and activities. The fall risk care plan, dated [DATE] and [DATE], documented that the resident was at risk for falls related to unsteady gait and balance, cognitive status, [MEDICAL CONDITION] medication use impaired vision and recent fall. Interventions and approaches were many and included completing fall risk assessments quarterly, a bed sensor alarm and staff to assist with transfers. The impaired cognition care plan dated [DATE] and [DATE] document that the resident had impaired cognition related to dementia, and [MEDICAL CONDITION]. The goals of the care plan were that the resident would follow simple commands and maintain the highest level of cognitive functioning evidenced by making simple needs known. The target date was [DATE]. Interventions and approaches were many including monitoring for change in cognition; assist with decision making as needed, reorientation and validation as needed and encouraging her to participate in activities, and resident likes to go outside often. The elopement care plan dated, [DATE] and [DATE], documented that the resident was at risk for elopement related to a history of wandering /and or elopement, exit seeking behaviors, chronic confusion or disorientation and [MEDICAL CONDITION]. The care plan goal documented is that the resident will not leave the facility unattended through the next target date of [DATE]. Approaches and interventions included a personal wander device, picture and face sheet in the facility wander books, use diversion when exit seeking increase 1:1 monitoring if indicated and many others. An interview with Resident #2 was attempted, on [DATE], at approximately 3:00 p.m.. The resident was observed lying in her bed. She was awake, pleasant and confused. She gave nonsensical answers when she was asked questions. Asked if she had had a fall she stated "My family". When asked how she was, she stated "Yeah." An Aide came into the resident's room and uncovered her wrist to reveal the wanderguard bracelet on her left arm. The bed alarm was attached on the right side of the bed. Half side rails were up on both sides of the bed. In an Interview with the Unit Manager (Employee #4) at 2:29 p.m., on [DATE] the Unit Manager was asked why a resident with a care plan for elopement, cognitive impairment and fall risks would be allowed to be outside alone. She stated that every day for over a year the resident would go outside twice a day and sit in the sun and would then bring herself back into the facility. She stated that resident never got up from her wheel chair or tried to get up and leave, so she was removed from elopement precautions. She felt the care plan was not accurate on the date the fall occurred and that the resident should not have been on elopement precautions. She stated that the wander guard that was on the resident was placed when her husband was a resident here. This was due to the resident talking about wanting to go home with him but after the resident's husband died [DATE] her exit seeking behavior calmed down. She felt the resident was not trying to exit but was most likely trying to come back into the facility when the fall occurred. The unit manager verified that the resident's care plans stated she was an elopement risk, a fall risk and was cognitively impaired. The unit manager was unable to provide documentation the resident had been evaluated to be safe outside alone and she was unable to provide documentation that the resident was removed from elopement precautions. An interview was conducted on ,[DATE]/

Based on record review, on observations, and on resident and staff interviews, the facility failed to ensure that the care plans for being at risk for elopement and falls (related to dementia, exit-seeking and/or wandering behaviors) were consistently implemented by staff for two (#8 and 2) of four residents reviewed for accidents. This related to the elopement with injury of a frail elderly resident (#8) and to a fall down the front entry stairway of another frail elderly resident (#2); both of whom were assessed with [REDACTED]. These actions resulted in findings of Immediate Jeopardy, which was removed on [DATE], and the severity and scope was reduced to a D. Findings include: 1. The ,[DATE] comprehensive care plan for Resident #8 was dated [DATE] (with a care plan meeting documented as being held on [DATE]); and covered various assessed concerns/problems. Included in the problems (among others) was her being at risk for falls; having mood symptoms of frequent crying episodes, restlessness and becoming easily annoyed at times; and having impaired cognition and communication related to dementia. The falls care plan included many approaches, several of which included keeping her in area where staff could monitor, low bed, and bed and chair alarm. [AGE] year old Resident #8 had admitted to the facility on [DATE] (per the medical record facesheet, which as noted as revised on [DATE]). The initial Minimum Data Set (MDS), with an assessment reference date of [DATE], indicated that she could answer the assessment questions but only scored 6 out of 15 in the section related to memory. She was noted with inattention and disorganized thoughts and some indicators of depression. Related to activities of daily living, she was coded as requiring limited assistance of one to dress, toilet, walk, and locomotion. Additionally, she was coded as unsteady in balance and as using a walker and a wheelchair for walking/locomotion. The MDS also coded her as having had a history of [REDACTED]. Included in this initial MDS's Care Area Assessment (CAA) Summaries was information regarding her having impaired communication related to her impaired cognition; and noted that she loses her train of thought a lot and may not fully understand what is being said to her. Additionally, the Falls CAA noted that she was at risk for falls due to history of a fall at home, where she sustained a laceration on the back of her head. Complications were noted to include: having impaired cognition due to advancing dementia; having poor safety awareness and making frequent attempts to get up on her own; having impaired balance while standing, turning and transferring; and being on an anti-depressant and a pain medication (due to shoulder pain and a long history of [MEDICAL CONDITION] arthritis). The Pain CAA noted (in part) "She is able to participate in therapy, feed herself, participates in her ADLs (activities of daily living) and wheels herself in the wheel chair readily. She does exhibit restlessness and attempts frequently to get up by herself. She is able to communicate need for pain med (medication) to the nurses." On [DATE], a care plan problem was added regarding her being at risk for elopement related to exit-seeking behaviors and [DIAGNOSES REDACTED]. A problem regarding low activity level had been revised on [DATE] and indicated that she had cognitive impairment; impaired long/short term memory and decision-making skills; impaired attention span, frequent episodes of crying and "looking for her car/husband/children;" states I have to go get my husband,"I am going home;" easily agitated; can be verbally aggressive; not always easy to re-direct; frequent episodes of being very angry; and verbally rude towards others. These care plan problems had been added in conjunction with an "Elopement Risk Assessment" done on [DATE] by the Skilled Sub-acute Unit (SSU) Manager. The facility staff did not consistently implement the above-mentioned care plan approaches for this cognitively and functionally impaired resident as follows: On [DATE], the nurse's note (timed at 3:00 a.m.) indicated that she rested on/off during the night with eyes closed; and that a wanderguard was in place due to exit-seeking behavior. The 9:30 a.m. note indicated that she was pleasant, cooperative and ate a good breakfast. Noted too was that she had not made any attempts to get out of bed unassisted-low bed, sensor bad in bed, wanderguard due to poor safety awareness. The 10:30 a.m. note indicated that she was propelling herself in the wheelchair; crying, looking for rings. The rings were locked in the medication cart-she had removed and placed them under pillow. The 10:30 a.m. note indicated that the results from the urine analysis culture and sensitivity test had been received and report faxed to the physician. Also that something for mood be prescribed for "crying jags, ^ (increased) anxiety, verbal abuse to staff and others, etc." Additionally a psychological evaluation was requested to determine competency. The 2:00 p.m. note indicated that she was attempting to exit doors-monitor and attempting to re-direct, distract, engage in activity. The 3:45 p.m. note indicated that a fax order for the psychological evaluation was received, along with an order for [REDACTED]. On [DATE], the nurse's note (timed 10:00 a.m.) indicated that the antibiotic was administered without difficulty. Two episodes of crying were noted along with the resident self-propelling in wheelchair and being rude to staff and roommate. The ordered pain medication was noted as also being given for complaint of pain. The 11:00 a.m. note indicated that the ordered pain medication appeared to be effective for left hip pain. The 12:30 p.m. note indicated that she was anxious, crying, and asking if they had seen her rings. It was noted that the anti-anxiety medication had been given at 12:00 p.m., (with the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"- poor"). It was also noted that she was wheeling herself around saying "I ' m going home;" that she refused lunch and took jacket out of the closet and tried to place it at the nursing station. It was noted that she was re-directed to her room. The 1:30 p.m. noted indicated that she was observed lying in parking lot on left side with leg bent and arms bent at sides; and complained of pain in extremities. A small abrasion to forehead was noted; along with 911 being dispatched and her being taken to hospital; and a message being left for her daughter. Regarding the above-mentioned fall with injury, the facility provided reports dated [DATE] and [DATE], which had been written by the Director of Nurses (DON). The reports indicated that Resident #8 went outside and the door alarm went off. A maintenance staff member (who had been using the nearby men's room) heard the alarm and went outside to look for who set off the alarm. He did not see anyone, so he silenced the alarm. It was noted that the staff member said he looked outside but did not look around the building for anyone, as he did not think that they would travel that fast. It was noted that the resident had gone around the corner and was on the ground moments later. When the resident was found, she was over the curb with the wheel chair on top of her body. The only obvious injury was an abrasion to the forehead. The resident was transferred to the hospital for evaluation and treatment; and was ultimately placed in a more secure locked environment. The [DATE] report indicated (in the section for description of corrective or proactive action(s) taken) that all staff in-serviced on the importance of looking beyond the entryway and around corners when the door alarm goes off. (However, review of the [DATE] training attendance sign-in sheets determined that only 73 of 132 staff were re-trained.) Also, the resident was noted as being transferred to a more secure environment for safety. On [DATE] at 6:19 p.m., the DON verified the above information, and indicated that the resident had gone to the ambulance entrance (located off of the 600 hall)-it was alarmed for when a wanderguard passed it and the alarm went off. The DON indicated that the resident was out there only a couple minutes-someone saw her outside and said she had tumbled over. The Maintenance Assistant (Employee #3) heard and looked but she had evidently gone off to the right around the side-and he did not go around the corner and look. On [DATE] at 10:10 a.m., the Maintenance Assistant (Employee #3) indicated that he heard the alarm while using the bathroom; and that it had been sounding several minutes. (He thought it was under 5 minutes by the time he got out of the bathroom). According to him, no other staff person had responded at that point. He looked up and down the hallway, then went through the double glass doors into the adjacent lobby and then to the double doors to the exit (next to which the wanderguard keypad was mounted. He said he went to the keypad and shut off the alarm; then took a step out of the door onto the 1-step up entry porch (located under a drive-through portico). He then looked left and right and did not see anyone so went back inside. This front walking surface (which was a one step-up from ground level porch area) stretched approximately 30 feet in each direction (or about 10 paces each way to either end of the building); and was adjacent to a driveway that ran in front of it (which was used as an ambulance entrance). He verified that he merely stepped out and checked in both directions and did not walk to either end of the porch