Every finding on record at Bernard Care Center

Based on observation, interview and record review, the facility failed to provide protection from sexual abuse to one resident (Resident #2), by Resident #1, who had a documented history of sexual preoccupation and sexually inappropriate behaviors. Resident #1 was observed standing over Resident #2, who had documented developmental disabilities and moderate cognitive impairment, while pulling up his/her pants. On [DATE] at 9 A.M., Social Services said the resident reported he/she had been asleep and stated upon waking, Resident #1 was positioned over Resident #2 while touching himself/herself. Resident #2 reported Resident #1 ejaculated into Resident #1's mouth, causing him/her to cough, and stated that he/she attempted to push Resident #1 away. Resident #1 said he/she placed his/her genitals in Resident #1's mouth and forced the resident to perform oral sex. Resident #2 was sent to the hospital following the incident and became upset when the hospital staff asked if they could examine him/her saying, I don't want to be hurt anymore and refused to be examined from the waist down. The census was 120. The administrator was notified on [DATE] of the immediate jeopardy (IJ) past non-compliance, which occurred on [DATE]. When the facility identified the issue, they separated the residents and sent Resident #2 to the hospital. Resident #1 was placed on additional monitoring. Staff were in-serviced on abuse and neglect. The IJ was corrected on [DATE]. Review of the facility's Abuse and Neglect policy, revised [DATE], showed:-Definitions:--Sexual Abuse is non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to the following:---Unwanted intimate touching of any kind especially of breasts or perineal area;---This also includes failure to intervene or attempt to stop or prevent non-consensual sexual activity or performance between residents; -Resident Assessment:--As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis. Review of the facility's Sexual Activity/Abuse and Neglect policy revised [DATE], showed:Procedure:-Non-consensual acts are not permitted.-Determination of ability to consent:--If the resident has a guardian or physical and/or cognitive impairment, an assessment should be completed to determine the resident's ability to consent. This assessment will be completed by the Interdisciplinary Care Team (IDT), with assistance from the resident's physician and/or psychiatrist as needed. The assessment shall include the following:---Awareness of the relationship including awareness of who is initiating the relationship, identity of the other person, and comfort level with sexual intimacy;---Ability to avoid exploitation including the resident's values and ability to refuse unwanted advances;---Awareness of potential risk associated with the relationship, including sexually transmitted diseases or pregnancy, if applicable, or reaction if the relationship ends;---The resident's guardian if applicable) will be invited to provide their guidance/opinion to the Interdisciplinary Care Team. Family members may be involved in the assessment as appropriate;---Residents will be assessed for their capacity to consent to sexual activity if they have a history of sexual activity, have indicated that they wish to engage in sexual activity, or if the facility or guardian otherwise believes that they should be assessed. All residents do not need to be assessed. Residents will be reassessed as needed;---If non-consensual sexual activity occurs, the abuse and neglect policy will be followed. Review of the facility's Accidents and Supervision policy, revised [DATE], showed:-Purpose:--Each resident will receive adequate supervision.-Definitions:--Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident;--Implementation of Interventions - using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes:---Communicating the interventions with all relevant staff;---Assigning responsibility;---Providing training as needed;----Documenting interventions;---Ensuring that the interventions are put into action;-Resident-directed approaches may include:--Implementing specific interventions as part of the plan of care;--Supervising staff and residents, etc;--Facility records document the implementation of these interventions;-Monitoring and modification processes include:--Ensuring that interventions are implemented correctly and consistently;--Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents;-Adequacy of supervision:--Defined by type and frequency;--Based on the individual resident's assessed needs and identified hazards in the resident environment. 1. Review of the facility investigation document, dated [DATE] at 8:00 A.M., showed:-Resident: Resident #1:-Incident location: Resident's room;-Incident Description:--Nurse Description: Licensed Practical Nurse (LPN) A was told by Certified Medication Technician (CMT) B, on duty on 100 unit, he/she heard a resident choking in his/her room. He/She went in to see what was going on. Resident #1 was standing over the bedside of Resident #2's bed. Emesis was noted on the floor;--Resident Description: The resident (Resident #1) said that he/she did ask Resident #2 to perform oral sex on him/her and Resident #2 did it. He/She said he/she did not touch Resident #2's private area but admitted to touching Resident #2's breast;-Immediate Action Taken:--LPN A interviewed both parties involved in the incident. The Nurse Supervisor, Director of Nursing (DON) Administrator, Medical Director (MD) were made aware. Resident #1's guardian was deceased . Tried calling the emergency contact - no answer;-Level of Consciousness - Alert;-Mobility - Ambulatory without assistance;-Mental Status - Oriented to person, situation, place, and time;-Predisposing factors - None noted;-Statements:--On [DATE], Resident #2 said he/she did perform oral sex on Resident #1 because he/she kept begging him/her to do it;--On [DATE], CMT B overheard a resident choking and went into Resident #2's room. He/She was lying in bed and Resident #1 was standing over him/her. Resident #1 was pulling his/her pants up. CMT B asked them what was going on and Resident #1 walked out without answering him/her. Resident #2 was choking and coughing, vomiting on the floor beside his/her bed. CMT B gave the resident water to clear his/her throat. He/She was unable to talk because he/she continued to have uncontrolled emesis. He/She was assessed as alert and in a lying position. LPN A and CMT B asked what happened and the resident stated that Resident #1 kept begging him/her to perform oral sex. He/She (Resident #1) kept forcing himself/herself on him/her (Resident #2), so he/she did it. He/She stated Resident #1 asked him/her to perform oral sex on him/her which he/she did willingly;-Resident-Resident #2:-Incident location - Resident's room;-Incident Description:-Nurse Description - LPN A was asked by CMT B, on duty on 100 unit, to come to a resident room because he/she suspected something had happened between Resident #1 and #2. CMT B said he/she heard Resident #2 choking in his/her room. CMT B went in to see what was going on with him/her (Resident #2). Resident #1 was standing over Resident #2, beside his/her bed. Emesis noted on the floor. Resident #1 was pulling up his/her pants. Resident #2 was lying in bed, fully clothed. CMT B came and got LPN A;-Resident Description - Resident #2 said to LPN A, Resident #1 asked him/her to perform oral sex on him/her. He/She said no at first but then Resident #1 touched his/her breast. Resident #1 started begging him/her and kept begging and begging, trying to coerce him/her into it. Resident #1 came closer to him/her, begging and pleading. He/She tried to push Resident #1 away, but he/she kept begging. So, he/she did it. He/She put Resident #1's private part into his/her mouth and then threw up. Emesis was observed on the floor. He/She denied Resident #1 touched his/her private area or tried to go in his/her pants;-Immediate Action Taken:-Description: Resident #2 was assessed by LPN A. The vomiting had stopped. He/She remained in supine position in bed, fully clothed in hospital pants and top. Resident #2 refused to answer simple questions from the nurse, but did give a statement to CMT B while the nurse was in the room. Call light in reach. Was encouraged to use call light for assistance or if he/she felt danger, unsafe, or needed to talk to staff;-Level of consciousness - Blank;-Mental status - Oriented to person, situation, place, and time;-Predisposing Physiological Factors - Impaired Memory and recent change in condition;-Statements:--Staff Description: On [DATE], LPN A was told by CMT B, on duty on 100 unit, he/she heard Resident #2 choking in his/her room. CMT B went in to see what was going on. Resident #1 was standing over Resident #2. Emesis was observed on the floor;--Resident Description: Resident #2 said Resident #1 did ask him/her to perform oral sex on him/her and he/she did it. Resident #2 said he/she did not touch his/her private area. Resident #1 did admit to touching Resident #2's breast;-Employee/Witness Name:-Date: [DATE];-CNA C stated when he/she went into Resident #2's room, he/she observed the resident to be fully dressed, lying on the bed. He/She was coughing and clearing his/her throat. He/She was not crying, yelling, or screaming until CMT B asked what was going on. He/She said nothing about what happened between himself/herself and Resident #1. CMT B asked Resident #1 what was going on and he/she left the room;-CMT B said while he/she was getting his/her cart ready for the morning medication pass, he/she heard a resident making loud vomiting and choking sounds. When he/she arrived at the room, Resident #1 was standing over Resident #2 with his/her pants down and Resident #2 was vomiting. Resident #1 hurried and pulled his/her pants up and left the room. While Resident #1 was leaving, he/she asked what was going on. Resident #1 kept saying nothing. When Resident #2 was finally able to stop vomiting, CMT B went and got the charge nurse. On arriving back to the room Resident #2 was asked what happened. Resident #2 said Resident #1 was touching his/her breast and kept begging for oral sex. He/She said Resident #1 kept begging, so he/she did it. Resident #1 had been placed in the dining room for one-to-one (1:1) monitoring. When Resident #1 was asked what happened again, he/she said he/she was only masturbating. 2. Review of Resident #1's behavior modification plan, dated [DATE] showed:-Supervision to redirect inappropriate or obsessive behavior;-Close observation to support social behavior and redirect preoccupations;-Limitations per PASRR: (Preadmission Screening and Resident Review, a federally required screening process used to check if a person applying to or living in a Medicaid-certified nursing facility has a serious mental illness, intellectual disability, or developmental disability);-Preoccupation with sexual content and labile affect (rapid, extreme, and uncontrollable changes in how a person shows their emotions);-Proactive Strategies:-Establish consistent staff rapport through daily 1:1 check-in;-Limit exposure to overstimulating environments;-Reactive Strategies:-Document all triggers, behaviors, and staff interventions;-Next review date: [DATE];-No current document noted in the resident's medical record. Review of the resident's care plan, updated [DATE], in use at the time of the investigation showed:-Problem:-PASRR long history of receiving psych treatment for bipolar, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, often making it hard to tell what is real and what is imagined), has disorganized thoughts, delusions, hallucinations, sexually inappropriate acting out, aggression, abusive/assaultive behaviors;-Date initiated: [DATE];-Date revised: [DATE];-Desired outcome:-Will remain safe in skilled nursing facility;-Date initiated: [DATE];-Date revised: [DATE];-Interventions:-Resident will be in lowest restrictive environment while maintaining protective oversight;-No other interventions noted;-Date initiated: [DATE];-No revision date noted-Problem:-Manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. These behaviors include verbal/physical aggression, being intrusive, delusions/hallucinations, sexually inappropriate;-Date initiated: [DATE];-Desired outcome:-Will minimize episodes of inappropriate behavior that can affect others;-Date initiate: [DATE];-Date revised: [DATE];-Interventions:-Administer and monitor medications as ordered;-Administer as needed (PRN) medications as needed/ordered when non-pharmacological interventions are non-effective;-If resident is disturbing others, encourage him/her to go to a more private area to voice concerns/feelings to assist with decreasing episodes of disturbing others;-Notify guardian/physician as needed;-Pharmacy consultant will review medications monthly and PRN;-Psych consultation for medication adjustments as needed/ordered;-Date initiated: [DATE];-Date revised: [DATE]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:-Cognitively intact;-No mobility devices;-Diagnoses included but not limited to high blood pressure, depression, diabetes. Review of the resident's care plan, in use at the time of the investigation, showed:-On [DATE], the resident was placed on 1:1 supervision temporarily due to allegation of sexually inappropriate activity with a female resident;Date Initiated: [DATE]. Observation on [DATE] at 10:11 A.M., showed the resident in his/her room. No 1:1 staff at Resident #1's door or inside of his/her room. During an interview on [DATE] at 10:11 A.M., Resident #1 said he/she knew Resident #2 and was talking to him/her. Resident #2 jacked him/her up a little. When asked what did jacked him/her up meant, Resident # said it was like a hand job. Resident #1 came (ejaculated) a few times. He/She didn't know if Resident #2 wanted to do it. His/Her facial expression showed he/she wasn't in the mood and wasn't ready for it. Resident #1 didn't rush Resident #2 into it. Resident #1 said he/she started to get horny. Resident #2 wasn't hurt and didn't cry. Resident #2 jacked him/her off and Resident #1 sucked on Resident #2's body part. Resident #1 put his/her penis into Resident #2's mouth. He/She came (ejaculated) on Resident #2's face, not in his/her mouth. Resident #1 said he/she walked into Resident #2's room and got aroused. He/She told the nurse he/she jacked off. He/She said it was two times, once in the mouth and the other time was a hand job. He/She told CMT B. During an interview on [DATE] at 1:37 P.M., CNA D said he/she knew Resident #1. Resident #1 made passes at a few women and had been at the facility about 6 years. He/She wasn't aware of any sexual behaviors that were documented in his/her record. The facility had not told them anything specifically to do when Resident #1 displays/acts of sexual behavior. CNA D said he/she didn't know why Resident #1 was in Resident #2's room because they were on different sides of the unit. He/She had just gotten to work the day of the allegation but didn't witness anything. Resident #1 was given a 1:1 assignment and was still on 1:1 monitoring. During an interview on [DATE] at 1:41 P.M., both LPN F and CMT E said they knew Resident #1. Both said he/she was still 1:1, but the staff probably walked away. Both said there should have been staff monitoring Resident #1. Neither were aware of any sexual behavior or preoccupation with sex. Resident #1 mostly talked about being a virgin. He/She would be re-directed. The talk was nothing intimidating and the behavior was not a threat to anyone. Resident #1 never touched anyone, and no one ever reported to either of them that he/she had touched someone. LPN F said he/she wouldn't have put anything/interventions in place. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed:-Moderately impaired;-Oral hygiene - Set-up/Clean-up assistance;-Personal hygiene- Supervision/touch assistance;-No assistive mobility devices;-High blood pressure, seizure disorder, and schizophrenia. Review of the resident's care plan, initiated [DATE], in use at the time of the investigation showed:-At risk for the following signs and symptoms related to diagnosis of intellectual disability. Difficulty communicating or socializing with others, difficulty with problem-solving or logical thinking, inability to connect actions with consequences, learning and developing more slowly than others, lower than average scores on IQ test (a standardized assessment designed to measure human cognitive abilities, problem-solving skills, and logical thinking), and trouble learning in school;-Date initiated: [DATE];-Date revised: [DATE];-Desired outcome:-Will have decreased signs and symptoms of the diagnosis of anxiety;-Interventions:-Ensure my environment is safe;-Date initiated: [DATE]. Review of the residents' notes showed:-On [DATE] at 7:30 A.M., CMT B was on the hall setting the cart up for morning med pass when this writer heard Resident #2 sounding like he/she was vomiting very loudly. When he/she got into the room Resident #1 was in the room standing over Resident #2 with his/her pants down. Resident #1 hurried up and pulled his/her pants up and left the room. The resident continued to choke and vomit. When the resident was able to calm down and stop choking the CMT asked what happened. The resident said Resident #1 came in his/her room and repeatedly begged for fellatio (oral sex), so he/she did it;-On [DATE] at 2:39 P.M., LPN A was asked by CMT B, on duty on 100 unit, to come to the resident's room because he/she suspected something had happened between Resident's #1 and 2. CMT B said he/she heard Resident #2 choking in his/her room. CMT B went in to see what was going on with Resident #2. Resident #1 was standing over him/her, beside his/her bed. Emesis was observed on the floor. Resident #1 was pulling up his/her pants. Resident #2 lay in bed fully clothed. CMT B came and got LPN A;-On [DATE] at 7:25 P.M., the hospital emergency room called. Report was given to LPN A. The resident was given a full work up for a sexually assaulted victim.-On [DATE] at 9 A.M., Social Services met with the resident individually for a psychosocial follow-up regarding a reported incident involving another resident. Resident #2 was able to participate in the assessment and provided a brief account of the incident. The resident said that he/she had been asleep and upon waking, he/she observed Resident #1 positioned over him/her while touching himself/herself. The resident reported the individual ejaculated into his/her mouth, causing him/her to cough, and said he/she attempted to push him/her away. The resident said, I am a man/woman, and no one should do a man/woman like that. The resident became upset while discussing the incident and said that he/she did not want to discuss the matter further. Social Services respected the resident's request and did not continue questioning regarding details of the incident.-On [DATE] at 10:26 A.M., an attempt was made to interview Resident #2, but he/she would not answer any questions or provide any information about what happened. Observation showed him/her with arms folded, blank stare, and at times, looking away or down. During an interview on [DATE] at 5:47 A.M., the Hospital Nurse said the responsible party (RP) said a staff member went by Resident #2's room that morning because he/she heard a strange noise. When the staff member went into the room, Resident #1 was pulling his/her pants up. Resident #2 communicated he/she was scared and worried and did not want to be hurt. While in the hospital, they were able to get the resident to answer some questions, however, he/she would become very upset. The resident got upset when the nurse asked if they could take his/her clothes off so they could do a physical exam. The resident said he/she did not want to be hurt anymore. They were not able to continue the exam below the waist as the resident became so upset he/she was verbally yelling. They elected to stop the exam completely. It took 30 - 40 minutes to get his/her shirt off to check his/her chest. The resident has intellectual disabilities and was very worried and scared that someone might come into his/her room. Resident #2 tried to say something about a hand job, but not much information could be obtained. The resident adamantly refused an examination below the waist. During an interview on [DATE] at 12:55 P.M., Resident #2's guardian said they had nothing on file regarding the resident being able to consent to sex. Sex was not an option, and it was not okay. During an interview on [DATE] at 1:53 P.M., Social Service Director (SSD) said Resident #1 was still on 1:1 monitoring. She expected staff to be in the room with him/her. She completed the PASRR, but said Resident #1's behavior had never gotten to this before. The facility didn't have any background details regarding previous history, only what was on the PASRR. Resident #1 had never been on 1:1 before now. He/She was able to cope and could be easily re-directed. Resident #1 liked to give hugs but didn't ask permission, would just do it. She had experienced that herself. She had spoken with Resident #1, had a counseling session, and was trying to get additional support. Staff were supposed to be 1:1 with the resident. SSD said she didn't have anything on file for Resident's #1 or #2 regarding the capacity to consent. If either had been assessed, the information would have been in the electronic medical record. She didn't think Resident #2 had the capacity to consent and if the guardian didn't want him/her to have sex, it should have been documented in his/her medical record. SSD said she was not aware of the guardians' wishes. She expected staff to intervene immediately. She expected all residents to be free from abuse. During an interview on [DATE] at 3:35 P.M., the Administrator said 1:1 monitoring meant to see the resident at all times, face to face. She expected staff to be present and monitoring Resident #1 during the 1:1 timeframe. She expected Resident #2 and all other residents to be free from abuse. 316993131661803166175

Based on observation, interview and record review, the facility failed to provide the necessary behavioral services as recommended by the admission Preadmission Screening and Resident Review (PASRR, a federally required screening process used to check if a person applying to or living in a Medicaid-certified nursing facility has a serious mental illness, intellectual disability, or developmental disability) assessment for one resident and follow the behavior modification plan for Resident #1, who had a documented history of sexual preoccupation and sexually inappropriate behaviors. Resident #1 was observed standing over a sleeping resident with documented developmental disabilities and moderate cognitive impairment (Resident #2) and begged and pleaded for oral sex. Resident #2 attempted to push Resident #1 away, but ultimately submitted to the unwanted sexual advances. Resident #2 was sent to the hospital following the incident and became upset when the hospital staff asked if they could examine him/her saying, I don't want to be hurt anymore and refused to be examined from the waist down. This deficient practice and had the potential to affect other residents in the facility. The census was 120.Review of the facility's Accidents and Supervision policy, revised [DATE], showed:-Purpose:--Each resident will receive adequate supervision.-Definitions:--Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident;--Implementation of Interventions - using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes:---Communicating the interventions with all relevant staff;---Assigning responsibility;---Providing training as needed;----Documenting interventions;---Ensuring that the interventions are put into action;-Resident-directed approaches may include:--Implementing specific interventions as part of the plan of care;--Supervising staff and residents, etc;--Facility records document the implementation of these interventions;-Monitoring and modification processes include:--Ensuring that interventions are implemented correctly and consistently;--Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents;-Adequacy of supervision:--Defined by type and frequency;--Based on the individual resident's assessed needs and identified hazards in the resident environment. Review of the facility's Behavior Health Services policy, revised [DATE], showed:-Assessment/Care Planning: The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Staff will:--Complete PASRR;--Obtain history from medical records, the resident, and as appropriate the resident's family and friends, regarding mental, psychosocial, and emotional health;--Utilize Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff;--Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident;-Responsibility and Enforcement:--The Social Service Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources. 1. Review of the facility investigation document, dated [DATE] at 8:00 A.M., showed:-Resident: Resident #1;-Incident location: Resident's room;-Incident Description:--Nurse Description: Licensed Practical Nurse (LPN) A was told by Certified Medication Technician (CMT) B, on duty on 100 unit, he/she heard a resident choking in his/her room. CMT B went in to see what was going on. Resident #1 was standing over the bedside of Resident #2's bed. Emesis noted on the floor;--Resident Description: Resident #1 stated to this nurse that he/she did ask Resident #2 to perform oral sex on him/her and Resident #2 did it. Resident #1 stated he/she did not touch Resident #2's private area but admitted to touching Resident #2's breast;-Immediate Action Taken:--This nurse interviewed both parties involved. Nurse Supervisor, Director of Nursing (DON) Administrator, Medical Director (MD) made aware. Resident #1's guardian was deceased . Tried to call the emergency contact - no answer;-Level of Consciousness - Alert;-Mobility - Ambulatory without assistance;-Mental Status - Oriented to person, situation, place, and time;-Predisposing factors - None noted;-Statements:--Resident #2 on [DATE]: He/She did perform oral sex on Resident #1 because he/she kept begging him/her to do it;--On [DATE]: CMT B overheard a resident choking. He/She went into Resident #2's room. He/She was lying in bed and Resident #1 was standing over him/her. Resident #1 was pulling his/her pants up. He/She asked them what was going on. Resident #1 walked out without answering him/her. Resident #2 was choking and coughing, vomiting on the floor beside his/her bed. CMT B gave the resident water to clear his/her throat. Resident #2 was unable to talk because he/she continued to have uncontrolled emesis. Resident #2 was assessed to be alert and in a lying position. LPN A and CMT B asked what happened and Resident #2 said that Resident #1 kept begging him/her to perform oral sex. He/She kept forcing himself/herself on him/her, so he/she did it. Resident #2 stated Resident #1 asked him/her to perform oral sex on him/her which he/she did willingly;-Resident-Resident #2;-Incident location - Resident's room;-Incident Description:-Nurse Description - LPN A was asked by CMT B, on duty on 100 unit, to come to a resident's room because he/she suspected something had happened between Resident's #1 and #2. CMT B stated he/she heard Resident #2 choking in his/her room. CMT B went in to see what was going on with him/her. Resident #1 was standing over Resident #2, beside his/her bed. Emesis noted on the floor. Resident #1 was pulling up his/her pants. Resident #2 was lying in bed, fully clothed. CMT B came and got LPN A;-Resident Description - The resident told LPN A Resident #1 asked him/her to perform oral sex on him/her. He/She said no at first but then Resident #1 touched his/her breast. Resident #1 started begging him/her. He/She kept begging and begging trying to coerce him/her into it. Resident #1 came closer to him/her, begging and pleading. He/She tried to push Resident #1 away, but he/she kept begging. So, he/she did it. He/She put Resident #1's private part into his/her mouth and threw up. Emesis was noted on floor. Resident #2 denied Resident #1 touched his/her private area or tried to go in his/her pants;-Immediate Action Taken:-Description: Resident #2 was assessed by LPN A. The vomiting had stopped. He/She remained in a supine position in bed, fully clothed in hospital pants and top. Resident #2 refused to answer simple questions by LPN A but did give a statement to CMT B while the nurse was in the room. Call light in reach. Was encouraged to use call light for assistance or if he/she felt danger, unsafe, or needed to talk to staff;-Level of consciousness - Blank;-Mental status - Oriented to person, situation, place, and time;-Predisposing Physiological Factors - Impaired Memory and recent change in condition;-Statements:--Staff Description: On [DATE], LPN A was told by CMT B, on duty on 100 unit, he/she heard Resident #2 choking in his/her room. CMT B went in to see what was going on. Resident #1 was standing over Resident #2. Emesis was noted on the floor;--Resident Description: Resident #2 told LPN A that Resident #1 did ask him/her to perform oral sex and he/she did it. Resident #2 said he/she did not touch his/her private area. Resident #1 did admit to touching Resident #2's breast;-Employee/Witness Name:-Date: [DATE];-CNA C said when he/she entered the resident was fully dressed, lying on the bed. He/She was coughing and clearing his/her throat. He/She was not crying, yelling, or screaming until CMT B asked what was going on. Resident #2 said nothing about what happened between himself/herself and Resident #1. CMT B asked Resident #1 what was going on and he/she left the room;-CMT B stated while he/she was getting his/her cart ready for the morning medication pass, he/she heard a resident making loud vomiting and choking sounds. When he/she arrived at the room, Resident #1 was standing over Resident #2 with his/her pants down and Resident #2 was vomiting. Resident #1 hurried and pulled his/her pants up and left the room. While Resident #1 was leaving, he/she asked what was going on. Resident #1 kept saying nothing. When Resident #2 was finally able to stop vomiting, he/she went and got the charge nurse. CMT B and LPN A returned to the room and asked Resident #2 what happened. Resident #2 said Resident #1 was touching his/her breast and kept begging for oral sex. He/She said Resident #1 kept begging, so he/she did it. Resident #1 had been placed in the dining room for one-to-one (1:1) monitoring. When Resident #1 was asked what happened again, he/she said he/she was only masturbating. 2. Review of Resident #1's behavior modification plan, dated [DATE] showed:-Supervision to redirect inappropriate or obsessive behavior;-Close observation to support social behavior and redirect preoccupations;-Limitations per PASRR:--Preoccupation with sexual content and labile affect (rapid, extreme, and uncontrollable changes in how a person shows their emotions);-Proactive Strategies:--Establish consistent staff rapport through daily 1:1 check-in;--Limit exposure to overstimulating environments;-Reactive Strategies:--Document all triggers, behaviors, and staff interventions;-Next review date: [DATE];-No current review document in the resident's medical record. Review of the resident's care plan, updated [DATE], in use at the time of the investigation showed:-Problem:-PASSR. Long history of receiving psych treatment for bipolar, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, often making it hard to tell what is real and what is imagined), has disorganized thoughts, delusions, hallucinations, sexually inappropriate acting out, aggression, abusive/assaultive behaviors;-Date initiated: [DATE];-Date revised: [DATE];-Desired outcome:-Will remain safe in skilled nursing facility;-Date initiated: [DATE];-Date revised: [DATE];-Interventions:-Resident will be in lowest restrictive environment while maintaining protective oversight;-No other interventions noted;-Date initiated: [DATE];-No revision date noted-Problem:-Manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. These behaviors include verbal/physical aggression, being intrusive, delusions/hallucinations, sexually inappropriate;-Date initiated: [DATE];-Desired outcome:-Will minimize episodes of inappropriate behavior that can affect others;-Date initiate: [DATE];-Date revised: [DATE];-Interventions:-Administer and monitor medications as ordered;-Administer as needed (PRN) medications as needed/ordered when non-pharmacological interventions are non-effective;-If resident is disturbing others, encourage him/her to go to a more private area to voice concerns/feelings to assist with decreasing episodes of disturbing others;-Notify guardian/physician as needed;-Pharmacy consultant will review medications monthly and PRN;-Psych consultation for medication adjustments as needed/ordered;-Date initiated: [DATE] and [DATE]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:-Cognitively intact;-No mobility devices;-Diagnoses included but not limited to high blood pressure, depression, diabetes. Review of the resident's care plan, in use at the time of the investigation, showed:-On [DATE], the resident was placed on 1:1 supervision temporarily due to allegation of sexually inappropriate activity with a female resident;Date Initiated: [DATE]. Observation on [DATE] at 10:11 A.M., showed the resident in his/her room. No 1:1 staff at Resident #1's door or inside of his/her room. During an interview on [DATE] at 10:11 A.M., Resident #1 said he/she knew Resident #2 and was talking to him/her. Resident #2 jacked him/her up a little. When asked what did jacked him/her up meant, Resident #1 said it was like a hand job. Resident #1 came (ejaculated) a few times. He/She didn't know if Resident #2 wanted to do it. His/Her facial expression showed he/she wasn't in the mood and wasn't ready for it. Resident #1 didn't rush Resident #2 into it. Resident #1 said he/she started to get horny. Resident #2 wasn't hurt and didn't cry. Resident #2 jacked him/her off and Resident #1 sucked on Resident #2's body part. Resident #1 put his/her genital into Resident #2's mouth. He/She ejaculated on Resident #2's face, not in his/her mouth. Resident #1 said he/she walked into Resident #2's room and got aroused. He/She told the nurse he/she jacked off. He/She said it was two times, once in the mouth and the other time was a hand job. He/She told CMT B. During an interview on [DATE] at 1:37 P.M., CNA D said he/she knew Resident #1. Resident #1 made passes at a few women and had been at the facility about six years. He/She wasn't aware of any sexual behaviors that were documented in his/her record. The facility had not told them anything specifically to do when Resident #1 displays/acts of sexual behavior. CNA D said he/she didn't know why Resident #1 was in Resident #2's room because they were on different sides of the unit. He/She had just gotten to work the day of the allegation but didn't witness anything. Resident #1 was given a 1:1 assignment and was still on 1:1 monitoring. During an interview on [DATE] at 1:41 P.M., both LPN F and CMT E said they knew Resident #1. Both said he/she was still 1:1, but the staff probably walked away. Both said there should have been staff monitoring Resident #1. Neither were aware of any sexual behavior or preoccupation with sex. Resident #1 mostly talked about being a virgin. He/She would be re-directed. The talk was nothing intimidating and the behavior was not a threat to anyone. Resident #1 never touched anyone, and no one ever reported to either of them that he/she had touched someone. LPN F said he/she wouldn't have put interventions in place. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed:-Moderately impaired cognition;-Oral hygiene - Set-up/Clean-up assistance;-Personal hygiene- Supervision/touch assistance;-No assistive mobility devices;-High blood pressure, seizure disorder, and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels and behaves). Review of the resident's care plan, initiated [DATE], in use at the time of the investigation showed:-At risk for the following signs and symptoms related to diagnosis of intellectual disability. Difficulty communicating or socializing with others, difficulty with problem-solving or logical thinking, inability to connect actions with consequences, learning and developing more slowly than others, lower than average scores on IQ test (a standardized assessment designed to measure human cognitive abilities, problem-solving skills, and logical thinking), and trouble learning in school;-Date initiated: [DATE];-Date revised: [DATE];-Desired outcome:-Will have decreased signs and symptoms of the diagnosis of anxiety;-Interventions:-Ensure my environment is safe;-Date initiated: [DATE]. Review of the residents' notes showed:-On [DATE] at 7:30 A.M., CMT B was on the hall setting the cart up for morning med pass when this writer heard Resident #2 sounding like he/she was vomiting very loudly. When this writer got into the room there was Resident #1 in the room standing over him/her in his/her bed with pants down. Resident #1 hurried up and pulled his/her pants up and left the room. The resident continued to choke and vomit. When the resident was able to calm down and stop choking this writer asked what happened. The resident stated that Resident #1 came in his/her room and repeatedly begged for fellatio (oral sex), so he/she did it;-On [DATE] at 2:39 P.M., LPN A was asked by CMT B, on duty on 100 unit, to come to resident room because he/she suspected something had happened between Resident's #1 and 2. CMT B stated he/she heard Resident #2 choking in his/her room. CMT B went in to see what was going on with Resident #2. Resident #1 was standing over him/her, beside his/her bed. Emesis noted on the floor. Resident #1 was pulling up his/her pants. Resident #2 lay in bed fully clothed. CMT B came and got LPN A;-On [DATE] at 7:25 P.M., the hospital emergency room called. Report was given to LPN A. The resident was given a full work up for a sexually assaulted victim.-[DATE] at 9 A.M., Social Services met with the resident individually for psychosocial follow-up regarding a reported incident involving another resident. Resident #2 was able to participate in the assessment and provided a brief account of the incident. The resident reported that he/she had been asleep and stated that upon waking, he/she observed Resident #1 positioned over him/her while touching himself/herself. The resident reported that the individual ejaculated into his/her mouth, causing him/her to cough, and said that he/she attempted to push him/her away. The resident said, I am a man/woman, and no one should do a man/woman like that. The resident became upset while discussing the incident and stated that he/she did not wat to discuss the matter further. Social Services respected the resident's request and did not continue questioning regarding details of the incident.-On [DATE] at 10:26 A.M., an attempt was made to interview Resident #2, but he/she would not answer any questions or provide any information about what happened. Observation showed him/her with arms folded, blank stare, and at times, looking away or down. During an interview on [DATE] at 5:47 A.M., the Hospital Nurse said the responsible party (RP) said a staff member went by Resident #2's room that morning because he/she heard a strange noise. When the staff member went into the room, Resident #1 was pulling his/her pants up. Resident #2 communicated he/she was scared and worried and did not want to be hurt. While in the hospital, they were able to get the resident to answer some questions, however, he/she would become very upset. The resident got upset when the nurse asked if they could take his/her clothes off so they could do a physical exam. The resident said he/she did not want to be hurt anymore. They were not able to continue the exam below the waist as the resident became so upset he/she was verbally yelling. They elected to stop the exam completely. It took 30 - 40 minutes to get his/her shirt off to check his/her chest. The resident has intellectual disabilities and was very worried and scared that someone might come into his/her room. Resident #2 tried to say something about a hand job, but not much information could be obtained. The resident adamantly refused an examination below the waist. During an interview on [DATE] at 12:55 P.M., Resident #2's guardian said they had nothing on file regarding the resident being able to consent to sex. Sex was not an option, and it was not okay. 3. During an interview on [DATE] at 1:53 P.M., Social Service Director (SSD) said Resident #1 was still on 1:1 monitoring. She expected staff to be in the room with him/her. She completed the PASRR but said Resident #1's behavior had never gotten to this before. The facility didn't have any background details regarding previous history, only what was on the PASRR. Resident #1 had never been on 1:1 before now. He/She was able to cope and could be easily re-directed. Resident #1 liked to give hugs but didn't ask permission, would just do it. She had experienced that herself. She had spoken with Resident #1, had a counseling session, and was trying to get additional support. Staff were supposed to be 1:1 with the resident and follow the behavior modification plan. She had not gotten around to updating the behavior modification plan. It was supposed to be updated yearly and whenever an event, such as this, occurred. She participated in care planning and could update the care plan. The behavior plan was there to help staff recognize the signs of inappropriate behavior. During an interview on [DATE] at 3:35 P.M., the Administrator said 1:1 monitoring meant staff are expected to always see the resident, face to face. She expected staff to be present and monitoring Resident #1 during the 1:1 timeframe. She expected staff to follow the behavior modification plan and other facility policies. She expected the behavior modification plan to have been updated and staff to follow whatever interventions Resident #1 had in place. 316993131661803166175

Based on interview and record review, the facility failed to report a concern regarding Resident #5 in accordance with the facility's procedure for reporting allegations of abuse. The census was 121.Review of the facility's Abuse and Neglect policy, revised 06/12/24, showed:Procedure for Response and Reporting Allegations of Abuse:-Any owner, operator, employee, manager, agent, or contractor of the facility can report an allegation of abuse to the abuse agency hotline without fear of retaliation;-When suspicion of abuse or reports of abuse occur, the following procedure will be initiated:--Respond to the needs of the resident and protect him/her from further incident;--Notifications, such as under the Elder Justice Act, should be made using a non-emergency number;--Notify the Administrator or designee;--Notify the attending physician, resident's family/legal representative, and Medical Director;--Monitor and document the resident's condition, including response to medical treatment or nursing interventions;--Document actions taken in the medical record;--Complete an incident report if indicated;--Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preference change as a result of an incident of abuse;The Administrator or designee will:-Administrator/Designee will complete an Administrative Investigation to include personal statements from staff and residents involved in a situation that has any type of accusations of abuse either staff or resident abuse;-Refer to the State Operations Manual (SOM) for reporting and utilize the Abuse Neglect Reporting Decision Tree to assess the particular incident. Best practice is to include the SOM and Decision Tree with the investigation. Should the incident be a reportable event, notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. Should the event not be reportable continue and complete the investigation with all supporting information and place file with all investigations;-Follow up with appropriate agencies, during business hours to confirm the report was received;-Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified;-After a conclusion based on the facts of the investigation is determined, internal reports, interviews and witness statements shall be released to those with a need to know. Even if the facility investigation is not complete, the Administrator will cooperate with any Department of Health and Senior Services investigation. The Administrator or designee will keep the resident or guardian/resident representative informed of the progress of the investigation as appropriate. Review of the resident's Discharge Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 06/26/26, showed:-Cognitively intact;-Personal hygiene, upper and lower body dressing - substantial/maximal assistance;-Diagnoses included but not limited to malignant neoplasm of colon (a serious disease where abnormal cells grow uncontrolled in the large intestine's inner lining). Review of the resident's progress note, dated 06/24/26 at 6:24 P.M., showed:-Late Entry;-Note Text: Social Services met with the resident representative regarding concerns previously shared by family members. The family expressed concern about an incident the resident reportedly disclosed to his/her family during a previous visit. The family indicated that the concern bad been discussed with the administration. The representative stated that the resident may have identified an individual involved. However, he/she (family member) had not personally witnessed any concerning behavior during recent visits. The representative expressed hesitation about reporting the concern for fear of potential backlash or negative consequences. The only information given to Social Services was that a male had entered his/her room during the night last week, and he/she did not want to discuss the matter any further. Representative stated that staff members have been caring, attentive, and responsive during his/her visits. However, they would like for the resident to be transferred to another facility. Social Services provided education regarding the facility's obligation to investigate and report allegations or concerns as appropriate. The representative was informed that reporting concerns is intended to ensure resident safety and appropriate follow-up. Social Services spoke with the administrator about what the family reported. The administrator confirmed that there was already communication with the family regarding the situation that occurred last week;-No documentation from the Administrator and/or Designee regarding steps taken after being made aware of the allegation;-No Department of Health and Senior Services (DHSS) notification documentation;-No documented notification of the attending physician, resident's family/legal representative, and Medical Director; -No completion of an incident report, if indicated;-No documentation regarding follow-up with appropriate agencies, during business hours to confirm the report was received;-No documentation within five working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. During an interview on 08/06/26 at 4:34 P.M., the Social Service Director (SSD) said she was familiar with Resident #5. Resident #5's family member was very involved in his/her care. The family member asked for a referral to another facility and didn't go into great detail, just wanted a referral to be sent as soon as possible. The family member told her Resident #5 had an incident over the weekend. Family member said a male came into his/her room and was standing at the foot of the resident's bed. SSD said she asked if the family member had reported it to administration. Family member said it had been reported to administration. SSD said she did what she could to resolve the concern. She spoke with the resident, but he/she didn't want to talk about it. SSD said she respected the request, sent the referral, and told the Administrator. The family and the resident told the Administrator and supposedly the staff working over the weekend. There should have been documentation regarding the incident from staff. They should have documented over the weekend whatever was told to them and any action taken. The family was in constant communication with her and seemed happy. Then all of a sudden, the family wasn't happy for the resident to be there anymore. She didn't expect her documentation to be the only entries about the concern and the allegation to be reported. During an interview on 08/07/26 at 1:32 P.M., the Assistant Director of Nursing (ADON) said whatever was done in response to Resident #5's concerns should have been documented and an investigation completed. During an interview on 8/6/26 at 5:20 P.M., the Administrator said she did not have a completed investigation. The family member told her a male had touched Resident #5 on the leg and then left the room. Another resident was assisting one of the resident's roommates and was the person who supposedly touched Resident #5's leg. The Administrator said the other resident said he/she had been in the room to assist Resident #5's roommate. The resident said he/she didn't try to do anything sexually to Resident #5. The Administrator said she told the resident he/she could not go into that room again. She spoke with the residents involved verbally, so there were no written statements or other documentation related to the investigation. She expected the allegation to have been reported, there to be documentation in the resident's chart, and a completed investigation and/or soft file. The resident had been discharged . 3095715