to look into the parking lots that were on either side of the building. This main entrance faces a busy street, but the driveways run at an angle from the street toward this particular ambulance entrance way. When the Maintenance Assistant went back inside the building, within minutes a resident (Resident #14), who was in the 600 hall dining room, was yelling out about a resident having fallen outside. When he saw the fallen resident, she was at the second parking spot in the western lot right next to the building; and had fallen over the cement parking bumper. The 2nd parking spot was observed to be visible about 2 to 3 paces from the front entrance. However, it could not be seen if one stood at that doorway and looked in that direction. The Maintenance Assistant verified that the alarm was set off only by the wanderguard mechanism worn by various residents (either on their arm, leg or chair). When the person with a wanderguard hit the sensor area, then the alarm sounded. This was observed to be a loud whooping sound, as well as a voiced message that sounded over the public address system "Door alarm, 600 hall." Both sounds continue until the alarm was turned off. Regarding the above 600 hall exit door, this entrance/exit portico area was observed to face a highly trafficked 7-lane city street. From the exit door, it was approximately 35 paces (or 105 feet) to that street (when walking straight ahead and through an area of curb-surrounded bushes. Two paved driveways ran through this portico entrance area. The West driveway to the street measured approximately 53 paces (or 160 feet); and the East driveway measured approximately 51 paces (or 153 feet). On [DATE] at 1:40 p.m., the witnessing resident (Resident #14) was interviewed. Resident #14 said that she had been sitting at the dining room window and saw Resident #8 wheeling down the sidewalk from the portico area. The left wheel of Resident #8's chair had slipped off the sidewalk and she had fallen down and rolled over the parking bumper. Resident #14 yelled and went out into the hallway and saw the Maintenance Assistant (Employee #3) and yelled for him. Resident #14 said he and other staff responded to her call for help right away. She did not recall one way or the other hearing the alarm sounding. On [DATE] at 2:55 p.m., the SSU Manager (Employee #1) indicated that from the time of admission the resident had periodic agitation, crying, wandering-behavior was up and down and seemed to escalate after lunch. Staff had been talking with the physicians and PA involved; laboratory work was done and the resident was on an antibiotic at time of the incident. She indicated that this resident was one for whom staff tried to redirect, calm and, as necessary, keep near to them -- e.g. 1:1 at times, or put by nursing station. The Unit Manager said she would even be brought into her office and she would sit there with the Unit Manager. The Unit Manager said she was on duty the day of the fall outside, but did not see the resident at the time. She indicated that the Maintenance Assistant (Employee #3) had responded to the wanderguard alarm going off; and that Resident #14 had called out about seeing her fall outside. On [DATE] at 3:15 p.m., a Nurse (Employee #2) indicated she was on the floor the day of the resident's fall. The LPN indicated that they tried to do informal 1:1 supervision with her so she would be with others and be distracted. On the day of the fall, she had been with an Aide, who was called to help in another resident's room. She heard that the Aide had then positioned the resident by the nursing station, which was common to do for that resident and some others. The Nurse indicated that she remembered seeing the resident earlier in the day, but did not hear the wanderguard alarm sounding because she was in another resident's room at the time. She got a call that the resident was in the parking lot and was told that the resident had flipped over the parking bumper barrier-she thinks that the wheelchair was to the side (and not on top of the resident) when she observed the resident. She also added that the resident in latter days of her stay was more agitated/upset; and that staff tried to figure out how to keep her comfortable. The LPN said she had given the resident an anti-anxiety medication that day (which was ordered to be given as needed for agitation; and noted on medication records as having been given at 12:00 p.m. with the medication effectiveness noted as being "- poor"). The Nurse also relayed that the resident was at that time on an antibiotic. Per the Nurse, every time she saw the physician or PA, she talked with them about the resident. The physician seeing her did not agree on using [MEDICATION NAME]-one wanted the anti-psychotic started and the other was against it and wrote an order to not use it. On [DATE] at 9:40 a.m., the Assistant Director of Nurses (ADON), who also served as the facility's Staff Developer for training, indicated that the expectation regarding the sounding wanderguard alarm was that ALL staff would respond to the area of the alert, except if unable to do so because of providing care to a resident. She indicated that the alarm was not to be turned off (at the keypad next to the alarming door) until the "trigger" was found (i.e. who/what caused the alarm to go off). She further indicated that the alarm continuing to sound brings additional staff that might be needed (e.g. if the resident would be injured and the 1st responder needing to stay with the resident while others obtained further help; or if more staff would be needed for a search etc.). She had no explanation for why this had not occurred in the case of Resident #8. The ADON indicated that all staff were trained upon hire during orientation; and provided a "Blue Ribbon Orientation Checklist" which indicated that newly hired staff received "Safety 101" training during orientation. This training included missing resident at a glance and elopement guide training. The ADON also indicated that staff annually attended mandatory in-services. Sheets of attendees for the last annual (on "Education Report by Course" forms) for the time period of [DATE] through [DATE]) included the "Silverchair Learning Systems" course "Missing Resident/Elopement"; and had 97 attendees. The attendees included the Maintenance Assistant (Employee #3) as well as 96 others. The course included definition of elopement, 6 risk factors for elopement, discussion of who may wander and why, and discussion of management of wandering. Included in the information was the question "What is elopement and what are the risk factors?" followed by "Elopement is unsupervised or unassisted flight from the facility. The resident did NOT elope if he/she was identified leaving the facility and was redirected back into the facility (the care plan worked!)." This policy/training was not implemented in the case of Resident #8, in that she was unmonitored to the extent that she left the facility unsupervised and unassisted; and sustained a fall with injury. 2. [AGE] year old Resident #2 was admitted to the facility initially [DATE], per the medical record facesheet dated as revised [DATE]. Nursing admission notes documented that she was most recently readmitted on [DATE], after hospitalization for a [MEDICAL CONDITION] she sustained after falling out of her wheel chair. During a medical record review, care plans for elopement, cognitive impairment and activities were noted. The fall risk care plan dated [DATE] and [DATE] documented that the resident was at risk for falls related to unsteady gait and balance, cognitive status, [MEDICAL CONDITION] medication use impaired vision and recent fall. Interventions and approaches were many and included completing fall risk assessments quarterly, a bed sensor alarm and staff to assist with transfers. The impaired cognition care plan dated [DATE] and [DATE] documented that the resident had impaired cognition related to dementia, and [MEDICAL CONDITION]. The goals of the care plan were that the resident would follow simple commands and maintain the highest level of cognitive functioning evidenced by making simple needs known. The target date was [DATE]. Interventions and approaches were many including monitoring for change in cognition; assist with decision making as needed, reorientation and validation as needed and encouraging her to participate in activities and documented that the resident liked to go outside often. The elopement care plan dated, [DATE] and [DATE], documented that the resident was at risk for elopement related to a history of wandering /and or elopement, exit seeking behaviors, chronic confusion or disorientation and [MEDICAL CONDITION]. The care plan goal documented was that the resident would not leave the facility unattended through the next target date of [DATE]. Approaches and interventions included a personal wander device, picture and face sheet in the facility wander books, use diversion when exit seeking, increase 1:1 monitoring, if indicated, and many others. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a history of dementia with agitation, chronic [MEDICAL CONDITION], hypertension, arthritis and unsteady gait. The resident sometimes understood others had impaired vision and was able to see large print and had corrective lenses. Her mental status was documented as problems with short and long term memory. She was able to recall the location of her room and staff names and faces. Her cognitive skills for daily decision making were moderately impaired defined as decisions poor; cues/ supervision required. The MDS documented the resident required extensive assistance with transferring and walking in her room. Walking in corridor and locomotion on unit was documented as limited assistance (she used wheel chair). Fall history documented a fall in the last month and a fall in the last two to six months. The facility staff did not consistently implement the above mentioned care plan approaches for this cognitively and functionally impaired resident as follows: Nurse's note, on [DATE], at 6:00 p.m., documented that the resident was started on [MEDICATION NAME] 5 mg (milligram) and was observed propelling herself up and down the halls going into rooms, pleasantly confused. Nurse's note, dated [DATE], at 5:00 a.m., the resident was observed putting jewelry in the bed of her roommate stating " I ' m putting it on my baby". She was also observed attempting to give another resident graham crackers and she was going into other resident ' s rooms. She was provided 1:1 monitoring and was redirected which was effective for short periods only. A fax to the resident's physician, dated [DATE], noted the resident was "very confused and doing odd behaviors". She was taking things from other resident ' s rooms and feeding bedridden patients. The fax revealed that the resident's [MEDICATION NAME] was discontinued the first part of October and that she had been started on [MEDICATION NAME] on [DATE] 5 mg daily by the psychiatric nurse practitioner. A physician's orders [REDACTED]. The Quarterly nursing data collection note, dated [DATE], documented the resident was at risk for falls, had altered safety awareness due to cognitive decline and wandered and was oblivious to safety needs, and was checked as not at risk for elopement. A weekly nursing note, dated [DATE], documented no behavior issues. On [DATE], the weekly nursing note, documented the resident was alert x 1 (i.e. only to self) and had a bed alarm and a wheel chair alarm. It noted that the resident could not understand information conveyed, and the plan of care was appropriate for the resident. physician's orders [REDACTED]. The Weekly Nurse's note, dated [DATE], documented the resident was alert and oriented x 1, had side rails up as an enabler, had a bed sensor alarm, wander guard bracelet on for exit seeking behavior, had no falls for seven days, and the plan of care appropriate for resident. Weekly Nurse's note, dated [DATE], documented the resident was alert and oriented x 1. She had a bed alarm, was attending activities, had no falls for seven days, was ambulating with assistance for short periods, and that the plan of care appropriate for resident. A nurse's note, dated [DATE] 2:50 p.m.., that documented the resident was observed on the ground outside of the building in front of steps laying flat on her back with her feet closest to the steps. The resident was able to verbally communicate with staff and her hand grips were equal. She complained of left leg discomfort and was unable to straighten her left leg without pain. There was a hematoma to her forehead. 911 was called as was the resident ' s physician and her responsible party and the resident was transferred to the hospital. The physician's hospital note, dated [DATE], documented the resident was admitted to the hospital with [REDACTED]. A report completed by the facility Director of Nursing DON, [DATE], documented the events surrounding the fall as follows: The Resident was found on the ground outside the facility on the front of the steps leading to the building. She was flat on her back with her feet facing the steps. She complained of left leg discomfort, hematoma was observed on her forehead and two skin tears on her right lower extremities. The Physician was called and ordered the resident to be transferred to hospital for evaluation and treatment. An investigation completed by the facilities' (DON) on [DATE], documented the analysis of the fall as follows. The resident would go outside three to four times each day. She would sit by the front door and watch visitors and sun herself. This day she apparently opened the gate at the top of the front entrance and fell down the four stairs. After examination at the hospital she had sustained a large hematoma on the forehead and a fractured femur. The DON documented the corrective action to be that the resident would no longer go outside unattended. On [DATE],at approximately 1:00 p.m., a review of the resident ' s current care plans revealed that her care plans had not been updated regarding the resident ' s need to be supervised when outside of the building . On [DATE] 9:45 a.m.., the elopement book was reviewed and found to have three residents pictured with information. Resident # 2 was not currently in the book as she should be according to the interventions of her elopement care plan. At that time the DON verified that the resident was not in the wander book at the reception desk or in the wander books at the two nurse ' s stations. In an interview (on at 2:29 p.m., on [DATE]) the Unit Manager (Employee #4) was asked why a resident with a care plan for elopement, cognitive impairment and fall risks would be allowed to be outside alone. She stated that every day for over a year the resident would go outside twice a day and sit in the sun and would then bring herself back into the facility. She stated that resident never got up from her wheel chair or tried to get up and leave, so she was removed from elopement precautions. She felt the care plan was not accurate on the date the fall occurred and that the resident should not have been on elopement precautions. She stated that the wander guard that was on the resident was placed when her husband was a resident here. This was due to the resident talking about wanting to go home with him, but after the resident ' s husband died [DATE], her exit seeking behavior calmed down. She felt the resident was not trying to exit but was most likely trying to come back into the facility when the fall occurred. The Unit Manager verified that the resident's care plans stated she was an elopement risk, a fall risk and was cognitively impaired. The unit manager was unable to provide documentation the resident had been evaluated to be safe outside alone and she was unable to provide documentation that the resident was removed from elopement precautions. An interview was conducted on [DATE], at approximately 3:30 p.m. with the DON. She stated she did not feel the resident was an elopement risk. She stated the wander guard bracelet was placed as a way to be able to know when the resident went outside so she was not in the sun to long. The DON stated the resident's husband lived here with her until his death in July of 2010 and he used to sit with her outside. She stated the resident sat outside every day for four years. After his death the staff at the reception desk would keep their eye on her so she was not in the sun for too long. She stated that she was here the Saturday of the fall and saw the resident sitting outside as she left. She stated that she felt the resident was trying to go down the steps when the fall occurred. At 6:09 p.m. , on that same day, the DON again stated that the resident had a wander guard so the front desk and others would know she was outside so they could keep an eye on her so she was not in the sun to long. She did not feel the resident was an elopement risk. She said that the day of the fall she assumes that the resident opened the gate but no one knows and the resident is not able to tell you. She stated that she is unable to think of any documentation on the resident evaluating her as safe to be outside alone. She stated that people change and do unexpected things. She stated the resident did not have elopement behaviors when this fall occurred. The DON stated she had been at this facility for nine years and cannot recall the resident having exit seeking behavior and that she cannot remember a time when the resident was not outside by herself. In regard to the elopement care plan she did not have an explanation for why the resident had the care plan. The DON was unable to provide documentation to support that the resident was not at risk for elopement as indicated by her care plan. At 2:20 p.m. on [DATE] an interview was conducted with Certified Nursing Assistant (CNA-Employee #6) . She indicated that she had been employed by the facility for 5 years. She stated that she was in the facility the day the resident fell . She related that on the day of the fall the resident was confused and that was normal for her and that the resident would normally go outside by herself and sits in the same spot in the sun. She stated she did not know if the resident took herself outside or if staff had assisted her to get outside the day of the fall as he was working with another resident when the fall occurred. On [DATE], at 4:51 p.m., a telephone interview was conducted with the weekend receptionist (#9) regarding the fall of the resident on [DATE]. She related that the resident liked to sit outside and that for the one and one-half years that she has been employed at the facility the resident has done this, always sitting in front of the steps or off to the right corner in the sun. Occasionally she would go to the left down the walk way and sit. On the date of the fall the resident had been sitting outside. The receptionist stated she could not remember if the wander guard alarmed or not when the resident went outside because sometimes the alarm worked and sometimes it did not. She stated that another resident had been sitting outside when resident #2 went outside. When that resident came inside he told her that he was in and that she would have to watch the resident. She stated that after about two minutes she got up to make coffee (the pot is to the right of the reception desk) and looked out the window for the resident. She saw the arm of the resident ' s wheel chair in a patch of sun and assumed the resident was still in her sunning spot. She stated that a few minutes later she heard the resident yell and she saw her at the bottom of the stairs with her wheel chair on top of her. She went to the resident to calm her and then left the resident in position at the bottom of the stairs to go inside to call for help. She stated that she called the resident's nursing station (100 hall ) and there was no answer so she paged over the PA system that she needed emergency help at the front lobby. She stated that staff responded and the resident was assessed and transported 911 to the hospital. She stated she did not know if the resident had ever tried to wander away in the past and that usually when the resident was outside there were other families and residents outside as well. An interview with Resident #2 was attempted, on [DATE], at approximately 3:00 p.m. The resident was observed lying in her bed. She was awake, pleasant and confused. She gave nonsensical answers when she was asked questions. Asked if she ' d had a fall, she stated "My family". When asked how she was, she stated "Yeah". A CNA came into the resident ' s room and uncovered her wrist to reveal the wanderguard bracelet on her left arm. The bed alarm was attached on the right side of the bed and half side rails were up on both sides of the bed. A review of the facility's plan related to the incidents regarding Resident #2 and 8 was reviewed: 1. Per in-service information provided on [DATE], the facility began in-servicing staff via [DATE] "Mandatory Wanderguard Alarm System" in-service conducted by ADON, with 73 staff documented as having attended. Initially during the investigative visit the DON indicated a staff of around 120, the NHA amended that to be 132. There was no specific plan at that time for ensuring that the other 59 employees received the training. Additionally, there was no documentation of attendance by the Maintenance Assistant (Employee #3). During the survey, the Maintenance Assistant said he remembers going, but had no explanation for not having signed the sheet. The DON verified with his supervisor (who was away at a confere

Based on record review, on observations, and on resident and staff interviews, the facility failed to maintain a level of supervision needed to ensure the safety and security of two (#8 and 2) of four residents reviewed for accidents. This related to the elopement with injury of a frail elderly resident (#8) and to a fall down the front entry stairway of another frail elderly resident (#2); both of whom were assessed with [REDACTED]. These actions resulted in findings of Immediate Jeopardy, which was removed on [DATE], and the severity and scope was reduced to a D. Findings included: 1. [AGE] year old Resident #8 was admitted to the facility on [DATE] per the medical record facesheet (noted as revised on [DATE]). The initial Minimum Data Set (MDS), with an assessment reference date of [DATE], indicated that she could answer the assessment questions but only scored 6 out of 15 in the section related to memory. She was noted with inattention and disorganized thoughts and some indicators of depression. Related to activities of daily living, she was coded as requiring limited assistance of one to dress, toilet, walk, and locomotion. Additionally, she was coded as unsteady in balance and as using a walker and a wheelchair for walking/locomotion. The MDS also coded her as having had a history of [REDACTED]. Included in this initial MDS's Care Area Assessment (CAA) Summaries was information regarding her having impaired communication related to her impaired cognition; and noted that she loses her train of thought a lot and may not fully understand what is being said to her. Additionally, the Falls CAA noted that she was at risk for falls due to history of a fall at home, where she sustained a laceration on the back of her head. Complications were noted to include: having impaired cognition due to advancing dementia; having poor safety awareness and making frequent attempts to get up on her own; having impaired balance while standing, turning and transferring; and being on an anti-depressant and a pain medication (due to shoulder pain and a long history of rheumatoid arthritis). The Pain CAA noted (in part) "She is able to participate in therapy, feed herself, participates in her ADLs (activities of daily living) and wheels herself in the wheel chair readily. She does exhibit restlessness and attempts frequently to get up by herself. She is able to communicate need for pain med (medication) to the nurses." The ,[DATE] comprehensive care plan for Resident #8 was dated [DATE] (with a care plan meeting documented as being held on [DATE]); and covered various assessed concerns/problems. Included in the problems (among others) was her being at risk for falls; having mood symptoms of frequent crying episodes, restlessness and becoming easily annoyed at times; and having impaired cognition and communication related to dementia. The falls care plan included many approaches, several of which included keeping her in area where staff could monitor, low bed, and bed and chair alarm. On [DATE], a care plan problem was added regarding her being at risk for elopement related to exit-seeking behaviors and [DIAGNOSES REDACTED]. A problem regarding low activity level had been revised on [DATE] and indicated that she had cognitive impairment; impaired long/short term memory and decision-making skills; impaired attention span, frequent episodes of crying and "looking for her car/husband/children;" states I have to go get my husband, "I am going home;" easily agitated; can be verbally aggressive; not always easy to re-direct; frequent episodes of being very angry; and verbally rude towards others. These care plan problems had been added in conjunction with an "Elopement Risk Assessment" done on [DATE] by the Skilled Subacute Unit (SSU) Manager. Nursing and other medical practitioner notes in Resident #8's medical record indicated an increase in mood/behavior problems in ,[DATE] as follows: a. The [DATE] "Geriatric Behavioral Management Assessment" note (written by an Advanced Registered Nurse Practitioner for the practitioner that had been seeing the resident in the facility since at least [DATE]) noted that Effexor (an anti-depressant, also known as Venlafaxine) had been increased to 150 mg on [DATE] and that they would continue to monitor. The [DIAGNOSES REDACTED]. " b. The nurses' notes between [DATE] and [DATE] noted behavior monitoring related to the Effexor (an anti-depressant medication) increase to 150 mg (milligrams). At times she