Based on interview and record review, the facility failed to thoroughly investigate an allegation involving one resident (Resident #5) after the family member reported to facility management and social services that another resident stood over the resident and touched Resident #5's leg. The census was 121. Review of the facility's Abuse and Neglect policy, revised 06/12/24, showed:-When suspicion of abuse or reports of abuse occur, the following procedure will be initiated:-Respond to the needs of the resident and protect him/her from further incident;-Notifications, such as under the Elder Justice Act, should be made using a non-emergency number;-Notify the Administrator or designee;-Notify the attending physician, resident's family/legal representative, and Medical Director;-Monitor and document the resident's condition, including response to medical treatment or nursing interventions;-Document actions taken in the medical record;-Complete an incident report if indicated;-Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preference change as a result of an incident of abuse;The Administrator or designee will:-Administrator/Designee will complete an Administrative Investigation to include personal statements from staff and residents involved in a situation that has any type of accusations of abuse either staff or resident abuse;-Refer to the State Operations Manual (SOM) for reporting and utilize the Abuse Neglect Reporting Decision Tree to assess the particular incident. Best practice is to include the SOM and Decision Tree with the investigation. Should the incident be a reportable event, notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. Should the event not be reportable continue and complete the investigation with all supporting information and place file with all investigations;-Follow up with appropriate agencies, during business hours to confirm the report was received;-Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified;-After a conclusion based on the facts of the investigation is determined, internal reports, interviews and witness statements shall be released to those with a need to know. Even if the facility investigation is not complete, the Administrator will cooperate with any Department of Health and Senior Services investigation. The Administrator or designee will keep the resident or guardian/resident representative informed of the progress of the investigation as appropriate. Review of Resident #5's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 06/26/26, showed:-Cognitively intact;-Personal hygiene, upper and lower body dressing - substantial/maximal assistance;-Diagnoses included but not limited to malignant neoplasm of colon (a serious disease where abnormal cells grow uncontrolled in the large intestine's inner lining). Review of the resident's progress note, dated 06/24/26 at 6:24 P.M., showed:-Late Entry;-Note Text: Social Services met with the resident representative regarding concerns previously shared by family members. The family expressed concern about an incident the resident reportedly disclosed to his/her family during a previous visit. The family indicated that the concern bad been discussed with the administration. The representative stated that the resident may have identified an individual involved. However, he/she (family member) had not personally witnessed any concerning behavior during recent visits. The representative expressed hesitation about reporting the concern for fear of potential backlash or negative consequences. The only information given to Social Services was that a male had entered his/her room during the night last week, and he/she did not want to discuss the matter any further. Representative stated that staff members have been caring, attentive, and responsive during his/her visits. However, they would like for the resident to be transferred to another facility. Social Services provided education regarding the facility's obligation to investigate and report allegations or concerns as appropriate. The representative was informed that reporting concerns is intended to ensure resident safety and appropriate follow-up. Social Services spoke with the administrator about what the family reported. The administrator confirmed that there was already communication with the family regarding the situation that occurred last week;-No documentation from the Administrator and/or Designee regarding steps taken after being made aware of the allegation;-No Department of Health and Senior Services (DHSS) notification documentation;-No documented notification of the attending physician, resident's family/legal representative, and Medical Director; -No completion of an incident report, if indicated;-No documentation regarding follow-up with appropriate agencies, during business hours to confirm the report was received;-No documentation within five working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified;-No documentation of the conclusion based on the facts of the investigation was determined;-No documentation of internal reports, interviews and witness statements;-No documentation of Administrator or designee informing the resident/resident representative of the progress of the investigation. During an interview on 08/06/26 at 4:34 P.M., Social Service Director (SSD) said she was familiar with Resident #5 and the family member was very involved in his/her care. The family member asked for a referral to another facility as soon as possible. The resident's family member said the resident had an incident over the weekend. Family member said another resident came into his/her room and was standing at the foot of his/her bed. SSD asked if the family member had reported it to administration. Family member said it had been reported to administration. SSD said she did what she could to resolve the concern. She spoke with the resident, but he/she didn't want to talk about it. SSD said she respected the request, sent the referral, and told the Administrator. She wasn't sure if there had been an investigation. The family and the resident told the Administrator and supposedly the staff working over the weekend. There should have been documentation regarding the incident from staff. They should have documented over the weekend on whatever was told to them and any action taken. She didn't expect her documentation to be the only entries about the concern. Because the incident was reported, there should have been an investigation. During an interview on 08/07/26 at 1:32 P.M., the Assistant Director of Nursing (ADON) said whatever was done in response to Resident #5's concerns should have been documented and an investigation completed. During an interview on 8/5/26 at 5:20 P.M., the Administrator said family members were at the facility. She was told another resident had touched Resident #5 on the leg and then left the room. The other resident was assisting one of Resident #5's roommates and then supposedly touched Resident #5's leg. The other resident said he/she didn't try to do anything sexually to Resident #5. The Administrator said she told the other resident he/she could not go into that room again. She spoke with the residents involved verbally, so there were no written statements or other documentation related to the investigation. She expected the allegation to have been reported, there to be documentation in the resident's chart, and a completed investigation and/or soft file. The resident had been discharged . 3095715

Based on interview and record review, the facility failed to provide physician ordered therapy evaluation and treatment for one resident (Resident #2) admitted to the facility for therapy services. The census was 121. Review of the facility's admission Process policy, revised 12/01/22, showed:-A Licensed/Registered Nurse will ensure that all admission paperwork, including physician orders, medications, diet orders, laboratory orders, etc. are followed;-The admission Coordinator will ensure that continuity from facility to facility or home to facility occurs and that the admission process is complete;-The admission Coordinator will ensure that all admission paper work is signed by the resident or legal guardian. All appointments are scheduled. All physician orders are noted and followed per policy;-An admission check list will be submitted from the Admissions Coordinator to the Administrator or designee after each admission is completed;-To ensure continuity of care for new admissions and readmissions the Admissions Coordinator may attend discharge meetings at the perspective healthcare facilities;-The Admissions Coordinator will meet with the Administrator or designee and Director of Nursing (DON), one week after new admission or readmission, the meeting will ensure that the resident's needs are being met and any care or treatment issues;-The RN will need to complete a chart audit within 24 hours of admission. Review of the facility's Transcription of Orders/Following Physician's Orders policy, revised 05/18/24, showed:Purpose:-The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders;Procedure:-Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical records in orders section. Review of Resident #2's hospital discharge paperwork, encounter date 01/04/26 and transport date 01/22/26, showed:-Additional Discharge Orders:-Primary disciplines requested: Skilled Nursing and Physical Therapy;-Therapy to evaluate and treat;-Requested start of care date: 24-48 hours;-Physician to follow patient's care (the person listed her will be responsible for signing ongoing orders): Primary Care Physician (PCP);-Certify that based on the findings, the following services are medically necessary skilled: Therapy to evaluate and treat. Review of the resident's Quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 07/06/26, showed:-Cognitively intact;-No assistive devices;-Upper/Lower body dressing - independent; Personal hygiene, shower/bathe, and oral hygiene - Setup or clean-up assistance;-Diagnoses included but not limited to, non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-Jakob diseases), Schizophrenia (a serious chronic mental health disorder that affects how a person thinks, feels, and behaves), Bipolar Disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, activity levels, and concentration), and hypertension (high blood pressure). Review of the resident's physician order sheet, in use at the time of the investigation, showed no documentation related to Physical Therapy to evaluate and treat. Review of the resident's care plan, in use at the time of the investigation, showed no documentation related to Physical Therapy evaluation and treat. Review of the resident's progress notes, showed no documentation related to Physical Therapy to evaluate and treat. During an interview on 08/06/26 at 4:05 P.M., Resident #2 said he/she had not gotten any therapy since he/she had been in the facility. He/She thought he/she would get therapy within the first two weeks but that didn't happen. A pinched nerve in his/her back caused his/her legs to be weak. He/She wanted the therapy to help get his/her legs stronger. He/She fell before because his/her legs gave out. During an interview on 08/06/26 at 4:34 P.M., the Social Service Director said the resident was supposed to be at the facility strictly for therapy. During an interview on 08/07/26 at 11:25 A.M., the Therapy Director said the resident had not gotten any therapy. She wasn't aware of the hospital discharge order recommendation to evaluate and treat for physical therapy. She had spoken with the resident multiple times and the resident said he/she was fine. If she had known about the therapy order to evaluate and treat, she would have evaluated the resident and treated if necessary. She didn't know who was responsible for reviewing hospital discharge paperwork. She had no documentation regarding physical therapy for the resident and said she wasn't aware of the evaluate and treat order. She expected the order to have been followed and the resident to have been evaluated and treated, if necessary. During an interview on 09/07/26 at 1:35 P.M., the Assistant Director of Nursing (ADON) said the charge nurse went through hospital discharge paperwork and reviewed all orders. She went through to make sure the admission checklist was completed, and orders were verified (admission Audit). The charge nurse contacted the other departments about orders that pertained to his/her department, specifically. The charge or admitting nurse should have gotten the evaluate/treat order related to physical therapy for the resident. They should have put the order into the medical record system and contacted therapy. She expected the charge or admitting nurse to have reviewed the orders, notified the doctor, entered the order, and contacted therapy. During an interview on 08/07/26 at 12:31 P.M., the Regional Nurse Consultant (RNC) said the Charge Nurse completing the admission was responsible for reviewing the orders, calling the physician, and verifying the orders. There should have been a daily clinical review where new admissions were reviewed and where the order should have been caught. The order should have been written for PT to evaluate and treat. She expected the admitting nurse to have reviewed the orders and to have gotten the evaluate and treat order. She expected the resident to have received therapy. 3091599

Based on interview and record review, the facility failed to have a licensed nurse in the facility to care for resident's basic needs for approximately five and a half hours, during the overnight shift that began on May 30, 2026. This practice had the potential to affect all residents who required skilled nursing care during the timeframe of 2:00 A.M. through 7:32 A.M. on May 31, 2026. The sample was 10. The census was 126. 1. During an interview on 6/10/26 at 9:30 A.M., the Administrator said she has been on her own for about a month with no Director of Nursing (DON). There is an interim type of nursing staff but she has never worked in long term care. They are hosting a job fair today and hopefully will get some applicants. She said they need a night nurse, that would help. 2. During an interview on 6/10/26 at 12:00 P.M., the Staffing Coordinator said typically there are only two nurses on the overnight shift which are 200 and 300 halls. The 200 nurse covers 100 hall and 200 hall. The 300 hall nurse covers 300 hall and 400 hall. If the 200 or 300 nurse calls in to work then they only have one nurse to cover all four halls. The other two halls have Certified Medication Technician (CMT) and/or Certified Nursing Assistant (CNA). There is also a CMT/CNA on 200, 2 CNAs with no CMT on 300, and one CMT on 400 hall. The staffing coordinator then looked at the nurse assignment sheet to confirm which staff worked the overnight shift on 5/30/26 into 5/31/26. Licensed Practical Nurse (LPN) C called out that day. There was never anyone scheduled for the 200 hall. LPN A, who worked the day shift, stayed over into part of the night shift on 5/30/26, until around 12:00 midnight. After LPN A left, then the assistant director of nursing (ADON) or Administrator, who is an LPN would have come in for the rest of the shift. Review of the assignment sheet for the overnight shift 5/30/26 into 5/31/26, showed: -One nurse, LPN C, scheduled on 300 hall to cover all four halls. -CMT E and CMT D covered 100 hall and 400 hall. During an interview on 6/10/26 at 12:26 P.M., the ADON said she did not come in to work the overnight shift on 5/30/26. During an interview on 6/10/26 at 1:05 P.M., the Administrator said she did not work the entire overnight shift on 5/30/26 after LPN A left. She came to the facility around midnight but she left around 2:00 A.M. She did not stay. There was not a nurse in the building after she left. She is an LPN. 5. During an interview on 6/10/26 at 2:30 P.M., the Human Resources (HR) Manager said she can print out the timecards to show the time LPN A left on 5/31/26 and the time another nurse would have entered the building in the morning. Both the Administrator and ADON are salary, so they do not clock in or out. Review of the timecards showed:-LPN A clocked out at 12:26 A.M. on 5/31/26. -LPN B clocked in at 7:32 A.M. on 5/31/26.-LPN A clocked in at 8:13 A.M. on 5/31/26 for the day shift. 6. During an interview on 6/10/26 at 3:23 P.M., the Administrator said she was available via phone after she left the morning of 5/31/26 and would have come in if needed. She is on-call 24/7 and the staff can call her all the time. 3031769

Based on interview and record review, the facility failed to honor the rights of residents to choose their own physician. The facility discontinued services with Physician A, who provided care to 35 residents, 31 of whom expressed a desire to continue care with Physician A. Five of the 31 residents were sampled and it was found the facility failed to coordinate continued access for care for all 5 (Residents #4, # 5, #6, #2, and #3). The sample was 6. The census was 127.Review of the facility's Resident Rights policy, dated 9/21/25, showed the following:-Purpose: To ensure that resident rights are protected;-Resident Rights Under Social Security Act: Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside facility. Facility must protect and promote rights of each resident, including each of the following rights:--Notice of Rights and Services: Facility must inform resident both orally and in writing in a language that resident understands of his or her rights and all rules and regulations governing resident conduct and responsibility during the stay in facility;--Free Choice:---Resident has the right to:----Choose a personal attending physician;----Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect Resident's well-being; and----Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment. 1. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/17/26, showed the following:-Cognitively intact;-Diagnoses included anxiety and depression. Review of the resident's Social Services (SS) note, dated 3/24/26 at 2:48 P.M., showed SS met with the resident to provide notification that Physician A will no longer maintain privileges at the facility, effective 3/31/26. The resident was educated regarding the requirement that attending physicians must hold active facility privileges in order to provide care within the facility. The resident was also informed of their right to choose an attending physician. The resident verbalized a preference to remain under the care of Physician A, citing satisfaction with care and desire for continuity of care. SS provided education that Physician A will not be able to provide care within the facility. Continued care with this provider would require outside appointments. The facility will assist in coordinating transportation in accordance with availability and facility processes. SS acknowledged the importance of continuity of care and reassured the resident that support will be provided to ensure safe coordination of care moving forward. Review of the resident's medical record, showed Physician B listed as the resident's primary care physician (PCP). During an interview on 4/7/26 at 12:05 P.M., the resident said management came to him/her and asked if he/she wanted to stay with Physician A or change to Physician B. The resident said he/she wanted to stay with Physician A. The Activity Director told the resident he/she had to change physicians because Physician A would no longer be able to practice at this facility and Physician's A office was too far. The resident wanted to go back to Physician A. 2. Review of Resident #5's annual MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Diagnoses included high blood pressure, anxiety disorder, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's SS note, dated 3/24/26 at 2:57 P.M., showed SS met with the resident to provide notification that Physician A will no longer maintain privileges at the facility, effective 3/31/26. The resident was educated regarding the requirement that attending physicians must hold active facility privileges in order to provide care within the facility. The resident was also informed of their right to choose an attending physician. The resident verbalized a preference to remain under the care of Physician A, citing satisfaction with care and desire for continuity of care. SS provided education that Physician A will not be able to provide care within the facility continued care with this provider would require outside appointments. The facility will assist in coordinating transportation in accordance with availability and facility processes SS acknowledged the importance of continuity of care and reassured the resident that support will be provided to ensure safe coordination of care moving forward. Review of the resident's medical record, showed Physician B listed as the resident's PCP. During an attempted interview on 4/7/26 at 11:40 A.M., the resident was unable to answer questions related to his/her physician. During an interview on 4/7/26 at 1:40 P.M., Family Member (FM) D said he/she was not notified about a PCP change for the resident. FM D wanted the resident to keep Physician A. 3. Review of Resident #6's annual MDS, dated [DATE], showed the following:-No cognitive impairment;-Diagnoses included high blood pressure and schizophrenia. Review of the resident's SS note, dated 3/24/26 at 2:52 P.M., showed SS spoke with the resident's guardian to provide notification that Physician A will no longer maintain privileges at the facility, effective 3/31/26. The resident's guardian was educated regarding the requirement that attending physicians must hold active facility privileges in order to provide care within the facility. The resident was also informed of their right to choose an attending physician. The resident's guardian verbalized a preference to remain under the care of Physician A, citing satisfaction with care and desire for continuity of care. SS provided education that Physician A will not be able to provide care within the facility. Continued care with this provider would require outside appointments. The facility will assist in coordinating transportation in accordance with availability and facility processes SS acknowledged the importance of continuity of care and reassured the resident that support will be provided to ensure safe coordination of care moving forward. Review of the resident's medical record, showed Physician B listed as the resident's PCP. During an interview on 4/7/26 at 1:12 P.M., FM E said he/she was the guardian for the resident. About two weeks ago, he/she was given the option to change the resident's PCP. FM E said he/she did not want to change PCP for the resident. He/She wanted the resident to remain under Physician A's care. To his/her knowledge, Physician A was still the resident's PCP. 4. Review of Resident #2's admission MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Diagnoses included stroke and cerebral palsy (a group of permanent, non-progressive neurological disorders). Review of the resident's SS note, dated 3/24/26 at 2:15 P.M., showed SS met with the resident and family to provide notification that Physician A will no longer maintain privileges at the facility, effective 3/31/26. The resident was educated regarding the requirement that attending physicians must hold active facility privileges in order to provide care within the facility. The resident was also informed of their right to choose an attending physician. The resident verbalized a preference to remain under the care of Physician A, citing satisfaction with care and desire for continuity of care. SS provided education that Physician A will not be able to provide care within the facility. Continued care with this provider would require outside appointments. The facility will assist in coordinating transportation in accordance with availability and facility processes. SS acknowledged the importance of continuity of care and reassured the resident that support will be provided to ensure safe coordination of care moving forward. Review of the resident's medical record, showed Physician B listed as the resident's PCP. 5. Review of Resident #3's admission MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Diagnoses included high blood pressure, diabetes, and dementia. Review of the resident's SS note, dated 3/24/26 at 2:13 P.M., showed SS met with the resident and family to provide notification that Physician A will no longer maintain privileges at the facility, effective 3/31/26. The resident was educated regarding the requirement that attending physicians must hold active facility privileges in order to provide care within the facility. The resident was also informed of their right to choose an attending physician. The resident verbalized a preference to remain under the care of Physician A, citing satisfaction with care and desire for continuity of care. SS provided education that Physician A will not be able to provide care within the facility. Continued care with this provider would require outside appointments. The facility will assist in coordinating transportation in accordance with availability and facility processes. SS acknowledged the importance of continuity of care and reassured the resident that support will be provided to ensure safe coordination of care moving forward. Review of the resident's medical record, showed Physician B listed as the resident's PCP. During an interview on 4/7/26 at 1:20 P.M., FM C said he/she was the guardian for Residents #2 and #3. The facility asked him/her if the residents could change to a new PCP. FM C said he/she wanted to keep Physician A as the resident's PCP. He/She was told Physician A would no longer be allowed in the facility. FM C did not have a car to take the residents to appointments outside the facility, so he/she felt he/she did not have a choice and agreed to change the resident's PCP to Physician B. 6. During an interview on 4/7/26 at 9:14 A.M., the Director of Nursing (DON) and Administrator said they received an email from the facility's corporate Chief Nursing Officer (CNO) in early March 2026 stating effective 3/31/26, Physician A would no longer have privileges with their organization. The DON said the email said to notify the residents of the change and see if they want to stay with Physician A. Physician A had 35 residents in the facility, 31 of whom wanted to stay with Physician A. The SS Director spoke with the residents regarding their rights to choose a physician. Physician A's residents were changed to Physician B because of the deadline issued by corporate. Review of an email received from the facility's corporate Regional Director of Operations on 4/7/26 at 2:50 P.M., showed no letter was issued to residents regarding the change from Physician A. The DON was to communicate with the residents, the guardians or responsible parties that Physician A was no longer going to have privileges in the facility and the resident could either choose a new physician who would be able to see them at the facility, or if they wanted to remain with Physician A we would arrange transportation to his/her private office to be seen. During an interview on 4/8/26 at 10:07 A.M., Physician A's Office Manager (POM) said Physician A had not had an examination office for about 15 years. Physician A preferred to see his/her residents onsite in the facility. During an interview on 4/8/26 at 11:53 A.M, the DON said they had not set up transportation for the residents that wanted to stay with Physician A. The DON said to her knowledge, Physician A did not have an office. 2797289

Based on interview and record review, the facility failed to ensure residents' code status with Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) or Do Not Resuscitate (DNR, does not want CPR) were verified upon admission and documentation maintained in the medical record for 13 out of 29 sampled residents (#2, #5, #7, #9, #12, #14, #15, #20, #35, #113, #115, #120, #138). The facility census was 131.Review of the facility's Communication of Code Status policy, revised [DATE], showed:-Purpose: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information;-Policy: The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive;-When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to: Full Code and Do Not Resuscitate;-The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record;-In the absence of an Advance Directive or further direction from the physician, the default direction will be Full Code;-The presence of an Advance Directive or any physician directives related to the absence or presence of an Advance Directive shall be communicated to Social Services;-The Social Services Director shall maintain a list of residents who have an Advance Directive on file;-The resident's code status will be reviewed at least quarterly and documented in the medical record. 1. Review of Resident #2's medical record, reviewed on [DATE], showed:-admitted [DATE];-An order dated [DATE], for full code;-The medical record contained no documentation of the resident's signed advanced directive. 2. Review of Resident #5's medical record, reviewed on [DATE], showed:-admitted on [DATE];-An order dated [DATE], for full code;-The medical record contained no documentation of the resident's signed advanced directive. 3. Review of Resident #7's medical record, reviewed [DATE], showed:-admitted on [DATE];-An order, dated [DATE], for full code;-The medical record contained no documentation of the resident's signed advanced directive. 4. Review of Resident #9's medical record, reviewed on [DATE], showed-admitted on [DATE];-An order, dated [DATE], for full code;-The medical record contained no documentation of the resident's signed advanced directive. 5. Review of Resident #12's medical record, reviewed on [DATE], showed: -admitted on [DATE];-An order, dated [DATE], for full code;-The medical record contained no documentation of the resident's signed advanced directive. 6. Review of Resident #14's medical record showed, reviewed on [DATE], showed:-admitted on [DATE];-An order, dated [DATE], for full code;-The medical record contained no documentation of the resident's signed advanced directive. 7. Review of Resident #15's medical record, reviewed on [DATE], showed:-admitted on [DATE];-An order, dated [DATE], for full code;-The medical record contained no documentation of the resident's signed advanced directive. 8. Review of Resident #20's medical record, reviewed on [DATE], showed: -admitted on [DATE];-An order, dated [DATE], for full code;-The medical record contained no documentation of the resident's signed advanced directive. 9. Review of Resident #35's medical record, reviewed on [DATE], showed:-admitted on [DATE];-An order dated [DATE];-The medical record contained no documentation of the resident's signed advanced directive. 10. Review of Resident #113's medical record, reviewed on [DATE], showed:-admitted on [DATE];-An order for full code;-The medical record contained no documentation of the resident's signed advanced directive. 11. Review of Resident #115's medical record, reviewed on [DATE], showed:-admitted on [DATE];-An order, dated [DATE], for full code;-The medical record contained no documentation of the resident's signed advanced directive. 12. Review of Resident #120's medical record, reviewed on [DATE], showed:-admitted on [DATE];-An order, dated [DATE], for full code;-The medical record contained no documentation of the resident's signed advanced directive. 13. Review of Resident #138's medical record, reviewed on [DATE], showed:-admitted on [DATE];-No orders for code status;-The medical record contained no documentation of the resident's signed advanced directive. 14. During an interview on [DATE] at 2:20 P.M., the Social Worker said the residents' code status should be reviewed and signed annually. The medical record should contain a signed code status form. On [DATE] at 3:19 P.M., the Social Services Director said she was under the impression that there was a code form within the admission contract and scanned in the medical record. The residents signed either full code or DNR. It was not until yesterday that she found out the code status form had to be separated from the admission contract. She could not find the code status forms for the residents. 15. During an interview on [DATE] at 1:00 P.M., the Administrator said she would expect all the residents to have a code status form in the medical record. The form is a part of the admission contract. The code status is expected to be reviewed annually.

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment throughout the facility. The facility failed to ensure noise levels were comfortable when the overhead announcements were too loud and the door to the smoking area slammed, for two residents (Residents #108 and #79). One resident (Resident #4) had soiled briefs on the bathroom floor. One resident had a clogged toilet (Resident #11). In addition, the facility failed to provide clean and well-maintained walls, floors, doors, and windows for the 400 locked unit, 300 hall, 100 hall, 200 hall, lobby, hospitality room, and Southern dining room. The facility census was 131.Review of the facility's Safe and Homelike Environment Policy, last reviewed on 6/5/25, showed:-Purpose: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the residents to use his or her personal belongings to the extent possible;-Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas;-A homelike environment is one that deemphasizes the institutional character of the setting, to the extent possible, and allows the residents to use those personal belongings that support a homelike environment;-Comfortable sound levels means levels that do not interfere with the resident's hearing, levels that enhance privacy when privacy is desired, and levels that encourage interaction when social participation is required. Review of the facility's Housekeeping-Deep Cleaning policy, last reviewed on 6/29/23, showed:-Deep cleaning is to be completed as scheduled. This includes floor cleaning (scrubbing and waxing included), windows to be cleaned and ensure no spider webs, floors at closets and doorways are free from was/dirt build up, etc.;-All areas should be monitored on a daily basis, and all resident living areas and non-living areas should be clean and odor free. Review of the facility's Daily Cleaning Checklist for resident rooms, undated, showed:-Resident room:--Pick up all paper, trach, etc., and dispose into cleaning cart;--Use high duster for dusting high places (vents and ceiling, corners);--Clean window edges and all furniture tops and sides;--Glass cleaner, clean windows, mirrors,-Resident Bathroom: Clean inside and outside and sides and base of toilet;-Mopping Residents' room:--Mop entire room, working your way out of the room, dip mob 2-3 times;--In heavy odor rooms, use odor counter at base of toilet;--As you move to the next room, clean the handrails and bumper base;--Clean front of the door. 1. Observation and interview on 12/15/25 at 11:50 A.M., showed Resident #108 walked out of the smoke room. As the resident was speaking, an overhead announcement began. The resident quit talking until the announcement was over. The resident said he/she could not talk over the loudspeakers. The overhead announcements did not always bother him/her so long as he/she could hear what was going on. Observation and interview on 12/16/25 at 11:09 A.M., showed Resident #79 sat in the hallway outside the smoke room. As the resident was speaking, staff came out of the smoke room. The door closed with a loud bang. The resident scrunched his/her eyes and said the door slamming bothered him/her. The smoke room door opened and closed again with a loud bang. The resident said that was a super slam! Boom! It could wake up the dead! Between 11:10 A.M. and 11:13 A.M., the door slammed shut seven times. During an interview on 12/19/25 at 8:59 A.M., the Administrator said there have been issues with the door slamming and they have had it fixed multiple times. She has received reports from residents that the door was broken, but they were not necessarily complaints. She can hear the door slam shut in her office. She has not received any complaints about the overhead speakers. 2. Observation in Resident #4's room on 12/15/25 at 10:50 A.M., showed one soiled brief on the floor in the corner of the bathroom. On 12/16/25 at 8:12 A.M., 8:39 A.M., 9:59 A.M., and 11:12 A.M., two soiled briefs lay on the floor in the corner of the bathroom. During an interview on 12/17/25 at 12:15 P.M., the resident said staff instructed him/her not to place soiled briefs in the trash cans. Residents are expected to ask for a trash bag from the staff to place the soiled brief in. During an interview on 12/19/25 at 12:50 P.M., Certified Medical Technician (CMT) B said staff give the residents on the 100 hall a trash bag to place their soiled briefs in. Staff will take the bagged soiled briefs from the residents and dispose of them in the locked soiled linen and trash room. If the resident is cognitively impaired, nursing staff should check the resident rooms and bathrooms for soiled briefs. Housekeeping will not pick up any trash that contains soiled briefs, and they will not pick up soiled briefs in the resident bathrooms. During an interview on 12/19/25 at 2:30 P.M., the Director of Housekeeping said normally nursing staff put soiled briefs in the dirty utility closet on the 100 hall. Residents were supposed to tell nursing staff if they needed to throw away a brief. During an interview on 12/19/25 at 1:00 P.M., the Administrator and the DON said staff are expected to check residents' rooms and bathrooms for soiled briefs and dispose of them in a timely manner. 3. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/4/25, showed:-Diagnoses included major depressive disorder, schizoaffective disorder, and epilepsy;-Moderately impaired cognition. Observation and interview on 12/15/25 at 11:28 A.M., showed the resident's toilet filled with toilet paper and feces. The toilet seat dirty with smeared brown matter. The resident said the toilet had been dirty since the day before and he/she had not been able to use it. On 12/16/25 at 8:19 A.M., the resident's toilet filled with toilet paper and feces. The toilet seat dirty with smeared brown matter. A strong feces odor permeated in the bathroom and the resident's room. On 12/16/25 at 11:58 A.M., the resident's toilet filled with toilet paper and feces. The toilet seat dirty with smeared brown matter. A strong feces odor permeated in the bathroom and the resident's room. During an interview on 12/19/25 at 1:00 P.M., the Administrator and DON said they would expect toilets to be clean and in working condition. 4. Observations of the 400 Secured Unit on 12/15/25 at 11:25 A.M., 12/16/25 at 10:31 A.M. and 12/17/25 at 9:20 A.M., showed:-The hallway floors with a buildup of dirt throughout hall. A buildup of dirt at cove bases throughout hall. A blackish buildup on both sides of thresh holds to resident rooms and in corners near the thresholds;-The locked doors to the unit had large areas of paint missing that revealed brownish metal under the windows and streaks and dried drips on the kickplates;-The wood railings on both sides of the doorway to the dining room had multiple areas of chipped paint;-A broken clock hung in the dining room;-Streaks and dried drips on the dining room door kickplate;-A blackish buildup around the threshold of the dining room;-Visible dust and dirt spots on the dining room windows;-Visible streaks and dried drips on the door kickplates of all resident rooms;The wall vent between rooms [ROOM NUMBERS] with a plastic food wrapper inside and visible dust on the slates;-Missing cove base around the perimeter of the toilet area of the shower room;-Baseball sized gouge in the wall above the cove base behind the shower room door;-The cove bases pulled away on both sides of the corner on the left side of the shower stall;-Missing 1 x 1 foot tiles on the right side of the shower stall. Observation on 12/15/25 at 11:42 A.M., of the bathroom for rooms [ROOM NUMBERS], showed the air vent cover was out of the wall, lying on the floor. A light bulb was exposed in the vent. Observation on 12/17/25 at 7:04 A.M., of the bathroom for rooms [ROOM NUMBERS], showed the air vent cover out of the wall and lay on the floor. A light bulb was exposed in the vent. Observation on 12/18/25 at 7:39 A.M., of the bathroom for rooms [ROOM NUMBERS], showed the air vent cover out of the wall lying on the floor. A light bulb was exposed in the vent. During an interview on 12/19/25 at 1:00 P.M., the Administrator said she would expect maintenance staff to ensure vents are in working order. 5. Observations of the 300 hall on 12/15/25 from 4:27 P.M. to 4:34 P.M. and 12/16/25 at 11:18 A.M. and 1:25 P.M., showed:-The plastic railing outside room [ROOM NUMBER] with a 6 inch x 4 inch crack in middle;-The plastic railing near room [ROOM NUMBER] with cracks along the seam at the top of the railing;-Blackish buildup at cove bases outside the clean utility closet and shower room across from room [ROOM NUMBER];-The shower room had a blackish buildup at the threshold and corners of the doorway. The shower room did not have any cove bases around the perimeter of the room. The door had paint scratches and chipped paint. The ceiling had black spotted areas above the orange pipes along the perimeter of the entry way into the shower room;-A strong musty odor in the shower room;-An approximate 6 inch crack and 2 inch gouge on the railing between the fire door and room [ROOM NUMBER];-Two used band aids on floor outside room [ROOM NUMBER];-The railings below the survey book sign across from room [ROOM NUMBER] cracked with exposed metal;-Chipped paint on the baseboards between rooms [ROOM NUMBERS];-Cracked and discolored ceiling around the vent by the utility closet;-The plastic railing across from room [ROOM NUMBER] had an approximate 6 inch by 3 inch crack in the middle and along the edges;-Blackish buildup at the cove bases on both sides, along the length of the hallway;-The floors towards the end of the 300 hall at the 200 hall entrance had black stains by the scale that extended the width of the hallway;-Approximately 4 feet of missing cove base on the left side at the end of the 300 hall across from room [ROOM NUMBER]. 6. Observations of the 100 unit on 12/16/25 from 8:13 A.M. to 8:36 A.M., showed:-Dried drops of varying sizes and colors and numerous black streaks across the dining room floor;-A heavy blackish build up at the cove base near the threshold of the dining room door;-Dust on the ceiling outside the dining room;-The windows in the dining room had a milky film;-Dried brown splatter and drops outside the dining room doorway;-Dark scuffs on the floor tiles throughout the hall;-Dust and black buildup at the cove bases on both sides along the length of the hallway from outside the dining room to the exterior exit door;-A tile with a 4 x 2 inch crack, outside of room [ROOM NUMBER];-At 8:22 A.M., housekeeping staff finished mopping in room [ROOM NUMBER]. The mop bucket had brownish water. Black discoloration and debris remained on the floor. The threshold to the room and the corners near the door had a visible black buildup of gunk;-A basketball sized area of white plaster on the wall outside the nurse's station;-Chipped edges and a strip of paint hung off the railing by room [ROOM NUMBER];-No threshold piece in the doorway of room [ROOM NUMBER];-Visible dust on ceiling near the nurse's station;-Exposed subfloor the size of a metal strip across the width of the floor between the fire doors by room [ROOM NUMBER];-Multiple chipped areas on the door of room [ROOM NUMBER]. 7. Observation of the 200 Hall on 12/16/25 from 1:40 P.M. to 2:00 P.M., and 12/18/25 at 10:03 A.M., showed:-The wall across from room [ROOM NUMBER] had brownish dried drips above and below the railing;-Heavy brown and black buildup of gunk on both sides of the threshold of the women's and men's bathroom;-Cracks in the ceiling paint around the vent outside room [ROOM NUMBER];-The door kickplate for room [ROOM NUMBER] had dried streaks and drips, gouges and chipped paint on the doorframe;-Visible dust and debris buildup on the baseboards on both sides for the length of the hallway, including the nurse's station;-Three gouges on the wall of the nurses' station facing the dining room;-The kickplates on the doors for rooms 200 through 212 including the tub/shower room and women's bathroom had streaks and dried drips;-The threshold for room [ROOM NUMBER] had a heavy buildup of brownish gunk on the metal piece;-The tinted windows in the dining room had multiple horizontal scratches and visible dust and dirt making the surfaces rough to the touch;-The shower room ceiling had cracked paint above the door and visible rust on the lower right corner of an empty metal sharps container on the wall;-Numerous smears and scratches on all three windows of the nurse's station. 8. Observation of the lobby on 12/18/25 at 8:39 A.M., showed:-An approximately 2 feet x 18 inches area of white putty above the vent over the receptionist's desk;-Visible dust and dirt spots on the windows throughout the lobby;-Paint chipped from the ceiling above the entrance to the 100 hall;-A broken outlet on the floor by the aviary with visible capped wires and an accumulation of debris and dust;-A large black smoker with two broken legs on the right side, slanting to the ground on the patio visible from the lobby. 9. Observation of the Hospitality Room on 12/17/25 at 8:33 A.M., showed:-Six residents ate breakfast;-Brownish/rusty stains approximately 3 feet x 6 inches and chipped paint on the ceiling over the sink;-Brown splatter on the ceiling near the snack machine;-Exposed wire in a light fixture outlet above the table where residents ate;-A beach ball sized area of chipped paint above the ceiling where residents ate;-Multiple areas of chipped areas exposing metal, aqua paint, yellow paint, pink paint and green paint on the doorframe. 10. Observation of the Southern Kitchen on 12/17/25 at 8:30 A.M., showed five residents ate breakfast. The floor to ceiling windows had a buildup of dust and dirt and various spots. 11. During an interview on 12/18/25 at 9:30 A.M., Certified Nurse Aide (CNA) B said the resident rooms and halls should be cleaner than they were. Due to short staffing, deep cleaning of resident rooms and the hallways were not being completed. The baseboards and floors needed attention, and a fresh coat of paint would be nice. CNA B had never seen anyone clean the insides or outside of the windows. During an interview on 12/18/25 at 9:54 A.M., CNA A said he/she frequently saw buildup at the cove bases in the hallways and thresholds to resident rooms. The floors did not look clean. 12. During an interview on 12/17/25 at 8:50 A.M., Laundry Aide (LA) C said he/she also works in housekeeping. Employees in the laundry and housekeeping departments had to cover the other department when they were short staffed. LA C said resident rooms should be cleaned every day. This included wiping down the bathroom sink, dressers and tables, and sweeping and mopping the floors. Housekeeping/Laundry staff selected three rooms every week on each hall to deep clean. Deep cleaning required all furniture to be moved out, wipe down the walls, wipe down every surface, mop and sweep. The Floor Technician swept and mopped the hallways and common areas. The floors were stripped, but he/she was not sure how frequently. He/She looked at the entrance to room [ROOM NUMBER] and said the floor looked very dirty and like it had not been cleaned in a while. The baseboards should be cleaned every two days. He/She did not think the baseboards looked clean. Broken handrails and chipped paint will be reported to the Maintenance Director. This is done by either by filling out a form by the time clock or telling the Maintenance Director in person. 13. During an interview on 12/17/25 at 8:59 A.M., Housekeeper D said he/she also worked in laundry. Housekeeping staff moved around and did not always clean the same hall. When he/she cleaned a resident room, he/she wiped down the overbed light, the front of the air conditioner, the call light, walls and baseboards. He/She also swept and mopped the floors and cleaned the resident bathrooms as well. Housekeeper D wiped down the sink and swept and mopped around the toilet and cleaned the toilet. The hallway baseboards should be cleaned three to four times a week. They have been short-staffed, so they must focus on the biggest issues first. The baseboards and floors in the hallway did not look like they had been cleaned. If something was damaged or needed repair, he/she would tell the Maintenance Director. Report forms were by the time clock. 14. During an interview on 12/18/25 at 10:05 A.M. and 2:30 P.M., the Director of Housekeeping and Laundry said they used to have four designated housekeepers and two floor technicians. That was cut back to three housekeepers and one floor technician. There were a few months when there were only two housekeepers, so staff would be pulled from laundry when they were short staffed. They hired another housekeeper yesterday. The floor technician was in an accident and has been out for the last three weeks. The elevator has also been broken which complicates staff ability to do their jobs. They have not been able to do their jobs to his expectations. He has been helping out to cover for laundry and housekeeping as well. They usually do not have issues, but the last seven to eight months have been a challenge. Some things were not getting done. The floor technician was responsible for cleaning the cove bases and thresholds. All housekeeping staff were responsible for wiping down the handrails and dusting the baseboards. The ceilings were not frequently dusted. He was aware the smoker was broken. When staff tried to move it, the legs broke. He thought maintenance was going to fix it. Housekeeping staff were supposed to clean the inside of the windows in resident rooms. He cleaned the windows, on the outside. Staff selected the rooms they would deep clean. There was not a set schedule. Staff were doing their best to provide a clean, comfortable and homelike environment for the residents. 15. During an interview on 12/18/25 at 10:43 A.M., the Administrator said they were in the process of replacing handrails. Residents were hard on the environment. The basketball sized patch was from a resident punching the wall but should have been painted. Residents in wheelchairs bumped into walls and doorframes. If staff saw something that needed to be repaired or replaced, they were supposed to put in a maintenance request or use the walkie/talkie to alert the Maintenance Director. Sometimes the housekeeping staff could only get the basics accomplished when cleaning resident rooms. Some rooms were more challenging than others. The floor technician was responsible for emptying the trash for the whole building and maintaining the floors for the whole building which included stripping, waxing, buffing and shining. The floor technician has been out for three weeks. They were trying to provide a clean and comfortable homelike environment for their residents. 1710443