was noted as being more cooperative and pleasant; and at other times she was noted to be crying without reason and needing redirection to her room and caution to not ambulate without assistance. c. On [DATE], the nurse's note (timed at 3:00 p.m.) indicated that the physician had been notified that the resident had episode of agitation and increased confusion, anger, paranoia, crying, which lasted approximately 2 ? hours; and then was calmer, more cooperative. She was noted as being given an ordered pain medication at onset for chronic back pain and appeared effective. Also noted was that blood work was due to be drawn [DATE]. The 5:00 p.m. note indicated she was propelling herself with wheelchair around the unit-denied pain or discomfort, no shortness of breath, no crying and behavioral issues at that time--continued to monitor. Additionally an Elopement Risk Assessment was found to have been done on that same day, due to exit-seeking behavior. The use of a wanderguard was care planned (and noted to be monitored by nursing) and included multiple approaches. Several of these included: re-direct resident from doors and exit PRN (as needed); use diversion when exit seeking; increased 1:1 monitoring if indicated; and personal wander prevention device. d. On [DATE], the nurse 's note (timed at 11:00 a.m.) noted that the attending physician's Physician Assistant (PA) was asked if he had examined her today. The resident's episodes of agitation/anxiety/crying were explained/discussed, along with the recent increase in the anti-depressant, Effexor. (The PA's note of that day noted that the Effexor was to continue and that psychological consult (on [DATE]) suggested a named anti-psychotic medication; and indicated to re-check labs.) The nurse's note indicate that the PA was to discuss further with the physicians for who he worked-one of the physician ' s wanted the anti-psychotic medication begun, while the other adamantly was against its use. The nurse's note also indicated that she became suspicious of the nurse when applying lotion to her toes; stating that the nurse wanted her to slip and fall. She was noted as being anxious and starting to cry. The nurse attempted to reassure her and that the facility did not want her to fall and that they cared about her. She was noted as saying "No you don't." It was also noted that they were awaiting laboratory and urinalysis results. The 9:00 p.m. note indicated that she was alert, anxious and upset about staying at the facility; yelling and trying to get out of bed three times, with staff re-directing her. She refused to stay in bed, verbalizing that she wanted to go home and be out of this place. Staff explained that it was late and nobody would be able to pick her up to take her home. Offered pain medication for complaint of back pain-resident refused to take it and threw it on the floor. e. On [DATE], the nurse 's note (timed at 1:20 a.m.) noted resident very upset that she now was a long term care placement; and did not want to stay. Stated: "I feel alone." She was noted as resting quietly at that time without further complaint. Also on [DATE] (untimed), the facility faxed to the physician with a question on the anti-psychotic and about laboratory work that was done, with culture and sensitivity results still pending. The physician replied do NOT give the named antipsychotic medication. f. On [DATE], the 4:,[DATE]:00 p.m. nurse's note indicated episodes of crying and wandering around the unit via wheelchair, stating "I ' m going home." She was also noted to try to get out of the exit door; and had been returned to room several times and assisted to the bathroom. The 8:00 p.m. note indicated that HS care given; call bell noted within reach and bed alarm on. g. On [DATE], the nurse's note (timed at 2:00 a.m.) indicated resting quietly in bed-no episodes of crying this shift and no complaints of pain or discomfort. The 8:00 a.m. note indicated morning care given; and that she was sitting in her wheelchair in her room and wandering around unit in the wheelchair-quiet. Then the 2:00 p.m. note indicated after noon she started crying and being angry. The 4:,[DATE]:00 p.m. note indicated that she was less confused and not crying; that she talked with her husband by phone and was less agitated. h. On [DATE], the nurse's note (timed at 3:00 a.m.) indicated that she rested on/off during the night with eyes closed; and that a wanderguard in place due to exit-seeking behavior. The 9:30 a.m. note indicated that she was pleasant, cooperative and ate a good breakfast. Noted too was that she had not made any attempts to get out of bed unassisted-low bed, sensor bad in bed, wanderguard due to poor safety awareness. The 10:30 a.m. note indicated that she was propelling herself in the wheelchair; crying, looking for rings. The rings were locked in the medication cart-she had removed and placed them under pillow. The 10:30 a.m. note indicated that the results from the urine analysis culture and sensitivity test had been received and report faxed to the physician. Also that something for mood be prescribed for "crying jags, ^ (increased) anxiety, verbal abuse to staff and others, etc." Additionally a psychological evaluation was requested to determine competency. The 2 p.m. note indicated that she was attempting to exit doors-monitor and attempting to re-direct, distract, engage in activity. The 3:45 p.m. note indicated that a fax order for the psychological evaluation was received, along with an order for [REDACTED]. i. On [DATE], the nurse's note (timed 10:00 a.m.) indicated that the antibiotic was administered without difficulty. Two episodes of crying were noted along with the resident self-propelling in wheelchair and being rude to staff and roommate. The ordered pain medication was noted as also being given for complaint of pain. The 11:00 a.m. note indicated that the ordered pain medication appeared to be effective for left hip pain. The 12:30 p.m. note indicated that she was anxious, crying, and asking if they had seen her rings. It was noted that the anti-anxiety medication had been given at 12:00 p.m. Also noted that she was wheeling herself around saying "I ' m going home;" that she refused lunch and took jacket out of the closet and tried to place it at the nursing station. It was noted that she was re-directed to her room. The 1:30 p.m. noted indicated that she was observed lying in parking lot on left side with leg bent and arms bent at sides; and complained of pain in extremities. A small abrasion to forehead was noted; along with 911 being dispatched and her being taken to hospital; and a message being left for her daughter. j. On [DATE], the nurse's note (timed at 10:00 a.m.) indicated that the hospital was called and that the resident had been admitted on [DATE] with a [DIAGNOSES REDACTED]. The hospital's Discharge Summary (with the listed date of discharge of [DATE]) listed the resident ' s attending physician as the signing physician of that document.. The initial admitting [DIAGNOSES REDACTED]. She was noted to have been admitted to the hospital. Also noted was that she had a history of [REDACTED]. Additional testing (via MRI) and neurology consult indicated that she was status [REDACTED]. "Neurology felt there was no further need for any intervention and the patient was subsequently discharged ." The physician noted discussing the discharge with the daughter, and due to her active attempts to elope, it was felt that she would most benefit from going to another facility with a secured unit. Regarding the above-mentioned fall with injury, the facility provided reports dated [DATE] and [DATE], which had been written by the Director of Nurses (DON). The reports indicated that Resident #8 went outside and the door alarm went off. A maintenance staff member (who had been using the nearby men ' s room) heard the alarm and went outside to look for who set off the alarm. He did not see anyone, so he silenced the alarm. It was noted that the staff member said he looked outside but did not look around the building for anyone, as he did not think that they would travel that fast. It was noted that the resident had gone around the corner and was on the ground moments later. When the resident was found, she was over the curb with the wheel chair on top of her body. The only obvious injury was an abrasion to the forehead. The resident was transferred to the hospital for evaluation and treatment; and was ultimately placed in a more secure locked environment. The [DATE] report indicated (in the section for description of corrective or proactive action(s) taken) that all staff in-serviced on the importance of looking beyond the entryway and around corners when the door alarm goes off. (However, review of the [DATE] training attendance sign-in sheets determined that only 73 of 132 staff were re-trained.) Also, the resident was noted as being transferred to a more secure environment for safety. On [DATE] at 6:19 p.m., the DON verified the above information, and indicated that the resident had gone to the ambulance entrance (located off of the 600 hall)-it was alarmed for when a wanderguard passed it and the alarm went off. The DON indicated that the resident was out there only a couple minutes-someone saw her outside and said she had tumbled over. The Maintenance Assistant (Employee #3) heard and looked but she had evidently gone off to the right around the side-and he did not go around the corner and look. On [DATE] at 10:10 a.m., the Maintenance Assistant (Employee #3) indicated that he heard the alarm while using the bathroom; and that it had been sounding several minutes. (He thought it was under 5 minutes by the time he got out of the bathroom). According to him, no other staff person had responded at that point. He looked up and down the hallway, then went through the double glass doors into the adjacent lobby and then to the double doors to the exit (next to which the wanderguard keypad was mounted. He said he went to the keypad and shut off the alarm; then took a step out of the door onto the 1-step up entry porch (located under a drive-through portico). He then looked left and right and did not see anyone so went back inside. This front walking surface (which was a one step-up from ground level porch area) stretched approximately 30 feet in each direction (or about 10 paces each way to either end of the building); and was adjacent to a driveway that ran in front of it (which was used as an ambulance entrance). He verified that he merely stepped out and checked in both directions and did not walk to either end of the porch to look into the parking lots that were on either side of the building. This main entrance faces a busy street, but the driveways run at an angle from the street toward this particular ambulance entrance way. When the Maintenance Assistant went back inside the building, within minutes a resident (Resident #14), who was in the 600 hall dining room, was yelling out about a resident having fallen outside. When he saw the fallen resident, she was at the second parking spot in the western lot right next to the building; and had fallen over the cement parking bumper. The 2nd parking spot was observed to be visible about 2 to 3 paces from the front entrance. However, it could not be seen if one stood at that doorway and looked in that direction. The Maintenance Assistant verified that the alarm was set off only by the wanderguard mechanism worn by various residents (either on their arm, leg or chair). When the person with a wanderguard hit the sensor area, then the alarm sounded. This was observed to be a loud whooping sound, as well as a voiced message that sounded over the public address system "Door alarm, 600 hall." Both sounds continue until the alarm was turned off. Regarding the above 600 hall exit door, this entrance/exit portico area was observed to face a highly trafficked 7-lane city street. From the exit door, it was approximately 35 paces (or 105 feet) to that street (when walking straight ahead and through an area of curb-surrounded bushes. Two paved driveways ran through this portico entrance area. The West driveway to the street measured approximately 53 paces (or 160 feet); and the East driveway measured approximately 51 paces (or 153 feet). On [DATE] at 1:40 p.m., the witnessing resident (Resident #14) was interviewed. Resident #14 said that she had been sitting at the dining room window and saw Resident #8 wheeling down the sidewalk from the portico area. The left wheel of Resident #8's chair had slipped off the sidewalk and she had fallen down and rolled over the parking bumper. Resident #14 yelled and went out into the hallway and saw the Maintenance Assistant (Employee #3) and yelled for him. Resident #14 said he and other staff responded to her call for help right away. She did not recall one way or the other hearing the alarm sounding. On [DATE] at 2:55 p.m., the SSU Manager (Employee #1) indicated that from the time of admission the resident had periodic agitation, crying, wandering-behavior was up and down and seemed to escalate after