Based on observation, interview, and record review, the facility failed to ensure comprehensive care plans were updated and accurate to reflect resident needs for 3 of 29 sampled residents (Residents #5, #6, and #100). The census was 131. Review of the facility's Comprehensive Care Plan policy, dated 10/21/24, showed:-Purpose: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment;-Procedure: The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed;-The comprehensive care plan will be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff). All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 1. Review of Resident #5's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease) and dementia;-Moderately impaired cognition. Review of the resident's care plan, in use at the time of the survey, showed the care plan did not address the resident's dementia diagnosis. During an interview on 12/19/25 at 1:20 P.M., the Director of Nursing (DON) said she expects the care plan to include if a resident has dementia. She expects goals and interventions to be placed on the care plan in order for the resident to receive appropriate care relating to their dementia. 2. Review of Resident #6's significant change MDS, dated [DATE], showed:-Diagnoses included diabetes, acute kidney failure, muscle weakness and dementia;-Severe cognitive impairment. Review of the resident's physician's order summary (POS) dated 12/2025, showed an order, dated, 5/6/24 admitting the resident to hospice care. Review of the resident's care plan, in use at the time of the survey, showed the care plan did not address the resident's hospice care. During an interview on 12/19/25 at 1:20 P.M., the DON said she expects the resident's care plan to include hospice care. 3. Review of Resident #100's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Used a wheelchair for mobility;-History of falls;-Diagnoses included uterine cancer, protein calorie malnutrition, Alzheimer's disease, depression, unsteadiness on feet and wandering. Review of the resident's fall risk evaluation, dated 9/29/25 at 4:29 P.M., showed:-History of falls: 1-2 in the past 3 months;-Level of consciousness: intermittent confusion;-Resident is ambulatory and incontinent;-Clinical suggestions: blank Review of the progress notes, showed:-On 10/2/25 at 4:40 P.M., the resident readmitted to the facility following a surgical repair to the femur;-On 10/9/25 at 4:00 A.M., the resident experienced an unwitnessed fall in his/her room and stuck his/her head. First aid provided, the physician notified. The resident was sent to the hospital for evaluation and treatment;-On 10/9/25 at 4:20 A.M., a fall risk evaluation note showed three or more in the last three months. Mental status: disoriented at all times. Balance problem when walking and standing;-On 10/12/25 at 5:10 P.M., the resident re-admitted to the facility. Resident diagnosed with a urinary tract infection (UTI) and administered a treatment. The resident was moved closer to the nurse's station for closer observation;-On 10/15/25 at 7:20 A.M., the resident noted to be on the floor of his/her room after an unwitnessed fall. Assessment completed no injuries noted. Various stages of bruising noted from previous falls. Physician notified orders given to send to emergency room for evaluation and treatment;-On 10/15/25 at 9:17 P.M., a nurse note: the resident re-admitted to the facility and bed alarm and floor mat in place for safety. Review of the resident's care plan, updated on 10/15/25, showed:-Problem: Had an unwitnessed fall and sustained a left hip fracture;-Outcome: Provide oversight and remain free from severe injury;-Interventions: Assessed for injury and pain to the left leg. Sent to the hospital for evaluation and treatment;-The care plan did not address the prior falls or the interventions put in place. During an interview on 12/18/25 at 11:32 A.M., the DON said the resident had multiple falls while at the facility. He/She often attempted to self-transfer out of bed or the wheelchair. Part of the facility interventions included frequent monitoring and bed and chair alarms. The care plan should have reflected the resident's falls and interventions put in place.

Based on observation, interview and record review, the facility failed to ensure physician orders were followed by failing to obtain yearly electrocardiograms (EKG, a test that records the heart's electrical signals to check the rate, rhythm, and overall function) as ordered for eight residents (Residents #4, #13, #14, #16, #35, #75, #83 and #115). In addition, the facility did not ensure recommendations were followed for a palliative care referral for one resident (Resident #120). The sample was 29. The census was 131. Review of the Following Physician's Orders policy, revised 5/18/24, showed:-Purpose: To ensure that all physician's orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician orders;-Procedure:--Upon receiving a physician order, it will be documented in the electronic medical record (EMR) in the orders section;--After diagnostic testing and other services are ordered, the nurse will document orders in the medical record and fill out the corresponding requisition for the specific services to be obtained. 1. Review of Resident #4's medical record showed:-Diagnoses include major depressive disorder (a mental disorder that causes persistent sadness and loss of interest in activities) and schizoaffective disorder (a mental disorder that causes disorganized thinking, mood swings and hallucinations);-A physician order, dated 5/28/24, for EKG yearly for long-term psychiatric medication use;-No documentation of EKG completed. 2. Review of Resident #13's medical record, showed:-Diagnoses include bipolar disorder (mood disorder that can cause intense mood swings), major depressive disorder, diabetes, and schizoaffective disorder;-A physician order, dated 2/10/22, for EKG yearly, starting on the 22nd of the month;-No documentation of EKG completed in 2025. 3. Review of Resident #14's medical record showed:-Diagnoses include cognitive communication deficit, schizophrenia (a mental disorder that distorts reality) and schizoaffective disorder;-A physician order, dated, 6/4/24, for EKG yearly for long-term psychiatric medication use;-No documentation of EKG completed. 4. Review of Resident #16's medical record, showed:-Diagnoses include lung disease, diabetes, stroke, adjustment disorder with mixed anxiety and depressed mood;-A physician order, dated 4/28/21, for yearly EKG, every day shift, every 12 months;-No documentation of EKG completed in 2025. 6. Review of Resident #35's medical record, showed:-Diagnoses include schizophrenia, diabetes, and anxiety;-A physician order, dated 9/3/21, for yearly EKG, starting on the 16th of the month; -No documentation of EKG completed in 2025. 7. Review of Resident #75's medical record, showed:-Diagnoses include lung disease, paralysis, chronic kidney disease, high blood pressure, and stroke;-A physician order, dated 1/5/24, for yearly EKG, every day shift, every 12 months;-No documentation of EKG completed in 2025. 8. Review of Resident #83's medical record, showed:-Diagnoses include diabetes, schizoaffective disorder, and multiple sclerosis (MS, autoimmune disease of the central nervous system);-A physician order, dated 4/28/21, for yearly EKG, starting on the 15th of the month;-No documentation of EKG completed in 2025. 9. Review of #115's medical record, showed:-Diagnoses include schizophrenia, dementia, high blood pressure, irregular movements, and diabetes;-A physician order, dated 4/29/24, for yearly EKG, once every 12 months;-No documentation of EKG completed. 10. Review of Resident #120's medical record, showed:-Diagnoses include anemia, heart failure, hypertension (high blood pressure), peripheral vascular disease (PVD, circulatory problem causing numbness/weakness), kidney failure, diabetes, hyperkalemia (too much potassium in the blood), hyperlipidemia (high cholesterol), aphasia (language disorder), cerebrovascular accident (CVA, stroke), hemiplegia (paralysis on one side of the body), seizure disorder, malnutrition, and depression. Review of the resident's hospital record for hospitalization 11/19/25 through 12/2/25, showed:-Intensive Care Unit course: admitted [DATE] for hyperosmolar hyperglycemic state (HHS, extremely high blood sugar), diabetic ketoacidosis (DKA, lack of insulin), septic shock, respiratory failure due to right upper lung (RUL) pneumonia, and severe hypernatremia (high sodium levels). In context of poor prognosis, appear to have transitioned to Do Not Resuscitate (DNR)/Do Not Intubate (DNI) on 11/22/25, pending continued discussion of hospice;-Floor course: Goals of Care (GOC) conversation with palliative care with family. DNR/DNI and will follow up with palliative care. No hospice at this time;-Discharge details: --Active issue requiring follow up: Palliative care, outpatient referral. Review of the resident's progress notes, dated 12/2/25 through 12/16/25, showed no documentation of a referral for palliative care. Review of the resident's physician order sheet (POS) for December 2025, showed no physician's order for palliative care evaluation/referral. 11. During an interview on 12/19/25 at 1:06 P.M., the Director of Nursing (DON) said there was an issue with the previous EKG company not receiving reimbursement. The facility then decided in April 2025 on purchasing an EKG machine and the facility Medical Director and their associate would complete the EKGs at the resident's bedside. The facility has not purchased an EKG machine, and the Medical Director has not provided any EKGs at the facility. The DON expects the yearly EKGs to be competed as ordered. All physician orders should be followed for hospice, palliative services or outside referrals.

Based on observation, interview and record review, the facility failed to follow the restorative nursing program (RNP) policy and ensure residents who had limited mobility received restorative nursing services to promote and maintain the residents' highest practical wellbeing (Residents #3, #16, #75 and #83). In addition, the facility did not have a functional restorative nursing program to ensure recommended restorative nursing exercises were provided on a continual basis. The facility did not have a system in place to ensure residents received assessments and referrals for restorative therapy. The sample was 47. The census was 131. Review of the restorative nursing program policy, reviewed 4/30/24, showed:-Purpose: To provide maintenance and restorative services designated to maintain or improve a resident's abilities to the highest practicable level;-Definition: The restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safety as possible. This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning;-Policy: -Cognitive and physical functioning of all residents will be assessed in accordance with the facility's assessment protocols; -The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's comprehensive assessment, goals and preferences; -Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to: -Maintaining proper positioning and body alignment; -Encouraging and assisting resident, as needed in turning and position changes; -Encouraging residents to remain active and assisting with any exercises according to the plan of care; -Promote independence in activities of daily living (ADL, the level of assistance needed to complete daily tasks), performing tasks for residents only as needed (PRN) to ensure completion of tasks; -Assisting residents in adjustment to their disabilities and use of any assistive devices; -Assisting residents with range of motion (ROM) exercises, performing passive range of motion (PROM) for residents who lack active range of motion (AROM); -Promoting continence with various toileting and/or bowel and bladder training activities; -All residents will receive maintenance nursing services as described, PRN by certified nurse aides (CNAs); -The restorative nurse and restorative aides receive additional training on restorative nursing program activities upon hire and PRN; -Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services, these services include PROM or AROM, splint or brace assistance, bed mobility training and skill practices, training and skill practice in transfers, walking, dressing and/or grooming, eating and/or swallowing, amputation/prosthesis care and communication training and skill practice; -Residents may receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer term stay, in conjunction with specialized rehabilitation therapy, or upon discharge from therapy; -Potential candidates for restorative nursing services may be identified through one or more of the following processes such as physical assessment, minimum data set (MDS, a federally mandated assessment instrument completed by facility staff) assessments, specialized rehabilitation assessment, and in-house referral due to unusual occurrence/events; -The restorative nurse is responsible for maintaining a current list of residents who require restorative nursing services, and for ensuring that all elements of each resident's program are implemented; -A resident's restorative nursing plan will include: -The problem, need, or strength the restorative tasks are to address; -The type of activity to be performed, the frequency and duration of activities; -Measurable goal and target date; -The discharging therapist, restorative nurse or designated licensed nurse will communicate to the appropriate restorative aide, the provisions of the restorative nursing plan, providing any necessary training to carry out the plan; -Restorative aides will implement the plan for a designated length of time, performing the activities, and document in the electronic health record; -The restorative nurse, or designated licensed nurse will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly; -When restorative nursing services are no longer warranted, or the resident is appropriate for being transferred to nursing assistants, the restorative aide, restorative nurse, and/or designated licensed nurse will train the appropriate nursing assistants on the maintenance care or activities that need to be provided on an ongoing basis;-Documentation: The facility maintains complete, accurate, and organized documentation of restorative treatments and the response to those treatments; -The need for restorative nursing services will be documented in the medical record, and indicated on the resident's plan of care. Documentation shall include the problem, need, or strength that is being addressed, measurable goal with a target date, the specific interventions/treatments to be provided, the frequency and durations of interventions/treatments; -Treatment provided as part of a restorative nursing program will be documented on a daily basis by the restorative aide, or other trained individual providing the treatment; -The treatment as described in the resident's care plan will be written on the designated restorative flowsheet; -The specific treatment provided will be initiated daily, or as specified by the care plan; -The number of minutes the treatment was performed will be recorded; -If the treatment is refused or withheld, a narrative note will be written explaining why; -If any unusual incident occurs during a treatment (fall, pain, swelling, skin breakdown), document in the narrative note and report to the resident's change nurse; -A weekly progress note will be written by the restorative aide and countersigned by a licensed nurse. The progress note shall include, but not limited to treatment provided, specific distance or repetitions, assistive devices, endurance and tolerance level and the amount of assistance needed and why; -The restorative nurse will document an evaluation monthly. The evaluation will include the problem, need, strength that is addressed, the resident's progress towards goals, tolerance or response to the treatment, any complication or risks associated with the restorative interventions, and a determination regarding the need for continued restorative services or rationale for discontinuing restorative services; -The resident's plan of care will be updated at routine intervals and as indicated. 1. Review Resident #3's physician order sheet (POS), showed an order, dated 8/11/25: admit to skilled therapy services. Review of the nursing restorative care program, November 2025, showed:-Frequency of restorative therapy (RT): Three times a week;-Plan of care: Blank;-Goal: Maintain bilateral lower extremity (BLE) ROM;-Approaches: BLE PROM and gentle stretching, all planes for 10 repetitions;-Update to plan of care: Blank. Review of the medical record, showed:-re-admitted [DATE];-Moderate cognitive impairment;-Used a wheelchair for locomotion;-Needs full staff assistance for oral hygiene, toileting, bathing, dressing, applying footwear and personal hygiene;-Did not receive restorative services or skilled therapy in November or December 2025;-Diagnoses included gastronomy tube (GT, hollow tube inserted into the stomach used when swallowing is not possible), protein calorie malnutrition, respiratory failure, abnormal posture, right and left knee contractures (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement), muscle wasting, abnormal posture, and altered mental status. Review of the care plan, revised 10/15/25, showed:-Problem: Unwitnessed fall from bed, no injury;-Desired outcome: Staff provide oversight and free from injury;-Interventions: Resident assessed AROM/PROM, staff educated for repositioning devices and bolster placed on the bed;-Problem: Limited physical mobility, unable to walk and uses a wheelchair for locomotion. Staff provide locomotion and full care; -Desired outcome: Remain free of complications related to immobility; -Interventions: Staff monitor, document and report any signs or symptoms of immobility worsening. Staff provide supportive care and assistance with mobility, referrals to physical and occupational therapy PRN;-The care plan did not address supportive devices or RT services. Review of the restorative nursing screen, dated 12/2/25, showed:-Reason for evaluation: Admission;-Self-care: Code the resident's need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness: dependent, a helper completed all the activities for the resident;-Indoor mobility: Need for assistance with walking from room to room: Dependent, helper completed all the activities for the resident;-Stairs: Need for assistance with internal/external stairs: Dependent;-Functional cognition: Assistance with planning regular tasks, shopping or medications: Dependent;-Device used: Manual wheelchair;-Currently prescribed to wear a splint/brace: No;-Able to effectively communicate: Yes;-Current situation: Currently receiving formalized rehabilitation therapy and expected to continue;-Eating: Not attempted due to medical condition;-Hygiene: Dependent with oral, toileting, bathing, dressing upper and lower body, transfers and personal hygiene;-Upper and lower extremity ROM: No impairments;-Walking not attempted due to medical condition or safety concerns;-Care planning: No interventions were selected. Review of the physical and occupational therapy evaluation, dated 12/3/25, showed:-Physical therapy assessment summary: -Communication: Sometimes understood, sometimes able to understand others; -Cognition: Moderate impairment; -Reason for therapy: Evaluation only, not applicable (N/A) for skilled therapy at this time; -Complexities: Limited daily assistance available, multiple medical conditions and medications; -Intervention modes: Can interventions be provided using treatment modes other than individual: No;-Occupational therapy summary: -Reason: Chart reviewed and evaluation completed. Patient not appropriate for skilled therapy. He/She is dependent for all ADLs and unable to follow simple commands. He/She can be resistive to PROM at times for severe contractures all extremities. He/She had poor rehabilitation potential and hospitalized frequently due to unstable medical conditions. 2. Review of Resident #16's medical record, showed: -Severe cognitive impairment;-Physical impairment upper and lower extremities one side;-Used a wheelchair for locomotion;-Staff provide assistance for eating, personal hygiene, transfers, dressing;-Diagnoses included lung disease, diabetes, aphasia (difficulty speaking), stroke, right sided paralysis, arthritis, lower back pain and protein malnutrition. Review of the POS, showed no orders for skilled or restorative therapy. Review of the physical therapy discharge summaries, dated 7/7/25, showed:-Discharge reason: Maximal potential achieved, referred for RNP;-Restorative programs: RNP established/trained, restorative ambulation program;-Ambulation program: Ambulated using hallway rail 15 feet, minimal cues. Review of the care plan, in use during the survey, showed:-Problem: Required assistance from staff with grooming, personal hygiene due to stroke and right sided weakness;-Desired outcome: Increase the level of independence with grooming and hygiene;-Interventions: Staff allow rest breaks between tasks, break tasks into smaller tasks, place supplies on bedside, praise when a grooming hygiene task, provide protective oversight and assist when needed;-The care plan did not address the RNP exercises. Observation and interview on 12/16/25, showed:-At 7:20 A.M., the resident in the hallway in his/her wheelchair. His/Her right arm was in a sling. The resident said he/she wore the sling daily;-At 12:22 P.M., the resident said he/she wore the sling due to a stroke, he/she cannot use his/her right arm well. He/She had not received therapy for several months and would like to have exercises to keep his/her muscles loose. Staff do not provide additional stretching, exercises or walking. Review of the medical record, showed no restorative nursing assessment, no orders for the sling and no restorative nursing orders. 3. Review of Resident #75's medical records, showed:-Cognitively intact;-Used a wheelchair for locomotion;-Staff assistance needed for dressing, hygiene, transfers and mobility;-Diagnoses included lung disease, stroke, paralysis or the right side, depression, kidney disease, high blood pressure, and vitamin deficiencies. Review of the care plan, in use during the survey, showed:-Problem: Requires assistance with daily care related to stroke affected the right side;-Desired outcome: Needs will be met;-Interventions: Allow time to complete tasks, monitor for decline in functions, provide assistance and cues, therapy to screen quarterly and PRN. Review of the POS in use at the time of the survey, showed no orders for skilled therapy or the RNP. Review of the medical record, showed no RNP assessments, or therapy interventions on the care plan. Observation and interview on 12/16/25 at 1:26 P.M, showed the resident up in the wheelchair. His/Her right arm appeared weak, and no splints were in place. The resident said he/she experienced a stroke years ago, and his/her right arm and right leg had been affected. He/She said he/she had received therapy previously. He/she received therapy several months ago, then therapy stopped due to insurance coverage. He/She had not received skilled therapy or restorative therapy. He/She would like to participate in the RNP to maintain strength. 4. Review of Resident #83's quarterly MDS, dated [DATE], showed:-Diagnoses included diabetes, schizoaffective disorder (mental health condition that includes features of both schizophrenia and a mood disorder, and Multiple Sclerosis (MS, autoimmune disease of the central nervous system);-Moderately impaired cognition. Review of the resident's care plan, in use at the time of the survey, showed:-Problem: Resident has limited physical mobility. Resident needs assistance with ADLs and transfers. Resident is unable to walk;-Goal: Resident will remain free of complications related to immobility through the next review date;-Interventions: Therapy as ordered and as needed. Review of the POS in use at the time of the survey, showed no orders for restorative therapy. Review on 12/18/25 at 8:40 A.M., of the resident's electronic medical record (EMR), showed:-No skilled or restorative therapy received. -No RT assessments noted in the record. 5. During an interview on 12/18/25 at 8:51 A.M., the Interim Regional Director of Rehabilitation Services said she had been overseeing the rehabilitation services at the facility since the beginning of 12/2025. Residents should receive a therapy assessment when re-admitted from the hospital, if a fall occurred or if the resident or staff express a change in status. The nursing department should send a referral email to the therapy department. The facility should have an RT program. When a resident is discharged from therapy, the therapy department should complete an RNP recommendation form and provide the form to the Director of Nursing (DON). She is not aware if the facility had a functional RNP in place. The facility had recently undergone management changes. Any resident who has a contracture, weakness from stroke or illness should be assessed for therapy for the RNP, there are likely many residents that need RNP. She has not had any discussions with management about the RNP. 6. During an interview on 12/18/25 at 11:02 A.M., the DON said the facility should have a RNP in place. The RNP has not been functional for several months due to budget cuts and staffing shortages. The facility had two restorative aides and now have one. That aide is also used for transportation outings with residents and is often pulled to the floor for staffing shortages. The DON said a RNP is important to help residents maintain current function or improve mobility. There is no system in place to ensure restorative therapy is provided to residents who need it. Normally, the RNP aide would document in the RNP binder for the residents who receive restorative nursing. The binder is not up to date and the Restorative Nursing Aide had been working in other areas. The DON planned to work with the Director of Therapy to discuss how to get the program functional. All residents should be assessed to receive RNP and the assessment should be in the medical record and in the care plan.

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account and by not reconciling each month. The facility also failed to ensure resident accounts did not have negative balances for three residents (Residents #88, #80 and #55). The facility managed funds for 105 residents. The facility census was 131.1. Review of the facility maintained attempted reconciliation forms for the period of 12/1/24 through 11/30/25, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation:-December 2024: -Ending balance per bank statement: $190,580.09; -Current balance per trust report: $167,812.94; -January 2025: -Ending balance per bank statement: $184,920.61; - Current balance per trust report: $114,518.60; -February 2025: -Ending balance per bank statement: $119,205.92; -Current balance per trust report: $97,453.71; -March 2025: -Ending balance per bank statement: $126,266.97; -Current balance per trust report: $108,864.75;-April 2025: -Ending balance per bank statement: $143,411.86; -Current balance per trust report: $128,859.85;-May 2025: -Ending balance per bank statement: $145,713.62; -Current balance per trust report: $131,083.97;-June 2025: -Ending balance per bank statement: $143,864.05; -Current balance per trust report: $133,879.96; -July 2025: -Ending balance per bank statement: $140,728.59; -Current balance per trust report: $127,210.36; -August 2025: -Ending balance per bank statement: $135,527.17; -Current balance per trust report: $127,771.77; -September 2025: -Ending balance per bank statement: $124,880.87; -Current balance per trust report: $128,398.49; -October 2025: -Ending balance per bank statement: $163,303.77; -Current balance per trust report: $165,744.39; -November 2025: -Ending balance per bank statement: $185,685.05; -Current balance per trust report: $168,871.93. During an interview on 12/19/25 at 11:40 A.M., the Business Office Manager (BOM) said the corporate BOM audited the resident trust fund reconciliations. There were outstanding checks and reimbursements owed by the corporation which had not been paid. She was not able to resolve those issues. This would need to be addressed with corporate BOM. During an interview on 12/19/25 at 2:29 P.M., the Administrator said the bank statements should reconcile with the resident trust fund balance. She was not aware there were reimbursements owed by the corporation. During an interview on 12/19/25 at 3:02 P. M., the corporate BOM said she was aware of the outstanding checks and owed reimbursements. She had made numerous requests for the reimbursements, but the Accounts Payable department was slow and had not provided the reimbursement money. 2. Review of Resident #88's most recent quarterly resident trust statement from 6/30/25 to 9/30/25, showed:-An opening balance of $50.07;-On 8/13/25 a balance of -$17.92;-On 9/26/25 a balance of -$111.92;-A closing balance of -$111.91. Review of the resident's 10/1/25 through 12/19/25 trust transaction history, showed:-An opening balance of -$111.91;-On 10/3/25 a balance of -$156.91;-On 10/10/25 a balance of -$145.91;-On 10/31/25 a balance of -$145.91. During an interview on 12/19/25 at 11:40 A.M., the BOM said the resident's account had negative balances because the resident's Medicaid check was less than the amount the resident was charged for room and board at the facility. 3. Review of Resident #80's most recent quarterly resident trust statement from 6/30/25 to 9/30/25, showed:-An opening balance of $$27.00;-On 7/15/25 a balance of -$700.00. During an interview on 12/19/25 at 11:40 A.M., the BOM said the resident had a negative balance because his/her Medicaid check was less than the amount the resident was charged for room and board. 4. Review of Resident #55's most recent quarterly resident trust statement from 6/30/25 to 9/30/25, showed:-An opening balance of $1,961.89;-On 8/7/2 a balance of $246.91;-On 8/12/25 a balance of -$35.09;-On 8/135 a balance of -$45.09;-On 8/19/25 a balance of -$0.09. During an interview on 12/19/25 at 11:40 A.M., the BOM said she didn't know why the resident's account had negative balances. The Activity Director (AD) oversaw petty cash, but didn't have access to the residents' account balances. She gave the AD a ledger with a $50.00 balance for each resident at the beginning of the month. The resident may have withdrawn money he/she did not actually have in his/her account. During an interview on 12/19/25 at 1:06 P.M. the AD said he was responsible for handing out petty cash to residents. He keeps a receipt book and logs the transactions on the ledger provided by the BOM. He did not know how much money residents had in their trust accounts. 6. During an interview on 12/19/25 at 2:29 P.M., the Administrator said resident trust accounts should never have negative balances. There should be a daily accounting of the balance for each resident's account. The BOM was responsible for the management of the residents' trust accounts.

Based on interview and record review, facility staff failed to complete an annual Minimum Data Set (MDS, a federally mandated comprehensive assessment instrument completed by facility staff) assessment for one resident (Resident #20) timely as required. The sample was 29. The facility census was 131.Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The annual assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987) comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA (Significant Change in Status Assessment) or an SCPA (Significant Correction to Previous Assessment) has been completed since staff completed the most recent comprehensive assessment; -The annual assessment ARD is the ARD of previous OBRA comprehensive assessment plus 366 calendar days, and ARD of previous OBRA Quarterly assessment plus 92 days. 1. Review of Resident #20's face sheet, showed he/she was admitted on [DATE]. Review of the resident's medical record, showed: -A quarterly MDS dated [DATE];-A quarterly MDS dated [DATE];-A quarterly MDS dated [DATE];-A quarterly MDS dated [DATE];-A quarterly MDS dated [DATE]; -No comprehensive assessment completed after August 2025. During an interview on 12/19/25 at 1:00 P.M., the administrator said she would expect MDS to be completed timely and to be accurate. She would staff to accurately complete the correct type of MDS.

Based on interview and record review, facility staff failed to assess residents using the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, no less frequently than once every 92 days as directed by the Resident Assessment Instrument (RAI) manual for one resident (Residents #120) out of 29. The facility census was 131. Review of the Resident Assessment Manual (RAI), dated 10/1/17, showed the Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The Assessment Reference Date (ARD) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. Review of Resident #120's medical record, showed:-A quarterly MDS dated [DATE];-A significant change MDS dated [DATE];-A late quarterly MDS, due August 2025, showed an ARD date of 9/22/25. During an interview on 12/19/25 at 1:00 P.M., the administrator said she would expect MDS to be completed timely and to be accurate. She would expect staff to accurately complete the correct type of MDS.

Based on interview and record review, the facility failed to assure the resident's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) accurately reflected the resident's status of having a life expectancy of less than 6 moths when they received hospice services (a service provided when a resident has a condition indicating a life expectancy of less than 6 months as certified by the hospice physician) for one of one hospice resident investigated for hospice services (Resident #6). The census was 131. Review of the facility's MDS policy, dated 11/6/23, showed Section J (Health Conditions) is to be completed by Nursing Staff. This section addresses any condition that impacts the resident's quality of life and functional status. Used to identify the number of health conditions that impact the resident's functional status and quality of life. Other areas in this section to assess are, dyspnea (difficulty breathing, tobacco use, prognosis, problem conditions and falls. Review of Resident #6's initial certification of terminal illness, dated 5/1/24, showed:-Written certification: based on my clinical judgement, I certify that this patient is terminally ill with a life expectancy of 6 months or less if the terminal disease runs its normal course;-The document was signed by the physician on 5/3/25. Review of the resident's significant change MDS, dated [DATE], showed:-Diagnoses included type two diabetes, acute kidney failure, muscle weakness and dementia;-Severe cognitive impairment;-Section J, does the resident have a life expectancy of 6 months or less: No. During an interview on 12/19/25 at 1:19 P.M., the Director of Nursing (DON) said she would expect the MDS to be accurate and reflect if the resident has a life expectancy of 6 months or less.

Based on interview and record review, the facility failed to ensure residents with a mental health disorder and/or individuals with intellectual disabilities had a DA-124 Level One Screen (used to evaluate for the presence of psychiatric conditions to determine if a Preadmission Screening/Annual Resident Review (PASARR) Level Two Screen was required), as required for one of three residents sampled (Resident #113) for PASARR. The sample was 29. The census was 131.Review of Resident #113's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/28/25, showed:-Entry date: 6/24/14;-readmitted : 2/4/14;-Diagnoses included depression, psychotic disorder and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's face sheet, showed diagnosis of other specified mental disorders due to known physiological condition. An on-set date, 5/8/24, showed diagnoses of major depressive disorder and disorganized schizophrenia. Review of the resident's medical records, showed:-No DA-124 Level one screen;-No PASARR Level two screen. During an interview on 12/18/25 at 3:19 P.M., the Social Services Director said resident PASARR assessments are uploaded in the medical record. On 12/19/25 at 10:50 A.M., the Social Services Director said the resident was admitted during a period when they did not need a PASARR. She did not know what the plan was for residents that were admitted prior to the PASARR, but they were grandfathered in. She was not aware of a new psych diagnosis since admission. Review of an email, dated 12/19/25, showed:-At 10:55 A.M., Department of Health and Senior Services (DHSS) asked Central Office Medical Review Unit (COMRU, the organization responsible for completion of level 2 PASARR assessments) to provide a PASARR for the resident;-At 11:10 A.M., COMRU replied, I am sorry, but I cannot provide a copy. The last one completed was in 11-1997. The Skilled Nursing Facility (SNF) will need to complete a new online application and indicated reason for submitting Replacement Form. During an interview on 12/19/25 at 1:00 P.M., the Administrator said COMRU said the residents that were at the facility prior to PASARR documents would be grandfathered in. She would expect the DA-124 to be completed upon admission or before.

Based on observation, interview, and record review, the facility failed to ensure dependent residents received activities of daily living (ADL) care for four sampled residents (Residents #27, #120, #5, and #6). The sample was 29. The census was 131.Review of the facility's Nail Care policy, revised 6/26/24, showed:-Purpose: The purpose of this procedure is to provide guidelines for the provision of care to resident's nails for good grooming and health;-Policy: Assessment of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences. Report unusual or abnormal conditions of the nails to the physician and the responsible party (curling, color changed, separation form the nail bed, redness, bleeding, pain, odor, infection). Identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease (PVD, a lack of blood flow in the legs caused by narrowing of the blood vessels), heart failure, kidney disease, or stroke. Routine cleaning and inspection of the nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. The resident's care plan will identify: The frequency of nail care to be provided, type of nail care provided and the person responsible for providing nail care to the resident;-Principles of nail care: Nails should be kept smooth to avoid skin injury. Only licensed nurses shall trim or file fingernails with diabetes. 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 9/5/25, showed:-Moderate cognitive impairment;-No rejection of care behavior exhibited;-Requires supervision with bathing and personal hygiene;-Diagnoses include schizophrenia (a mental disorder that distorts reality) and diabetes. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident is at risk for self-care deficit related to bathing;-Interventions: Provide assistance with ADLs as needed;-The care plan did not address refusal of care by the resident. Observation on 12/15/25 at 10:55 A.M., showed the resident in his/her room. His/Her fingernails on both hands approximately 0.5 inches (in.) long. The nails were jagged with dark matter underneath the nails. During an interview, the resident said his/her nails need to be cleaned and trimmed. Observation on 12/16/25 at 8:15 A.M., showed the resident in the dining room, eating breakfast and touching his/her food with his/her hands. His/Her fingernails on both hands were long, jagged, and with dark matter underneath the nails. During an interview with on 12/19/25 at 8:30 A.M., Certified Medicine Technician (CMT) B said the resident occasionally refuses showers and nail care. Nail care should be done anytime a resident requires it. If a resident refuses, then the staff should attempt again later. 2. Review of Resident #120's quarterly MDS, dated [DATE], showed:-Mild cognitive impairment;-Diagnoses include anemia, heart failure, hypertension (high blood pressure), PVD, kidney failure, diabetes, hyperkalemia (too much potassium in the blood), hyperlipidemia (high cholesterol), aphasia (language disorder), cerebrovascular accident (CVA, stroke), hemiplegia (paralysis on one side of the body), seizure disorder, malnutrition, and depression;-Moderate assistance required with oral hygiene, toileting, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Review of the resident's care plan, in use during survey, showed:-Problem: Resident requires assistance with his/her ADL functions including transfer and dressing. He/She can perform many of his/her tasks with set up and supervision;-Interventions included provide assistance, supervision, and set up as needed. Observation on 12/16/25 at 1:38 P.M., showed the resident's fingernails were long with dirt underneath the nail bed. Observations on 12/17/25 at 9:19 A.M., 12/18/25 at 10:50 A.M., and 12/19/25 at 11:00 A.M., showed the resident's fingernails were approximately 1/3 in. long in with dirt underneath the nail bed. The resident's right thumb was thick and curved forward. During an interview on 12/19/25 at 12:30 P.M., Certified Nurse Aide (CNA) Q and CNA R said the resident normally does not refuse care. The resident will sometimes ball up his/her hands during nail care. If staff explain to the resident what care they are providing, the resident is compliant. Any care that is refused by the resident is reported to the nurse right away. During an interview on 12/19/25 at 1:15 P.M., the Director of Nursing (DON) said the resident's nails are expected to be cleaned and trimmed on shower days and as needed. Refusals of care are expected to be documented on the care plan and the resident's medical record. 3. Review of Resident #5's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease) and dementia;-Moderately impaired cognition;-Staff supervision required for bathing and personal hygiene. Review of the resident's care plan, in use at the time of the survey, showed the care plan did not include the resident's ADL care needs. Observation on 12/15/25 at 2:15 P.M., showed a strong odor coming from the resident. His/Her beard was disheveled. During an interview, the resident said he/she wanted the beard shaved off. Observation on 12/16/25 at 8:18 A.M., showed the resident in the dining room. His/Her beard long and disheveled. A sweat odor was coming from the resident. 4. Review of Resident #6's significant change MDS, dated [DATE], showed:-Diagnoses include diabetes, acute kidney failure, muscle weakness, and dementia;-Severe cognitive impairment;-Dependent on staff for showering and personal hygiene. Review of the resident's electronic medical record (EMR) profile photo, from the time of admission, showed the resident's hair was short and his/her face was clean shaven with no beard. Observations on 12/16/25 at 8:23 A.M. and 12/18/25 at 7:42 A.M., showed the resident with long, stringy hair, and an unkempt beard. During an interview on 12/19/25 at 8:58 A.M., LPN A said the resident's hair was long and he/she needs a haircut. Staff are responsible for setting up appointments for the resident to go to the barber. He/She expects staff to use their professional judgement when deciding if a resident needs their beard shaved, if the resident cannot communicate their needs. Any nursing staff can assist with shaving. Residents can also make an appointment to go to a barber. 5. During an interview on 12/19/25 at 1:23 P.M., the Director of Nursing (DON) said any nursing staff can assist residents with shaving their beard. The facility also has a part-time barber with whom residents can make appointments. She expects resident care plans to reflect ADL needs and interventions.