lunch. Staff had been talking with the physicians and PA involved; laboratory work was done and the resident was on an antibiotic at time of the incident. She indicated that this resident was one for whom staff tried to redirect, calm and, as necessary, keep near to them -- e.g. 1:1 (one on one) at times, or put by nursing station. The Unit Manager said she would even be brought into her office and she would sit there with the Unit Manager. The Unit Manager said she was on duty the day of the fall outside, but did not see the resident at the time. She indicated that the Maintenance Assistant (Employee #3) had responded to the wanderguard alarm going off; and that Resident #14 had called out about seeing her fall outside. On [DATE] at 3:15 p.m., a Nurse (Employee #2) indicated she was on the floor the day of the resident ' s fall. The LPN indicated that they tried to do informal 1:1 supervision with her so she would be with others and be distracted. On the day of the fall, she had been with an Aide, who was called to help in another resident ' s room. She heard that the Aide had then positioned the resident by the nursing station, which was common to do for that resident and some others. The Nurse indicated that she remembered seeing the resident earlier in the day, but did not hear the wanderguard alarm sounding because she was in another resident's room at the time. She got a call that the resident was in the parking lot and was told that the resident had flipped over the parking bumper barrier-she thinks that the wheelchair was to the side (and not on top of the resident) when she observed the resident. She also added that the resident in latter days of her stay was more agitated/upset; and that staff tried to figure out how to keep her comfortable. The LPN said she had given the resident an anti-anxiety medication that day (which was ordered to be given as needed for agitation; and noted on medication records as having been given at 12:00 p.m. with the medication effectiveness noted as being "- poor "). The Nurse also relayed that the resident was at that time on an antibiotic. Per the Nurse, every time she saw the physician or PA, she talked with them about the resident. The physician seeing her did not agree on using Seroquel (an anti-psychotic medication) -- one wanted the anti-psychotic started and the other was against it and wrote an order to not use it. On [DATE] at 9:40 a.m., the Assistant Director of Nurses (ADON), who also served as the facility's Staff Developer for training, indicated that the expectation regarding the sounding wanderguard alarm was that ALL staff would respond to the area of the alert, except if unable to do so because of providing care to a resident. She indicated that the alarm was not to be turned off (at the keypad next to the alarming door) until the "trigger" was found (i.e. who/what caused the alarm to go off). She further indicated that the alarm continuing to sound brings additional staff that might be needed (e.g. if the resident would be injured and the 1st responder needing to stay with the resident while others obtained further help; or if more staff would be needed for a search etc.). She had no explanation for why this had not occurred in the case of Resident #8. The ADON indicated that all staff were trained upon hire during orientation; and provided a "Blue Ribbon Orientation Checklist" which indicated that newly hired staff received "Safety 101" training during orientation. This training included missing resident at a glance and elopement guide training. The ADON also indicated that the staff annually attended mandatory in-services. Sheets of attendees for the last annual (on "Education Report by Course" forms) for the time period of [DATE] through [DATE]) included the "Silverchair Learning Systems" course "Missing Resident/Elopement"; and had 97 attendees. The attendees included the Maintenance Assistant (Employee #3) as well as 96 others. The course included definition of elopement, 6 risk factors for elopement, discussion of who may wander and why, and discussion of management of wandering. Included in the information was the question "If you think that a resident is missing, you should try to find them quickly by yourself so nobody else will find out." The correct answer was "False," with the additional information "If a resident is thought to be missing, the elopement procedure should be initiated which included all staff." Additionally: "The person in charge of the search will assign staff members to look in certain areas." The exterior search techniques stated: "Exterior of the Building within 10 feet - search all rooms using the interior search technique. Look under and behind all plant life - trees, shrubs, etc." The exterior ground of the facility information included: "Search the Parking Lot(s) - Physically look under and inside all vehicles on the property, look on all sides of the vehicle" and went on to describe searches of culverts/ditches, retention ponds and dumpsters. This policy/training was not implemented in the case of Resident #8, either in the lack of a thorough search by Employee #3 or in other staff responding in a timely manner to the sounding alarm. 2. A review of Resident #2's medical record revealed a nurses note, dated [DATE], at 2:50 p.m. and documented that the resident was observed on the ground outside of the building in front of steps lying flat on her back with her feet closest to the steps. The resident was able to verbally communicate with staff and her hand grips were equal. She complained of left leg discomfort and was unable to straighten her left leg without pain and there was a hematoma to her forehead. 911 was called along with the resident ' s physician and responsible party. The resident was transferred to the hospital. The physician's hospital note, dated [DATE], documented the resident was admitted with a displaced comminuted fracture of the distal left femur as well as multiple contusions and abrasions. The facility completed a report, on [DATE], documenting the events surrounding the fall. The circumstances of the event documented stated: The Resident was found on the ground outside the facility on the front of the steps leading to the building. She was flat on her back with her feet facing the steps. She complained of left leg discomfort, hematoma was observed on her forehead and two skin tears on her right lower extremities. The Physician was called and ordered the resident to be transferred to hospital for evaluation and treatment. Review of Resident #2's face sheet, physicians notes dated [DATE] and the Quarterly Minimum Data Set ,dated [DATE], documented that [AGE] year old resident was originally admitted to the facility [DATE]; with her most recent admission being [DATE], when she returned from the hospital after falling from her wheel chair and fracturing her left hip. The [DATE] hospital physician's note documented the resident had history of [DIAGNOSES REDACTED], dementia, sundowners syndrome, valvular heart disease, [DIAGNOSES REDACTED]and hypertension and unsteady gait. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented a history of dementia with agitation, chronic atrial fibrillation, hypertension, arthritis and unsteady gait. An investigation of the fall was completed by the facility DON, on [DATE]; and the analysis and corrective action were documented by the DON as follows: This resident would go outside three to four times each day. She would sit by the front door and watch visitors and sun herself. This day she apparently opened the gate at the top of the front entrance and fell down the four stairs. After examination at the hospital she had sustained a large hematoma on the forehead and a fractured femur. The plan now is for her not to go out unattended. On [DATE] through [DATE], observations were made of the main entrance at the west side of the building where the resident fell . There were two hollow tubular gates which were approximately wait high and ended approximately two feet from the ground. The two gates met in the middle at the top of four stairs and did not have a latching mechanism but would close on their own if left open. If walking up the steps the gates would be pushed toward the building to open. If going down the steps the gates would be pulled toward the building to be opened. A side walk extended south from the porch, to a parking lot. The side walk was fenced on one side, the side away from the building until approximately what would be the end of the 400 Hall where it opened into a parking lot. The side walk to the north of the porch was fenced on the far side, all the way around to the other side of the building where it opened into a service alley. A review of the resident's care plans that were active during the time of the fall revealed she was at risk for falls, elopement and was cognitively impaired. The fall risk care plan, dated [DATE] and [DATE], documented that the resident was at risk for falls related to unsteady gait and balance, cognitive status, psychotropic medication use impaired vision and recent fall. Interventions and approaches were many and included completing fall risk assessments quarterly, a bed sensor alarm and staff to assist with transfers. The impaired cognition care plan, dated [DATE] and [DATE], documented that the resident had impaired cognition related to dementia, and reactive confusion. The goals of the care plan were that the resident would follow simple commands and maintain the highest level of cognitive functioning evidenced by making simple needs known. The target date was [DATE]. Interventions and approaches were many including monitoring for change in cognition; assist with decision making as needed, reorientation and validation as needed and encouraging her to participate in activities and documented that the resident liked to go outside often. The elopement care plan, dated [DATE] and [DATE], documented that the resident was at risk for elopement related to a history of wandering /and or elopement, exit seeking behaviors, chronic confusion or disorientation and reactive confusion. The care plan goal documented was that the resident would not leave the facility unattended through the next target date of [DATE]. Approaches and interventions included a personal wander device, picture and face sheet in the facility wander books, use diversion when exit seeking, increase 1:1 monitoring, if indicated, and many others. An activities care plan, dated [DATE] documented that the resident loved to sit outside. Despite the risks identified for the resident, there was no definitive documentation as to whether she required monitoring when she was outside or not. On [DATE], at 9:45 a.m., the wander book at the reception desk was reviewed and found to have the photos and face sheets of three residents. Resident # 2 was not one of the residents in the book. The resident ' s care plan stated that a face sheet for the resident as well as picture identification of the resident was to be in the wander books. At this time the DON verified that the resident was not in the wander book at the reception desk and that she was not in the wander books at either nurse ' s station. In an Interview with the Unit Manager, (Employee #4) at 2:29 p.m., on [DATE] the unit manager was asked why a resident with a care plan for elopement, cognitive impairment and fall risks would be allowed to be outside alone. She stated that every day for over a year the resident would go outside twice a day and sit in the sun and would then bring herself back into the facility. She stated that resident never got up from her wheel chair or tried to get up and leave, so she was removed from elopement precautions. She felt the care plan was not accurate on the date the fall occurred and that the resident should not have been on elopement precautions. She stated that the wander guard that was on the resident was placed when her husband was a resident here. This was due to the resident talking about wanting to go home with him but after the resident ' s husband died [DATE] her exit seeking behavior calmed down. She felt the resident was not trying to exit but was most likely trying to come back into the facility when the fall occurred. The Unit Manager verified that the resident's care plans stated she was an elopement risk, a fall risk and was cognitively impaired. The unit manager was unable to provide documentation the resident had been evaluated to be safe outside alone and she was unable to provide documentation that the resident was removed from elopement precautions. An interview was conducted, on [DATE], at approximately 3:30 p.m. with the DON. She stated she did not feel the resident was an elopement risk. She stated the wander guard bracelet was placed as a way to be able to know when the resident went outside so she was not in the sun to long. The DON stated the resident's husband lived here with her until his death in July of 2010 and he used to sit with her outside. She stated the resident sat outside every day for four years. After his death the staff at the reception desk would keep their eye on her so she was not in the sun for too long. She stated that she was here the Saturday of the fall and saw the resident sitting outside as she left. She stated that she felt the resident was trying to go down the steps when the fall occurred. At 6:09 p