Based on observation, interview and record review, the facility failed to ensure that residents received proper treatment and care to maintain mobility and good foot health for five residents (Resident #128, #105, #45, #17 and #1). The sample was 29. The census was 131.Review of the facility's Podiatry (foot) Services policy, revised, 5/14/24, showed:-Purpose: It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health;-Policy: Foot care that is provided in the facility, such as toenail clipping for residents without complication disease processes, shall be provided by staff who have received education and training to provide this service. Residents requiring foot care who have complication disease processes will be referred to qualified professional such as a podiatrist (foot doctor). Employees should refer an identified need for foot care to the Social Worker (SW) or designee. The SW or designee will assist residents in making appointments. Review of the facility's Nail Care policy, revised 6/26/24, showed:-Purpose: The purpose of this procedure is to provide guidelines for the provision of care to resident's nails for good grooming and health;-Policy: Assessment of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences. Report unusual or abnormal conditions of the nails to the physician and the responsible party (curling, color changed, separation form the nail bed, redness, bleeding, pain, odor, infection). Identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease (PVD, a lack of blood flow in the legs caused by narrowing of the blood vessels,) heart failure, kidney disease, or stroke. Routine cleaning and inspection of the nails will be provided during activities of daily living (ADL) care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. The resident's care plan will identify: The frequency of nail care to be provided, type of nail care provided and the person responsible for providing nail care to the resident.-Principles of nail care: Nails should be kept smooth to avoid skin injury. Toenails of residents with diabetes or circulation problems shall be filed only. 1. Review of Resident #128's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/20/25, showed:-Moderate cognitive impairment;-No rejection of care behavior exhibited;-Diagnoses include schizophrenia (a mental disorder that distorts reality);-Requires supervision or touching assistance with lower body dressing, putting on and taking off footwear, personal hygiene and bathing. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident is independent with ADLs but requires cueing at times for hygiene needs;-Interventions: Remind the resident of good hygiene. Provide protective oversight and assist when needed. Review of the resident's physician order sheet (POS), showed an order, dated 4/29/21, for may see podiatrist. Review of the resident's medical record, reviewed during the survey from 12/15/25 through 12/19/25, showed no documented podiatry visits or consults. Observation on 12/15/25 at 11:13 A.M., showed the resident wore slide-on sandals with his/her toes exposed. His/Her toenails on both feet approximately an inch long, thick, jagged and curled under. Both feet extremely dry with large flakes of dry skin. 2. Review of Resident #105's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-No rejection of care behavior exhibited;-Diagnoses include diabetes and schizophrenia;-Requires partial to moderate assist putting on and taking off footwear and lower body dressing;-Requires supervision or touching assistance with personal hygiene and bathing. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident is at risk for alteration in health related to diabetes;-Interventions: Refer to podiatrist or foot care nurse to monitor and document foot care needs and to cut long nails. Review of the resident's POS showed an order, dated 5/14/21, for may see podiatrist. Review of the resident's medical record, reviewed during the survey from 12/15/25 through 12/19/25, showed no documented podiatry visits or consults. Observation on 12/17/25 at 10:00 A.M., showed the resident wore gray slipper socks that were brown on the bottom of the sock. The socks had large holes exposing the resident's heels. Certified Medicine Technician (CMT) B removed the resident's socks and a large of amount of white flakes fell out of the socks. The resident's toenails were approximately 0.5 inches (in) long, thick, and jagged. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-No rejection of care behavior exhibited;-Diagnoses include anxiety, depression and schizophrenia;-Requires supervision or touching assistance with putting on and taking off footwear, lower body dressing, personal hygiene and bathing. Review of the resident's care plan, in use at the time of survey, showed:-Plan: The resident is independent with ADLs but does require supervision and cues to maintain hygiene;-Intervention: Protective oversight and provide assistance where needed. Review of the resident's POS, showed an order dated, 4/27/21, for may see podiatrist. Review of the resident's medical record, reviewed during the survey from 12/15/25 through 12/19/25, showed no documented podiatry visits or consults. Observation on 12/17/25 at approximately 10:05 A.M., showed the resident lay in bed with his/her feet exposed. His/Her feet extremely dry with large flakes of dry skin falling off his/her feet. The resident's toenails thick and jagged. During an interview, the resident said he/she would like to have his/her feet moisturized and toenails groomed. 4. Review of Resident #17's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-No rejection of care behavior exhibited;-Diagnoses include PVD and schizophrenia;-Requires supervision or touching assistance with putting on and taking off footwear, lower body dressing, personal hygiene and bathing. Review of the resident's care plan, in use of the time of survey showed:-Plan: The resident is independent with ADLs;-Intervention: Protective oversight and provide assistance where needed.Observation on 12/16/25 at 8:39 A.M., showed the resident sat at the bedside. His/Her ankles and feet slightly edematous (swollen). Both feet extremely dry with large flakes of skin coming off. During an interview, the resident said he/she thought his/her feet were dry and needed lotion. During an interview on 12/17/25 at 10:15 A.M., CMT B said many residents on the resident's hall shower and get dressed independently. Most of the residents do not refuse ADL care. If the podiatrist is in the building during smoke time, the resident will refuse the visit because he/she does not want to miss out on smoking. 5. Review of Resident #1's POS, showed an order, dated 3/10/23, for may see podiatrist; Review of the resident's care plan, revised 7/25/25, showed:-Problem: The resident requires assistance with ADLs due to pain;-Desired outcome: The resident will improve level of function;-Interventions: Encourage participation to fullest extent. Staff monitor and report any changes. Review of the resident's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Uses a wheelchair for mobility;-Staff provide supervision to touching assistance for hygiene needs;-Diagnoses include lung disease, obesity, high blood pressure, lower spine dysfunction, heart disease, chronic pain, and osteoporosis. Review of the resident's medical record, reviewed during the survey from 12/15/25 through 12/19/25, showed no documented podiatry visits or consults. Observation on 12/16/25 at 10:23 A.M., showed the resident asleep in bed. His/Her feet were exposed and his/her right big toenail was thick, dark yellow, and approximately 1.0 in long. During an interview on 12/17/25 at 9:15 AM the resident said he/she had a very long toenail and the nail rubs on his/her slipper. He/She had not seen the podiatrist for the toenail. The staff had not offered the podiatrist to see him/her. A doctor should cut the long toenail. Staff assists him/her with bathing. He/She would like to have a doctor look at his/her toenails to get the long nail trimmed. During an interview on 12/17/25 at 1:43 P.M., the Social Service Designee (SSD) said the resident has not been seen by a podiatrist and does have a history of refusals. 6. During an interview on 12/17/25 at 10:15 A.M., CMT B nursing staff are expected to notify the Director of Nursing (DON) or Assistant Director of Nursing (ADON) if residents require toenail trimming. Moisturizing a resident's feet can be done anytime by any nursing staff member. If a resident is unable to apply lotion to their feet, then the facility will supply them with some type of moisturizer. Staff should change a resident's socks if they are soiled or have holes in them. If a resident refuses any type of care staff should let the nurse know and document the refusals. 7. During an interview on 12/18/25 at 8:15 A.M., Licensed Practical Nurse (LPN) F said the nurses complete weekly skin assessments on the residents. The assessment includes removing the resident's socks and examining the resident's feet. Podiatry is consulted for diabetics and for residents that have extremely thick toenails. The nurse can trim or file toenails for residents who are not diabetic. 8. During an interview on 12/17/25 at 8:30 A.M., the DON said some residents refuse to have foot care completed by staff and the podiatrist. The podiatrist comes to the facility about every two to three months. If a resident refuses foot care, staff is expected to document this in the medical record and on the care plan. She expects staff to moisturize the resident's feet on their shower days and as needed. She expects staff to notify her or the charge nurse if the resident needs their toenails trimmed. She expects staff to change the resident's socks if soiled or if there are holes in the socks. 9. During an interview on 12/17/25 at 1:43 P.M., the SSD said staff notifies her of residents that need to be seen by the podiatrist. She will obtain a consent and schedule the resident to be seen. The aides are responsible for notifying the nurses of a resident's toenail needs and the nurses should assess and determine if the residents need to be seen by the podiatrist. Refusals should be documented in the resident's medical record. 2686150

Based on observation, interview and record review, the facility failed to ensure physician orders were obtained for feeding tube water flushes and to ensure staff documented the date and time tube feeding formula was hung for one of two residents sampled with feeding tubes (Resident #120). The facility census was 131. Review of the facility's Following Physician's Orders policy, revised 5/18/24, showed:-Procedure: Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical records in the Orders section;-Clarification of physician's orders will be obtained if the order is either unclear or the nurse is uncomfortable in implementation of the physician's orders;-The nurse in charge of medication administration must review all their designatedMedication Administration Records (MARs) and Treatment Administration Record (TARs) prior to the end of their shift to ensure that all medications/treatments scheduled to be given on their shift were administered according to the physician's order and that all necessary interventions were taken in the event of an omission;-The Resident Care Coordinator (RCC)/Unit Manager/designated nurse will review all electronic MARs/TARs and compare all medications to the medications available for each resident in the facility weekly to ensure availability;-The physician is expected to sign all of their orders electronically in the Electronic Health Record;- Medical Records Coordinator/designee will audit electronic signatures by running report weekly on orders pending electronic signatures. The Director of Nursing (DON) and Administrator are to be notified of physician orders still needing signatures. The physicians who have orders that need to be electronically signed, will be contacted requesting they sign the orders. Review of Resident #120's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/22/25, showed:-Mild cognitive impairment;-Diagnoses included anemia, heart failure, hypertension (high blood pressure), peripheral vascular disease (PVD, circulatory problem causing numbness/weakness), kidney failure, diabetes, hyperkalemia (too much potassium in the blood), hyperlipidemia (high cholesterol), aphasia (language disorder), cerebrovascular accident (CVA, stroke), hemiplegia (paralysis on one side of the body), seizure disorder, malnutrition, and depression;-Moderate assistance with oral hygiene, toileting, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene;-Weighs 103 pounds;-Has feeding tube. Review of the resident's care plan, in use at the time of survey, showed:-Problem: Resident is at risk for aspiration;-Interventions included: Diet provided as ordered (continuous tube feeding);-Problem: The resident has dehydration or potential fluid for deficit related to nothing by mouth (NPO) diet;-Interventions: Administer water flushes per orders (per pump). Review of the resident's hospital record, dated 12/2/25, showed:-admitted : 11/19/25;-discharged : 12/2/25;-Intensive Care Unit (ICU) course: Admit 11/19/25, transferred out 11/24/25. Reason for admission: hyperosmolar hyperglycemic state (HHS, extremely high blood sugar)/diabetic ketoacidosis (DKA, lack of insulin) septic shock/respiratory failure due to right upper lung (RUL) pneumonia, severe hypernatremia (high sodium levels;-Hospital course: He/She was found to have severe hypernatremia and cystic fibrosis sepsis, aspiration pneumonia, admitted to ICU for brief intubation, insulin drip, hypernatremia management, now extubated, transitioned to floor. He/She underwent gastronomy tube (g-tube, a tube surgically inserted into the stomach to provide hydration, nutrition, and medications) replacement on 12/1/25 after his/her g-tube was dislodged. He/She will be discharged back to nursing facility;-discharged on continuous tube feed rate 55 milliliters (ml) per (/) hour (hr), Glucerna (calorie dense formula) 1.5 cal;-No documentation of water flushes, rate or frequency. Review of the resident's physician orders sheet (POS), for December 2025, showed:-An order, dated 12/2/25, NPO diet related to dysphagia;-An order, dated 12/2/25, Glucerna 1.5, 55 ml per/hour for 22 hours every shift for supplement;-An order, dated 11/4/25, 150 cubic centimeters (cc) water flush via g-tube every four hours;-An order, dated 12/2/25, to discontinue 150 cc water flush via g-tube every four hours;-An order, dated 12/16/25, enteral feed order every four hours related to hyperkalemia, 150 cc free water every four hours, auto infuse via pump. Observation on 12/15/25 through 12/19/25, showed:-On 12/15/25 at 4:07 P.M., showed the resident in bed, with g-tube infusing at 55 ml/hr. The formula bottle showed no documentation of the time it was hung and started infusing;-On 12/16/25 at 12:50 P.M., the resident in bed. His/Her g-tube infused at 55 ml/hr. G-tube pump showed the water flush set at 100 cc every hour;-On 12/17/25 at 9:19 A.M., the resident in bed. G-tube infused at 55 ml/hr. G-tube pump showed the water flush set 150 cc every four hours;-On 12/18/25 at 10:50 A.M., the resident in bed. G-tube infused at 55 ml/hr and water flush set at 150 cc. The formula bottle showed no documentation of the time it was hung and started infusing;-On 12/19/25 at 11:00 A.M., the resident in bed with eyes closed. The g-tube infused at 55 ml/hr. G-tube pump showed the water flush set at 150 ml. The formula bottle showed no documentation of the time it was hung and started infusing. During an interview on 12/19/25 at 1:00 P.M., the Director of Nursing (DON) said she expected staff to ensure the resident had physician's orders for water flushes. She expected staff to follow physician's orders. She expected staff to document the date, time, infuse rate, and formula type on the bottle. When the resident returned from the hospital, he/she was on 100 ml water flush.

Based on interview and record review, the facility failed to provide protective oversight for one of three sampled residents with a history of substance abuse and seizures. The facility was aware this resident had left on an LOA several times and returned after drinking. The facility had not developed and evaluated interventions on the resident's care plan and documented education with the resident. The resident signed out of the facility for a leave of absence (LOA) on 12/9/22. The resident told staff he/she would return that evening. The resident did not return until 12/11/22 and missed 4 doses of seizure medication. When the resident returned, and was potentially intoxicated, he/she went to bed. Staff did not contact the physician regarding the resident's condition and missed medications. On 12/12/22 at 3:30 A.M., staff noted the resident with signs and symptoms of a possible seizure. The resident was observed to be unresponsive with labored breathing. At the hospital, the resident was intubated and admitted to the intensive care unit (ICU) (Resident #1). In addition,when the resident returned to the facility from the hospital on 12/15/22, the facility failed to evaluate and place interventions in the resident's care plan, and failed to educate the resident regarding drinking and not taking his/her medications. The census was 128. The Administrator was notified on 2/22/23 at 2:15 P.M. of an Immediate Jeopardy (IJ) which began on 12/11/22. The IJ was removed on 2/23/23 as confirmed by surveyor onsite verification. Review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, revision dated 7/12/22, showed the following: -Purpose: Establish policy and procedure regarding the transfer/discharge of residents; -Definitions: Therapeutic Leave: Absences for purposes other than required hospitalization ; -Return after Therapeutic Leave: When a resident goes on therapeutic leave and returns later than agreed upon, that is not a resident-initiated discharge. The resident must be permitted to return and be appropriately assessed for any ill-effects from being away from the facility longer than expected and provided any needed medications or treatments which were not administered because they were out of the building. If a resident has not returned from therapeutic leave as expected, documentation in the medical record should show evidence that the facility attempted to contact the resident and resident representative. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/20/22, showed the following: -No cognitive impairment; -No behaviors or moods; -Independent with activities of daily living; -Diagnoses of seizure disorder, malnutrition and depression. Review of the resident's face sheet, showed the following diagnoses; -Unspecified cirrhosis of the liver (severe scarring of the liver); -Alcohol dependence with withdrawal unspecified. Review of the resident's Order Summary Report, dated October 2022, showed an order dated 9/6/22, for Keppra tablet (treatment for seizures) 1000 milligrams two times per day related to unspecified convulsions. Review of the resident's medical records, showed the following: -No documentation of the resident going LOA on 10/12/22; -10/13/22 at 7:30 A.M, the resident returned to the facility. The resident voiced no complaints of pain, discomfort or distress. The resident ambulated with his/her wheelchair. -Review of the resident's October 2022 Medication Administration Records (MAR), showed on 10/12/22, a blank spot for the morning (7:00 A.M.) medication administration and showed the Keppra was administered in the evening (8:00 P.M.); -There was no documentation notifying the resident's physician of the resident's missed medication; -10/15/22 at 2:33 P.M., the resident went for a LOA in a cab. The resident said he/she would return early in the afternoon. The resident took no medication with him/her. The DON was made aware of the resident going on a LOA. At 7:12 P.M., the resident remained out of the facility on a LOA; -10/16/22 at 8:31 A.M., the resident returned as the nurse was leaving the parking lot at approximately 8:30 P.M. last evening (10/15/22). The resident was in a cab. The resident was assisted to his/her wheelchair and into the facility by night shift staff. Documentation showed the resident was intoxicated, had an unsteady gait and slurred speech. The cab driver said the resident was too intoxicated to stand up and get out of the cab. The night shift reported this behavior; -No documentation notifying the resident's physician regarding being intoxicated upon his/her return; -10/21/22 at 11:47 A.M., the resident went on a LOA. The resident said he/she would return by dinner. The resident's evening medications were given to the resident to take with him/her; -10/22/22 at 3:49 P.M., the resident returned to the facility; -Review of the resident's October MAR, dated 10/21/22 evening administration and 10/22/22 morning administration, showed a 1 (resident absent without medication); -There was no documentation of notifying the resident's physician regarding the missed medications; -11/07/22 at 8:11 P.M., the resident went on a LOA at 7:00 A.M. rounds and remained on LOA at this time. Report was given to the coming nurse; -11/08/22 at 1:25 P.M., the resident had not returned to the facility. A call was placed to the resident's physician's office. The Nurse Practitioner (NP) was made aware of the resident's absence without medications. The NP said to call and let the office know if the resident returned. A call was placed to the resident's cell phone number with no answer and went directly to voicemail. Social Services was made aware; -There was no documentation of when the resident returned to the facility or if the NP was notified of the resident's return as requested; -Review of the resident's November MAR, dated 11/7/22 through 11/8/22, showed a 1 for all four doses of Keppra; -12/3/22 at 6:33 P.M., the resident arrived back in the facility at approximately 4:30 P.M. The resident showed signs and symptoms of being intoxicated such as he/she smelled of alcohol and was stumbling while walking with walker. The resident denied being intoxicated at this time and went to his/her room to lie down; -Review of the resident's November MAR, dated 11/3/22, showed a 1 for the 7:00 A.M. administration of Keppra; -There was no documentation notifying the resident's physician regarding the resident drinking alcohol while on LOA or missing medication; -12/9/22 at 2:16 P.M., the resident went LOA just before lunch and said he/she would be returning this evening before 8:00 P.M. The resident did leave a phone number where he/she could be reached; -12/12/22 at 6:27 A.M., the resident returned at approximately 6:45 P.M. on 12/11/22 (Sunday) from being on LOA all weekend. Upon return, the resident showed signs of intoxication. At about 9:00 P.M., the resident approached the nurse and asked if he/she had any medication he/she needed to take. The nurse searched the MAR and informed the resident he/she had nothing to take. The resident said he/she was going to lay down for the night. At approximately 12:00 A.M., during rounds, the nurse looked in on the resident and he/she appeared to be asleep with no visible signs of distress. At approximately 3:30 A.M., the nurse was called to the resident's room. Upon arrival it was noted the resident was unresponsive, some labored breathing and foaming at the mouth. The resident did not respond to sternal rubs (application of painful stimuli with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli). An ambulance was called for emergency. The DON was made aware; -Review of the resident's December MAR, showed a 1 for the 12/9/22 evening administration, 12/10/22 for the morning and evening administration and 12/11/22 for the morning administration, and a blank spot for 12/11/22 evening administration of the Keppra; -There was no documentation of staff attempting to contact the resident during the LOA, notifying the resident's physician regarding the resident returning showing signs and symptoms of alcohol intoxication (smelling of alcohol and stumbling when walking) or missed medications. Review of the resident's care plan, revised dated 3/23/22, showed no documentation regarding the resident going on a LOA and returning to the facility showing signs and symptoms of being intoxicated or documentation showing the resident had missed medications, including his/her seizure medications when on LOA. Review of the resident's After Visit Summary Hospital Record, dated 12/12/22 through 12/15/22, showed the following: -Instructions: The resident came to the hospital since he/she was having seizures after leaving facility and not having taken seizure medications. The resident had a very severe seizure and thus he/she had to be intubated (a tube through a person's mouth or nose, and into the airway/windpipe. Intubation is used when a person isn't able to breathe on his/her own.) to assure that he/she would be able to breath during the episode. Once the seizure was stopped, the resident was given care in the ICU. The resident was monitored closely and removed from the breathing tube. The resident then went to the medical floor where he/she was monitored for alcohol withdrawal and placed on the right medications. It is important the resident abstain from drinking alcohol and regularly take medications that are prescribed. The resident has had many admissions for seizures and these can lead to damage to his/her brain and can be very dangerous if the seizures happen at the wrong place and time. Review of the resident's revised care plan, dated 12/19/22, showed no documentation of new interventions regarding the resident going on LOA and returning intoxicated or regarding the resident having missed medications when on LOA. During an interview on 12/28/22 at 10:21 A.M., Nurse A said the resident left on 12/9/22 and said he/she would be back around 7:00 P.M. to 8:00 P.M. Nurse A said the resident was known to be gone days at a time. Nurse A said he/she probably should have documented the resident had not returned and not had his/her medication. Nurse A did not contact the resident because the resident was his/her own responsible party. During an interview on 12/28/22 at 11:00 A.M., Nurse B said he/she received in report, at the beginning of his/her evening/night (7:00 P.M. to 7:00 A.M.) shift on 12/9/22, the resident went on LOA and would probably be back around 8:00 P.M. Nurse B said the resident was known for going out for a couple of days at a time. Nurse B did not have any concerns with the resident's medication. When the resident returned, he/she did not give the resident any medication or call the resident's physician until the resident had a seizure. The resident was intoxicated when he/she returned. Nurse B did not know the facility's policy on when a resident does not return to the facility. During an interview on 2/7/23 at 12:15 P.M., the Social Service Director (SSD) said he/she was not aware the resident would come back to the facility intoxicated, but did hear through some talk at the facility. The SSD said the facility started an Alcoholic Anonymous meeting in October of 2022. The SSD said the resident came to one meeting and did not come back. The SSD said he/she did offer the resident other options, but did not offer the resident to see a psychologist regarding his/her alcoholism. The SSD said he/she did not document the resident's issue in the resident's medical record. During an interview on 12/28/22 at 9:48 A.M., the Director of Nursing (DON) said the charge nurse should have tried to call the number the resident left and encourage the resident to come back to the facility for his/her medications. The DON said the charge nurse should have notified the resident's physician of the situation and document the orders given. When the resident returned intoxicated, the charge nurse should have called the resident's physician for orders or instructions regarding the resident's care. The resident's intoxication and missed medication should have been care planned. During an interview on 2/22/23 at 2:54 P.M., the Administrator said when the resident returned intoxicated and having missed medications, she expected the charge nurse to contact the physician for orders and instructions. The Administrator said she did not know why the physician was not notified. During an interview on 2/16/23 at 9:05 A.M., Physician D said the resident missing doses of his/her seizure medication could cause the resident to have a seizure. Physician D said if a resident returned to the facility intoxicated and missed seizure medications, he/she expected the charge nurse to contact him/her or the Nurse Practitioner for guidance. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with the State law (section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violation(s). MO00211150