Based on record review, observations, facility policy, and resident and staff interviews, the administration failed to provide resource management to meet the needs of two (#8 and 2) of four residents reviewed for accidents,. The Administration did not ensure that the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities. This related to not implementing policies/procedures to ensure the well-being of these two residents, who were assessed with [REDACTED]. These events resulted in findings of Immediate Jeopardy, which was removed on [DATE], and the severity and scope was reduced to a D. Findings include: Review of the "Position Description" for the Administrator (received from the facility on [DATE] and included in the Administrator's employee file), revealed that the Administrator's "Function": "The Administrator is responsible for day-to-day clinical and administrative activities of the facility including profit and loss responsibility and assures compliance with all state and federal regulations. This employee provides leadership to all facility staff in meeting the goal of providing quality resident care." The "Responsibilities " section of the position description included (but was not limited to): "*5. Recruit, hire and provide orientation/training for a sufficient number of qualified staff to carry out facility programs and services." "*9. Maintain and guide the implementation of facility policies and procedure in compliance with corporate, state, federal and other regulatory guidelines." "*13. Ensure a safe, clean and comfortable environment for residents, visits and staff. Maintain a file for and monitor incident reports." "*19. Adheres to facility policies and procedures and participates in facility quality improvement and safety programs." 1. [AGE] year old Resident #8 was admitted to the facility on [DATE] per the medical record facesheet (noted as revised on [DATE]). The initial Minimum Data Set (MDS), with an assessment reference date of [DATE], indicated that she could answer the assessment questions but only scored 6 out of 15 in the section related to memory. She was noted with inattention and disorganized thoughts and some indicators of depression. Related to activities of daily living, she was coded as requiring limited assistance of one to dress, toilet, walk, and locomotion. Additionally, she was coded as unsteady in balance and as using a walker and a wheelchair for walking/locomotion. The MDS also coded her as having had a history of [REDACTED]. Included in this initial MDS's Care Area Assessment (CAA) Summaries was information regarding her having impaired communication related to her impaired cognition; and noted that she loses her train of thought a lot and may not fully understand what is being said to her. Additionally, the Falls CAA noted that she was at risk for falls due to history of a fall at home, where she sustained a laceration on the back of her head. Complications were noted to include: having impaired cognition due to advancing dementia; having poor safety awareness and making frequent attempts to get up on her own; having impaired balance while standing, turning and transferring; and being on an anti-depressant and a pain medication (due to shoulder pain and a long history of [MEDICAL CONDITION] arthritis). The Pain CAA noted (in part) " She is able to participate in therapy, feed herself, participates in her ADLs (activities of daily living) and wheels herself in the wheel chair readily. She does exhibit restlessness and attempts frequently to get up by herself. She is able to communicate need for pain med (medication) to the nurses. " The ,[DATE] care plan covered various assessed concerns/problems, including (among others) being at risk for falls; having mood symptoms of frequent crying episodes, restlessness and becoming easily annoyed at times; and having impaired cognition and communication related to dementia. The falls care plan included many approaches, several of which included keeping her in area where staff could monitor, low bed, and bed and chair alarm. On [DATE], a care plan problem was added regarding her being at risk for elopement related to exit-seeking behaviors and [DIAGNOSES REDACTED]. A problem regarding low activity level had been revised on [DATE] and indicated that she had cognitive impairment; impaired long/short term memory and decision-making skills; impaired attention span, frequent episodes of crying and "looking for her car/husband/children;" states I have to go get my husband, "I am going home;" easily agitated; can be verbally aggressive; not always easy to re-direct; frequent episodes of being very angry; and verbally rude towards others. These care plan problems had been added in conjunction with an "Elopement Risk Assessment" done on [DATE] by the Skilled Sub-Acute Nursing (SSU) Manager. The facility staff did not consistently implement the above-mentioned care plan approaches for this cognitively and functionally impaired resident as follows: On [DATE], the nurse's note (timed at 3:00 a.m.) indicated that she rested on/off during the night with eyes closed; and that a wanderguard was in place due to exit-seeking behavior. The 9:30 a.m. note indicated that she was pleasant, cooperative and ate a good breakfast. Noted too was that she had not made any attempts to get out of bed unassisted-low bed, sensor bad in bed, wanderguard due to poor safety awareness. The 10:30 a.m. note indicated that she was propelling herself in the wheelchair; crying, looking for rings. The rings were locked in the medication cart-she had removed and placed them under pillow. The 10:30 a.m. note indicated that the results from the urine analysis culture and sensitivity test had been received and report faxed to the physician. Also that something for mood be prescribed for "crying jags, ^ (increased) anxiety, verbal abuse to staff and others, etc." Additionally a psychological evaluation was requested to determine competency. The 2:00 p.m. note indicated that she was attempting to exit doors-monitor and attempting to re-direct, distract, engage in activity. The 3:45 p.m. note indicated that a fax order for the psychological evaluation was received, along with an order for [REDACTED]. On [DATE], the nurse's note (timed 10:00 a.m.) indicated that an antibiotic was administered without difficulty. Two episodes of crying were noted along with the resident self-propelling in wheelchair and being rude to staff and roommate. The ordered pain medication was noted as also being given for complaint of pain. The 11:00 a.m. note indicated that the ordered pain medication appeared to be effective for left hip pain. The 12:30 p.m. note indicated that she was anxious, crying, and asking if they had seen her rings. It was noted that the anti-anxiety medication had been given at 12:00 p.m., (with the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"- poor"). It was also noted that she was wheeling herself around saying "I ' m going home;" that she refused lunch and took jacket out of the closet and tried to place it at the nursing station. It was noted that she was re-directed to her room. The 1:30 p.m. noted indicated that she was observed lying in parking lot on left side with leg bent and arms bent at sides; and complained of pain in extremities. A small abrasion to forehead was noted; along with 911 being dispatched and her being taken to hospital; and a message being left for her daughter. On [DATE] at 10:10 a.m., the Maintenance Assistant (Employee #3) indicated that he heard the alarm while using the bathroom; and that it had been sounding several minutes. (He thought it was under 5 minutes by the time he got out of the bathroom). According to him, no other staff person had responded at that point. He looked up and down the hallway, then went through the double glass doors into the adjacent lobby and then to the double doors to the exit (next to which the wanderguard keypad was mounted. He said he went to the keypad and shut off the alarm; then took a step out of the door onto the 1-step up entry porch (located under a drive-through portico). He then looked left and right and did not see anyone so went back inside. This front walking surface (which was a one step-up from ground level porch area) stretched approximately 30 feet in each direction (or about 10 paces each way to either end of the building); and was adjacent to a driveway that ran in front of it (which was used as an ambulance entrance). He verified that he merely stepped out and checked in both directions and did not walk to either end of the porch to look into the parking lots that were on either side of the building. This main entrance faces a busy street, but the driveways run at an angle from the street toward this particular ambulance entrance way. When the Maintenance Assistant went back inside the building, within minutes a resident (Resident #14), who was in the 600 hall dining room, was yelling out about a resident having fallen outside. When he saw the fallen resident, she was at the second parking spot in the western lot right next to the building; and had fallen over the cement parking bumper. The 2nd parking spot was observed to be visible about 2 to 3 paces from the front entrance. However, it could not be seen if one stood at that doorway and looked in that direction. The Maintenance Assistant verified that the alarm was set off only by the wanderguard mechanism worn by various residents (either on their arm, leg or chair). When the person with a wanderguard hit the sensor area, then the alarm sounded. This was observed to be a loud whooping sound, as well as a voiced message that sounded over the public address system "Door alarm, 600 hall." Both sounds continue until the alarm was turned off. Regarding the above 600 hall exit door, this entrance/exit portico area was observed to face a highly trafficked 7-lane city street. From the exit door, it was approximately 35 paces (or 105 feet) to that street (when walking straight ahead and through an area of curb-surrounded bushes. Two paved driveways ran through this portico entrance area. The West driveway to the street measured approximately 53 paces (or 160 feet); and the East driveway measured approximately 51 paces (or 153 feet). Regarding the above-mentioned fall with injury, the facility provided reports dated [DATE] and [DATE], which had been written by the Director of Nurses (DON). The reports indicated that Resident #8 went outside and the door alarm went off. A maintenance staff member (who had been using the nearby men's room) heard the alarm and went outside to look for who set off the alarm. He did not see anyone, so he silenced the alarm. It was noted that the staff member said he looked outside but did not look around the building for anyone, as he did not think that they would travel that fast. It was noted that the resident had gone around the corner and was on the ground moments later. When the resident was found, she was over the curb with the wheel chair on top of her body. The only obvious injury was an abrasion to the forehead. The resident was transferred to the hospital for evaluation and treatment; and was ultimately placed in a more secure locked environment. The [DATE] report indicated (in the section for description of corrective or proactive action(s) taken) that all staff in-serviced on the importance of looking beyond the entryway and around corners when the door alarm goes off. (However, review of the [DATE] training attendance sign-in sheets determined that only 73 of 132 staff were re-trained.) Also, the resident was noted as being transferred to a more secure environment for safety. On [DATE] at 6:19 p.m., the DON verified the above information, and indicated that the resident had gone to the ambulance entrance (located off of the 600 hall)-it was alarmed for when a wanderguard passed it and the alarm went off. The DON indicated that the resident was out there only a couple minutes-someone saw her outside and said she had tumbled over. The Maintenance Assistant (Employee #3) heard and looked but she had evidently gone off to the right around the side-and he did not go around the corner and look. On [DATE] at 1:40 p.m., the witnessing resident (Resident #14) was interviewed. Resident #14 said that she had been sitting at the dining room window and saw Resident #8 wheeling down the sidewalk from the portico area. The left wheel of Resident #8's chair had slipped off the sidewalk and she had fallen down and rolled over the parking bumper. Resident #14 yelled and went out into the hallway and saw the Maintenance Assistant (Employee #3) and yelled for him. Resident #14 said he and other staff responded to her call for help right away. She did not recall one way or the other hearing the alarm sounding. On [DATE] at 2:55 p.m., the SSU Manager (Employee #1) indicated that from the time of admission the resident had periodic agitation, crying, wandering-behavior was up and down and seemed to escalate after lunch. Staff had been talking with the physicians and PA involved; laboratory work was done and the resident was on an antibiotic at time of the incident. She indicated that this resident was one for whom staff tried to redirect, calm and, as necessary, keep near to them -- e.g. 1:1 at times, or put by nursing station. The Unit Manager said she would even be brought into her office and she would sit there with the Unit Manager. The Unit Manager said she was on duty the day of the fall outside, but did not see the resident at the time. She indicated that the Maintenance Assistant (Employee #3) had responded to the wanderguard alarm going off; and that Resident #14 had called out about seeing her fall outside. On [DATE] at 3:15 p.m., a Nurse (Employee #2) indicated she was on the floor the day of the resident ' s fall. The LPN indicated that they tried to do informal 1:1 supervision with her so she would be with others and be distracted. On the day of the fall, she had been with an Aide, who was called to help in another resident ' s room. She heard that the Aide had then positioned the resident by the nursing station, which was common to do for that resident and some others. The Nurse indicated that she remembered seeing the resident earlier in the day, but did not hear the wanderguard alarm sounding because she was in another resident ' s room at the time. She got a call that the resident was in the parking lot and was told that the resident had flipped over the parking bumper barrier-she thinks that the wheelchair was to the side (and not on top of the resident) when she observed the resident. She also added that the resident in latter days of her stay was more agitated/upset; and that staff tried to figure out how to keep her comfortable. The LPN said she had given the resident an anti-anxiety medication that day (which was ordered to be given as needed for agitation; and noted on medication records as having been given at 12:00 p.m. with the medication effectiveness noted as being "- poor"). The Nurse also relayed that the resident was at that time on an antibiotic. Per the Nurse, every time she saw the physician or PA, she talked with them about the resident. The physician seeing her did not agree on using [MEDICATION NAME]-one wanted the anti-psychotic started and the other was against it and wrote an order to not use it. On [DATE] at 9:40 a.m., the Assistant Director of Nurses (ADON), who also served as the facility's Staff Developer for training, indicated that the expectation regarding the sounding wanderguard alarm was that ALL staff would respond to the area of the alert, except if unable to do so because of providing care to a resident. She indicated that the alarm was not to be turned off (at the keypad next to the alarming door) until the "trigger" was found (i.e. who/what caused the alarm to go off). She further indicated that the alarm continuing to sound brings additional staff that might be needed (e.g. if the resident would be injured and the 1st responder needing to stay with the resident while others obtained further help; or if more staff would be needed for a search etc.). She had no explanation for why this had not occurred in the case of Resident #8. The ADON indicated that all staff were trained upon hire during orientation; and provided a "Blue Ribbon Orientation Checklist" which indicated that newly hired staff received "Safety 101" training during orientation. This training included missing resident at a glance and elopement guide training. The ADON also indicated that the staff annually attended mandatory in-services. Sheets of attendees for the last annual (on "Education Report by Course" forms) for the time period of [DATE] through [DATE]) included the "Silverchair Learning Systems" course "Missing Resident/Elopement"; and had 97 attendees. The attendees included the Maintenance Assistant (Employee #3) as well as 96 others. The course included definition of elopement, 6 risk factors for elopement, discussion of who may wander and why, and discussion of management of wandering. Included in the information was the question "What is elopement and what are the risk factors?" followed by "Elopement is unsupervised or unassisted flight from the facility. The resident did NOT elope if he/she was identified leaving the facility and was redirected back into the facility (the care plan worked!)." Also included in the course information was the question "If you think that a resident is missing, you should try to find them quickly by yourself so nobody else will find out." The correct answer was "False," with the additional information "If a resident is thought to be missing, the elopement procedure should be initiated which included all staff." Additionally: "The person in charge of the search will assign staff members to look in certain areas." The exterior search techniques stated: " Exterior of the Building within 10 feet - search all rooms using the interior search technique. Look under and behind all plant life - trees, shrubs, etc." The exterior ground of the facility information included: "Search the Parking Lot(s) - Physically look under and inside all vehicles on the property, look on all sides of the vehicle" and went on to describe searches of culverts/ditches, retention ponds and dumpsters. These Administrative training policies were not implemented in the case of Resident #8, in that she was unmonitored to the extent that on [DATE] she left the facility unsupervised and unassisted (sustaining a fall with injury); and in that there was a lack of staff responding in a timely manner to the sounding alarm, as well as a lack of a thorough search by Employee #3 who did respond to the alarm. 2. A review of Resident #2's face sheet, physicians notes, dated [DATE], and the Quarterly Minimum Data Set, dated dated [DATE], documented that the [AGE] year old resident was originally admitted to the facility on [DATE], with her most recent admission being [DATE], when she returned from the hospital after falling from her wheel chair and fracturing her left hip. The hospital physician's note documented that the resident had history of [MEDICAL CONDITION], dementia, sundowner's syndrome, valvular [MEDICAL CONDITIONS] and hypertension and unsteady gait. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a history of dementia with agitation, chronic [MEDICAL CONDITION], hypertension, arthritis and unsteady gait. A review of the resident's care plans revealed she was at risk for falls, elopement and was cognitively impaired. The fall risk care plan, dated [DATE] and [DATE], documented that the resident was at risk for falls related to unsteady gait and balance, cognitive status, [MEDICAL CONDITION] medication use impaired vision and recent fall. Interventions and approaches were many and included completing fall risk assessments quarterly, a bed sensor alarm and staff to assist with transfers. The impaired cognition care plan, dated [DATE] and [DATE], documented that the resident had impaired cognition related to dementia, and [MEDICAL CONDITION]. The goals of the care plan were that the resident would follow simple commands and maintain the highest level of cognitive functioning evidenced by making simple needs known. The target date was [DATE]. Interventions and approaches were many including monitoring for change in cognition; assist with decision making as needed, reorientation and validation as needed and encouraging her to participate in activities and documented that the resident liked to go outside often. The elopement care plan, dated [DATE] and [DATE], documented that the resident was at risk for elopement related to a history of wandering /and or elopement, exit seeking behaviors, chronic confusion or disorientation and [MEDICAL CONDITION]. The care plan goal documented was that the resident would not leave the facility unattended through the next target date of [DATE]. Approaches and interventions included a personal wander device, picture and face sheet in the facility wander books, use diversion when exit seeking, increase 1:1 monitoring, if indicated, and many others. An activities care plan, dated [DATE] documented that the resident loved to sit outside. Despite the risks identified for the resident, there was no definitive documentation as to whether she required monitoring when she was outside or not. The facility did not ensure that this at risk resident's care plan was being followed, as follows: On [DATE], at 9:45 a.m.., the wander book at the reception desk was reviewed and found to have the photos and face sheets of three residents. Resident # 2 was not one of the residents in the book. The resident ' s care plan stated that a face sheet for the resident as well as picture identification of the resident was to be in the wander books. At this time the DON verified that the resident was not in the wander book at the reception desk and that she was not in the wander books at either nurse ' s station. The care plan review also revealed that the care plans had not been updated since the resident ' s fall, stating that she was not be outside unattended as was stated by the DON in the resolution of her investigation. A review of Resident #2's medical record revealed a nurses note, dated [DATE], at 2:50 p.m. and documented that the resident was observed on the ground outside of the building in front of steps lying flat on her back with her feet closest to the steps. The resident was able to verbally communicate with staff and her hand grips were equal. She complained of left leg discomfort and was unable to straighten her left leg without pain and there was a hematoma to her forehead. 911 was called along with the resident ' s physician and responsible party. The resident was transferred to the hospital. The physician's hospital note, dated [DATE], documented the resident was admitted with a displaced comminuted [MEDICAL CONDITION] left femur as well as multiple contusions and abrasions. The facility completed a report, on [DATE], documenting the events surrounding the fall. The circumstances of the event documented stated that the resident was found on the ground outside the facility on the front of the steps leading to the building. She was flat on her back with her feet facing the steps. She complained of left leg discomfort, hematoma was observed on her forehead and two skin tears on her right lower extremities. The Physician was called and ordered the resident to be transferred to hospital for evaluation and treatment. An investigation of the fall was completed by the facility DON, on [DATE]; and the analysis and corrective action were documented by the DON as follows: This resident would go outside three to four times each day. She would sit by the front door and watch visitors and sun herself. This day she apparently opened the gate at the top of the front entrance and fell down the four stairs. After examination at the hospital she had sustained a large hematoma on the forehead and a fractured femur. The plan now is for her not to go out unattended. In an interview (at 2:29 p.m. on [DATE]), the Unit Manager (Employee #4) was asked why a resident with a care plan for elopement, cognitive impairment and fall risks would be allowed to be outside alone. She stated that every day for over a year the resident would go outside twice a day and sit in the sun and would then bring herself back into the facility. She stated that resident never got up from her wheel chair or tried to get up and leave, so she was removed from elopement precautions. She felt the care plan was not accurate on the date the fall occurred and that the resident should not have been on elopement precautions. She stated that the wander guard that was on the resident was placed when her husband was a resident here. This was due to the resident talking about wanting to go home with him but after the resident ' s husband died [DATE] her exit seeking behavior calmed down. She felt the resident was not trying to exit but was most likely trying to come back into the facility when the fall occurred. The unit manager verified that the resident ' s care plans stated she was an elopement risk, a fall risk and was cognitively impaired. The unit manager was unable to provide documentation the resident had been evaluated to be safe outside alone and she was unable to provide documentation that the resident was removed from elopement precautions. An interview was conducted (on [DATE], at approximately 3:30 p.m.) with the DON. She stated she did not feel the resident was an elopement risk. She stated the wander guard bracelet was placed as a way to be able to know when the resident went outside so she was not in the sun to long. The DON stated the resident's husband lived here with her until his death in July of 2010 and he used to sit with her outside. She stated the resident sat outside every day for four years. After his death the staff at the reception desk would keep their eye on her so she was not in the sun for too long. She stated that she was here the Saturday of the fall and saw the resident sitting outside as she left. She stated that she felt the resident was trying to go down the steps when the fall occurred. On 6:09 p.m., that same day, the DON again stated that the resident had a wander guard so the front desk and others would know she was outside so they could keep an eye on her so she was not in the sun to long. She did not feel the resident was an elopement risk. She said that the day of the fall she assumes that the resident opened the gate but no one knows and the resident is not able to tell you. She stated that she is unable to think of any documentation on the resident evaluating her as safe to be outside alone. She stated that people change and do unexpected things. She states the resident did not have elopement behaviors when this fall occurred. The DON stated she had been at this facility for nine years and cannot recall the resident having exit seeking behavior and that she cannot remember a time when the resident was not outside by herself. In regard to the elopement care plan she did not have an explanation for why the resident had the care plan. The DON was unable to provide documentation to support that the resident was not at risk for elopement as indicated by her care plan. At 2:20 p.m., on [DATE], an interview was conducted with Certified Nursing Assistant ( CNA-Employee #6) . She indicated that she had been employed by the facility for 5 years. She stated that she was in the facility the day the resident fell . She related that on the day of the fall the resident was confused and that was normal for her and that the resident would normally go outside by herself and sits in the same spot in the sun. She stated she did not know if the resident took herself outside or if staff had assisted her to get outside the day of the fall as he was working with another resident when the fall occurred. On [DATE], at 4:51 p.m., a telephone interview was conducted with the Weekend Receptionist (Employee #9) regarding the fall of the resident on [DATE]. She related that the resident liked to sit outside and that for the one and one-half years that she has been employed at the facility the resident has done this, always sitting in front of the steps or off to the right corner in the sun. Occasionally she would go to the left down the walk way and sit. On the date of the fall the resident had been sitting outside. The receptionist stated she could not remember if the wander guard alarmed or not when the resident went outside because sometimes the alarm worked and sometimes it did not. She stated that another resident had been sitting outside when resident #2 went outside. When that resident came inside he told her that he was in and that she would have to watch the resident. She stated that after about two minutes she got up to make coffee (the pot is to the right of the reception desk) and looked out the window for the resident. She saw the arm of the resident ' s wheel chair in a patch of sun and assumed the resident was still in her sunning spot. She stated that a few minutes later she heard the resident yell and she saw her at the bottom of the stairs with her wheel chair on top of her. She went to the resident to calm her and then left the resident in position at the bottom of the stairs to go inside to call for help. She stated that she called the resident's nursing station (100 hall ) and there was no answer so she paged over the PA system that she needed emergency help at the front lobby. She stated that staff responded and the resident was assessed and transported 911 to the hospital. She stated she did not know if the resident had ever tried to wander away in the past and that usually when the resident was outside there were other families and residents outside as well. On [DATE] through [DATE], observations were made of the main entrance at the west side of the building where the resident fell . There were two hollow tubular gates which were approximately wait high and ended approximately two feet from the ground. The two gates met in the middle at the top of four stairs and did not have a latching mechanism but would close on their own if left open. If walking up the steps the gates would be pushed toward the building to open. If going down the steps the gates would be pulled toward the building to be opened. A sidewalk extended South from the porch, to a parking lot. The side walk was fenced on one side, the side away from the building until approximately what would be the end of the 400 Hall where it opened into a parking lot. The side walk to the north of the porch was fenced on the far side, all the way around to the other side of the building where it opened into a service alley. A review of the nurse note's prior to and around the time of the fall documented that the resident did have episodes of wandering inside the facility and that she was confused. The facility allowed the resident to go outside the building unassisted despite the serious risks that were identified. A nurse's note, on [DATE], at 6:00 p.m., documented that the resident was started on [MEDICATION NAME] 5 mg (milligrams) and was observed propelling herself up and down the halls going into rooms, pleasantly confused. A nurse's note, dated [DATE], at 5:00 a.m., the resident was observed putting jewelry in the bed of her roommate stating "I'm putting it on my baby". She was also observed attempting to give another resident graham crackers and she was

Based on record review and staff interview, the facility failed to ensure that the care plan for one (#2) of four residents reviewed related to accidents was updated after hospitalization for a fall/fracture, to reflect the need for supervision when outside of the facility. Findings include: Review of Resident #2's face sheet, physician's notes, dated 1/15/2011, and the Quarterly Minimum Data Set, dated dated [DATE], documented that the [AGE] year old resident was admitted to the facility 12/09/2004 originally, with her most recent admission being 1/22/2011 (when she returned from the hospital after falling from her wheel chair and fracturing her left hip). The hospital physician's note documented the resident had history of [MEDICAL CONDITION], dementia, sundowners syndrome, valvular [MEDICAL CONDITIONS] and hypertension and unsteady gait. The Quarterly Minimum Data Set, ((MDS) dated [DATE], documented a history of dementia with agitation, chronic [MEDICAL CONDITION], hypertension, arthritis and unsteady gait. A nurse's note, dated 1/15/2011 (timed at 2:50p.m.), documented that the resident was observed on the ground outside of the building in front of the steps lying flat on her back with her feet closest to the steps. The resident was able to verbally communicate with staff and her hand grips were equal. She complained of left leg discomfort and was unable to straighten her left leg without pain. There was a hematoma to her forehead. 911 was called as was the physician and the resident's responsible party and the resident was transferred to the hospital. The physician's hospital note, dated 1/15/2011, documented the resident was admitted to the hospital with [REDACTED]. The facility completed a report, on 1/15/2011, documenting the events surrounding the fall. The circumstances of the fall were documented as: The Resident was found on the ground outside the facility on the front of the steps leading to the building. She was flat on her back with her feet facing the steps. She complained of left leg discomfort, hematoma was observed on her forehead and two skin tears on her right lower extremities. The Physician was called and ordered the resident to be transferred to hospital for evaluation and treatment. An investigation was completed by the facility Director of Nursing (DON) on 1/25/2011. The analysis and corrective action were documented by the DON as follows: This resident would go outside three to four times each day. She would sit by the front door and watch visitors and sun herself. This day she apparently opened the gate at the top of the front entrance and fell down the four stairs. After examination at the hospital she had sustained a large hematoma on the forehead and a fractured femur. The plan now is for her not to go out unattended. An activities care plan dated 12/14/110 documented that the resident loved to sit out side. There was no documentation that she required monitoring. There was no update to the activity care plan post fall regarding the need to be attended when ouside the facility. A care plan (with an intial date of 6/15/2010) documented the resident to have impaired cognition related to dementia with active confusion. Interventions included using simple and direct commands, reorientation and validation, monitoring for changes in cognition and encouraging activities. The care plan documented that the resident was readmitted on 1/22/2011 and that the resident enjoys going outside, but it was not updated to say the resident needed to be attended when she was outside. A care plan, with initial date of 6/15/2010, documented the resident to be at risk for elopement related to a history of wandering and or elopement, exit seeking behaviors, chronic confusion or disorientation and active confusion. Goal is stated as Resident will not leave facility unattended through next review. The target dates documented were 9/15/2010, 12/07/2011, and 1/28/2011. Interventions documented were redirect resident from doors and exits as needed, observe for exit seeking behaviors, increase one on one monitoring if indicated, personal wander prevention device, check functioning daily and placement every shift, picture identification and face sheet in wander books, assess for wandering and elopement patterns, assess for ambulation program, as well as other interventions. There were no changes to the care plan documented after the resident's 1/22/2011 readmission to the facility after the fall, regarding her need for supervision when outside of the building. On 3/3/2011 9:45a.m the elopement book was reviewed and found to have pictures and face sheets for three residents. Resident # 2 was not in the book as stated in the interventions of her care plan. A care plan with an initial date of 6/15/2010 identified the resident to be at risk for falls related to cognitive status , unsteady gait, [MEDICAL CONDITION] medication use, impaired vison and history of falls. The Goal documented was that resident would not experience injury from falls. The interventions were documented as change in cognitive status, change in functional status, complete fall risk on admission and quarterly, assess ability to follow directions, assure clear pathways, call bell in reach, bed alarm for resident safety, and multiple other interventions. Readmitted s of 09/07/2010 and 1/22/11 were documented in the margin of the care plan. There was no doumentation updating the care plan after the resident ' s return to the facility on [DATE]. The care plan continued to reflect that the resident liked to be outside however did not document the need for the resident to be accompanied when outside of the facility. The nurse tech information cardex documented a bed sensor mat and wander guard to be in use for resident. There was no documentation regarding the resident's need to be attended when outside of the facility. In an interview (conducted on 3/2/2011 at 2:29 p.m. , the Unit Manager ( Employee #4) confirmed that the careplans for the resident were not updatd after her return from the hospital on [DATE] to reflect the need for her to be attended when outside of the faility. In an interview, at 4:33p.m. on 3/2/2011, The Registered Nurse MDS/Care Plan Coordinator (Employee #5) was asked when care plans were updated. She stated she updates careplans quarterly when she does the MDS. Subsequently, on 3/3/2011, at 4:30 p.m. , the MDS/Care Plan Coordinator reviewed the resident's nursing careplans. Since the resident's return to the facility on [DATE] she found updates to the physical therapy plan of care only. She stated that when a resident returns from the hospital the care plan is updated by the coordinator when the MDS is completed. Prior to the completion of the MDS the unit manger is responsible to update the careplan. The MDS/ Care Plan coordinator, confirmed the careplans for the resident were not updated after the fall to reflect the need for the resident to be attended when outside of the facility. In an interview, on 3/2/2011 at 2:29 p.m., The Unit Manager (Employee #4) verified the resident's care plans for elopement, fall risk and dementia had not been updated to reflect the need for the resident to be attended when outside of the facility. In an interview with the DON (on 3/3/2011 at 4:48 p.m.), she stated there was no written policy regarding careplans and who is responsible for post hopsital updates to them. She stated that updating the care plans was an interdisciplinary function.