Based on interview and record review, the facility failed to provide services to promote the highest practicable physical well-being by failing to monitor and implement interventions to prevent further exposure of one of three sampled residents (Resident #1) to ongoing aspiration risk after it became evident that a staff member who regularly provided care to the resident refused to adhere to the resident's physician-ordered diet due to his/her dysphagia (difficulty swallowing). When the resident experienced respiratory distress and became unresponsive, the facility failed to give paramedics a full report on the resident's condition and baseline mental status. The census was 133. Review of the resident's care plan, dated 11/14/14, showed alteration in health related to high blood pressure, dysphagia, gastrostomy tube ([DEVICE]) placement and cardiovascular accident (stroke) with right-sided [MEDICAL CONDITION] (weakness on one side of the body) and mechanically altered diet. Review of the resident's physician's order sheet (POS), dated 11/14/14 through 12/14/14, showed an order, dated 11/14/14 for [MEDICATION NAME] 1.5 (calorically dense, fiber-containing tube feeding formula), 1 can bolus (intermittent feeding) if the resident consumed less than 50% of his/her meal. Review of the resident's dietary department communication sheet, dated 11/15/14, showed an order for [REDACTED]. Review of the resident's nurse's note, dated 11/19/14 at 1:30 P.M., showed while receiving meals in the facility aspiration dining room, the resident refused to feed him/herself and when fed by staff, he/she allowed the food to run out of his/her mouth. When the resident did accept a bite of food, he/she just held the food in his/her mouth. The resident was not receiving an adequate amount of nutrition from meals. Staff notified the therapy department of the resident's poor eating habits and poor appetite. Further review of the resident's POS, dated 11/14/14 through 12/14/14, showed an order, dated 11/19/14 for discontinuation of regular liquids, the start of nectar thickened liquids with all meals and [MEDICATION NAME] 1.5, 50 cubic centimeters (cc) per hour per [DEVICE] 7:00 P.M. until 7:00 A.M. An order, dated 11/24/14, was for suctioning as needed (PRN) due to congestion. Further review of the resident's dietary department communication sheet, dated 11/24/14, showed an order for [REDACTED]. During an interview on 1/29/15 at 1:58 P.M., the Dietary Manager said the only dietary orders for the resident received from staff were dated 11/15/14 and 11/24/14. The dietary department had no other dietary orders for the resident on file. Review of the resident's speech therapy daily treatment note, dated 11/25/14 at 6:17 P.M., showed completion of a speech therapy evaluation. The resident required a maximum amount of cues in order to maintain eye contact and completely participate in the evaluation. He/she had difficulty getting food to his/her mouth, demonstrated a severe swallow initiation delay of eight to ten seconds and required both verbal and tactile cues to complete the task. The resident displayed severe oropharyngeal dysphagia (difficult/painful swallowing due to improper function of the mouth and throat) characterized by difficulty manipulating bolus (round mass of chewed food), decreased A (anterior) >P (posterior) transit time, delayed swallow initiation and residue post swallow. He/she did not cough or choke during the evaluation. During an interview on 2/3/15 at 12:40 P.M., the Speech Language Pathologist (SLP) said the resident had difficulty moving food around in his/her mouth. Due to a decline in cognitive functioning, he/she appeared to have forgotten what to do when food was placed in his/her mouth. The decrease in A>P transit time meant that the food sat in the resident's mouth for a long time. Consequently, the SLP feared that staff might assume the resident had swallowed all the food placed in his/her mouth and put the resident to bed, causing him/her to choke on food still sitting on the tongue. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/27/14, showed the following: -Admission on 11/14/14; -[DIAGNOSES REDACTED]. -Long and short-term memory problems; -Mechanically altered diet; -51% or more of total calories received via tube feeding; -Total dependence on the assistance of one staff with eating. During an interview on 2/11/15 at 6:40 P.M., the Aspiration Dining Room Nurse A said the resident was cognitively unable to feed him/herself and did not even attempt to do so. Review of the Assistant Director of Nurse's (ADON's) written statement, dated 2/10/15, showed she received a text message from an unidentified staff person (who wished to remain anonymous) on 11/30/14, complaining that the resident's family member Certified Nurse Assistant (CNA) B was checking behind staff who provided the resident's care and behaving in a verbally aggressive manner towards them. During an interview on 2/5/15 at 2:52 P.M., the ADON said she did not attempt to call the phone number displayed as the sender of the text message. As of the date of the interview, she did not ask CNA B about the allegations, not wishing to be perceived as being accusatory based upon limited information which might or might not have been true. Review of the ADON's summary of events noted, dated 2/6/15, showed staff began complaining about CNA B coming into the facility when not scheduled to work, giving orders and directions on how to provide the resident's care. Employees were afraid to take care of the resident due to the behavior displayed by CNA B. Nurses in the facility were concerned about CNA B's intimidation of the staff. The employees' concerns were shared with the administrator. Two nurses redirected CNA B for giving the resident fluids of a different consistency from what was documented on the plan of care. Staff were expected to follow policy and procedure. The facility stressed the importance of following physician's orders for the safety of all residents in the facility. No one reported witnessing the resident being fed. Review of an investigation summary, dated 2/6/15, showed when concerns about CNA B giving staff a hard time with instructions he/she wanted them to carry out when caring for the resident were initially texted to the ADON, the goal was to ensure that the motivation for the text messages was not a personal issue between two co-workers. A second text message showed that several of CNA B's co-workers from nurses down to CNAs were also concerned. There was to be a meeting, but the resident went to the hospital and the meeting was never held. As of the date of the investigation summary, the facility planned to speak with CNA B and issue a disciplinary action against him/her for failure to follow facility protocol when giving the resident thin liquids when he/she was previously informed that the resident should only receive thickened liquids. No staff reported witnessing the resident being fed on the days in question. During interviews on 1/28/15 at 9:34 A.M. and 2/4/15 at 10:47 A.M., the administrator said prior to the complaint investigation, she was unaware that staff had witnessed or had knowledge of CNA B feeding the resident after the physician's NPO diet order was in place. Staff were expected to report information of that nature to her or their supervisors. After learning of the allegations about CNA B's behavior, the administrator conducted an internal investigation. During the course of her internal investigation, staff informed the administrator that they would see CNA B giving the resident water after the physician's order for thickened liquids was in place. When they attempted to intervene, CNA B would get an attitude with them and say that the resident was his/her family member. Review of the resident's medical record, showed no social service notes documenting CNA B's difficulty accepting the resident's change in condition or attempts to address his/her failure to adhere to the physician's dietary orders. During an interview on 2/11/15 at 7:05 P.M., CNA C said CNA B was adamant that staff should give the resident extra water via his/her [DEVICE], even after nursing staff explained why it would not be a good idea to administer any more water than was ordered via tube flushes. During an interview on 2/11/15 at 6:27 P.M., the Care Plan Nurse said she saw CNA B give the resident regular water (date unknown) which ran back out of the sides of the resident's mouth. The Care Plan Nurse reminded CNA B that the resident had a physician's order for thickened liquids and CNA B stopped what he/she was doing. The Care Plan Nurse only saw the aide giving the resident thin liquids once while the order for thickened liquids was in place. The Care Plan Nurse did not report CNA B's behavior to anyone. During an interview on 2/11/15 at 6:50 P.M., Unit Manager D said he/she was present when the Care Plan Nurse reminded CNA B that the resident required thickened liquids. CNA B paused until the Care Plan Nurse walked away and then continued to give the resident regular water. The water ran out of the side of the resident's mouth, due to the resident's facial droop from a previous stroke, but the resident did not cough. Unit Manager D assumed that CNA B did not hear the Care Plan Nurse, so he/she asked CNA B if he/she had heard what the Care Plan Nurse said. CNA B then stopped giving the resident water, so the situation did not seem to be that serious. Unit Manager D could not recall whether or not he/she reported the incident to anyone. Further review of the resident's POS, dated 11/14/14 through 12/14/14, showed an order dated 12/2/14, for a chest x-ray to rule out pneumonia. Review of the resident's chest x-ray results, dated 12/2/14, showed small right lower lobe pneumonia. Review of the resident's speech therapy treatment note, dated 12/2/14 at 2:49 P.M. showed speech therapy consisted of oral care and several sips of nectar thick liquids. The resident continued to initiate swallow in eight to ten seconds which was severe-profound. Further review of the resident's POS, dated 11/14/14 through 12/14/14, showed the following: -An order, dated 12/3/14, for oxygen at 2 liters per nasal cannula as needed (PRN); -An order, dated 12/3/14, for [MEDICATION NAME] (antibiotic) 500 milligrams (mg) per gastrointestinal tract (GIT) times seven days; -An order, dated 12/3/14, for an increase of water flushes to 150 cc every four hours. Review of the resident's speech therapy daily treatment note, dated 12/3/14 at 6:20 P.M., showed the SLP reassessed the resident who demonstrated a swallow of 12-14 seconds, which was essentially a non-existent swallow. The SLP wrote a recommendation to make the resident's dietary intake status nothing by mouth (NPO) with continuous tube feedings and to continue keeping the head of the bed (HOB) at a 90 degree angle to prevent aspiration of his/her tube feedings. Staff was to provide oral care two to three times daily. During an interview on 2/3/15 at 12:40 P.M., the SLP said placing the resident's HOB at less than a 90 degree angle increased his/her aspiration risk from reflux (leakage of the stomach contents back into the esophagus) even when the resident was not eating. Ninety percent of individuals who received tube feedings experienced reflux due to not chewing their nourishment. If the resident experienced reflux, it could go right into his/her airway and result in stomach acid and bacteria going into his/her lungs. Oral care was important because swabbing the mouth cleared away the build-up of dried saliva and mucous. The resident could aspirate on mucous. Further review of the resident's care plan, dated 11/14/14, showed an intervention dated 12/3/14, for his/her HOB to be up at 90 degrees at all times. An intervention dated 12/4/14, showed speech therapy recommended NPO status. Staff was directed to provide all nutrition and fluids via [DEVICE] as ordered. Review of the resident's nurse's notes, showed on 12/4/14 at 2:00 P.M., the resident was up in bed with the HOB at a 45 degree angle. Further review of the resident's POS, dated 11/14/14 through 12/14/14, showed an order dated 12/4/14, for NPO and continuous tube feeding of [MEDICATION NAME] 1.5 at 50 cc per hour while on antibiotics 12/9/14 then to re-evaluate. During an interview on 1/23/15 at 3:56 P.M., the resident's physician said the resident's intake status was NPO for the remainder of December 2014. Review of the resident's undated CNA care plan, showed pureed diet, nectar thickened liquids and bolus tube feedings were discontinued on 12/4/14. Starting on 12/4/14, the resident was to take nothing by mouth and receive continuous tube feedings. During interviews on 1/29/15 at 11:50 A.M. and on 2/11/15 at 7:05 P.M., CNA C said the resident was not allowed to eat in his/her room because he/she had to be monitored. CNA C did not actually see CNA B feed the resident after staff received the NPO physician's order. However, after the NPO order was in place, at various times during his/her oncoming rounds, he/she observed CNA B cleaning the resident's mouth and CNA B would tell CNA C that he/she had gotten the resident to eat. Sometimes, there would be dishes on the shelf over the resident's bed. CNA B knew about the resident's NPO status. CNA B was in complete denial. Prior to the resident's NPO status, the resident cheeked the food or allowed it to run out of his/her mouth when fed, but CNA B would still say that the resident was eating. CNA C never refuted anything CNA B said. Though CNA C knew about the resident's NPO status, he/she thought that since CNA B was related to the resident, he/she could go against physician's orders even though the rest of the staff did not. During an interview on 1/27/15 at 9:51 A.M., CNA B denied ever feeding the resident after the NPO physician's order was in place. CNA B said he/she did not struggle with accepting the resident's NPO status. The SLP made it clear that he did not want the resident to eat anymore. CNA B did not see anyone else feeding the resident. CNA B was not the resident's power of attorney. During interviews on 1/20/15 at 1:31 P.M. and on 1/29/15 at 11:41 A.M., Nurse G said CNA B was adamant about removal of the resident's [DEVICE] in two weeks and the resident eating again despite Nurse G's efforts to reason with CNA B. During an interview on 1/20/15 at 11:16 A.M., Nurse H said the other nurses asked him/her to speak to CNA B because CNA B did not want the resident to stop eating. Review of the resident's speech therapy treatment note, dated 12/4/14 at 1:51 P.M., showed the SLP educated CNA B about his reasons for changing the resident's intake status to NPO and the importance of being compliant for the next several weeks. During an interview on 2/3/15 at 12:40 P.M., the SLP said after the resident's physician issued an order for [REDACTED]. He explained the risks posed by the resident continuing to try to eat and CNA B said he/she understood. Continuing to feed the resident after the physician's order was issued for NPO posed severe danger because by then, the resident could no longer swallow pureed food. The most the resident could safely handle would be two or three teaspoons of lemon ice because the sourness and coldness would assist in increasing sensory puckering, salivation and facilitate swallowing. Review of the resident's nurse's notes, showed on 12/5/14 (no time documented), the resident was in bed with the HOB at a 45 degree angle. On 12/6/14 at 2:00 P.M., the resident was in bed with the HOB at a 30 degree angle. During an interview on 2/11/15 at 7:15 P.M., CNA F said on or around the weekend of 12/6/14, he/she witnessed CNA B in the main dining room feeding the resident regular water and pureed food. Staff had previously received the resident's NPO physician's order. As food dribbled from the sides of the resident's mouth, CNA B scooped it up and put it back into the resident's mouth. The resident began coughing slightly. The second time CNA B put the food back into the resident's mouth, he/she coughed harder. CNA B then gave the resident water in an attempt to clear up the coughing. Because CNA B attempted to give the resident water via a straw, he/she did not appear to receive any of the water. There were no other staff members in the dining room at the time. CNA F knew about the resident's NPO status, but said nothing to CNA B or anyone else because CNA F thought CNA B had the right, as a family member who was very involved in the resident's care, to feed the resident. CNA F also assumed that CNA B received permission from the aspiration dining room nurse because CNA B would have had to enter the aspiration dining room in order to get the pureed food. While feeding the resident, CNA B said aloud that no one was going to tell him/her that he/she could not feed the resident, that the resident was going to eat and receive some water. Review of the resident's departmental notes, showed the following: -12/8/14 at 3:35 P.M., showed staff continued to provide maximum assistance with all activities of daily living. The resident could not complete any aspects of his/her care due to impaired functional abilities related to a cardiovascular accident (stroke); -12/10/14 at 10:42 A.M., The resident displayed facial droop and continued not to be appropriate for intake by mouth. The resident finished the prescribed round of antibiotics, but continued to display a wet cough and gurgly voice when attempting to vocalize. Review of the resident's nurse's notes, dated 12/10/14 at 2:00 P.M., the resident was in bed with the HOB at a 45 degree angle. Further review of the resident's POS, dated 11/14/14 through 12/14/14, showed an order dated 12/10/14, that staff may recheck the resident's CXR. Review of the resident's nurse investigative report, signed 1/5/15, showed Nurse E reported to the resident's physician CXR results from 12/2/14 that he/she thought was a new CXR. The physician's orders based upon that report were to monitor the resident and call the office with an update in a few days. The resident continued to show signs of respiratory infection. During an interview on 1/23/15 at 3:56 P.M., the resident's physician said the decision of whether or not to carry out the 12/10/14, CXR order was left up to nursing judgement. He issued the order because staff reported that the resident had only showed minimal improvement after one course of antibiotics. Review of the resident's nurse's notes, dated 12/13/14 at 12:00 P.M., showed the resident was in bed with the HOB at a 45 degree angle. Further review of the resident's POS, dated 11/14/14 through 12/14/14, showed an order dated 12/14/14, for [MEDICATION NAME] 500 mg per GIT times five days. Review of the resident's nurse's notes, showed the following: -12/15/14 at 10:00 A.M., the resident's physician visited and gave new orders for [MEDICATION NAME] (breathing treatment) treatment four times a day and PRN. The resident's lungs remained coarse. Staff administered Tylenol for increased temperature; -12/17/14 (no time documented), the resident was in bed with the HOB elevated at a 45 degree angle; -12/18/14 at 3:00 P.M., the resident was in bed with the HOB elevated at a 45 degree angle. His/her temperature was fluctuating up and down. Vital signs were temperature 98.8 (normal temperature range 97.8 - 99.1 degrees Fahrenheit ), pulse 88 (normal rate 60-100 beats per minute), respiration 24 (normal range 12-18 breaths per minute), blood pressure 130/88 (normal range 90/60 mm/Hg to 120/80 mm/Hg). Staff attempted to suction the resident's mucous due to audibly coarse lungs and the resident clinched his/her teeth down on the suction catheter tube. At 6:00 P.M., the resident's oxygen saturation was 84% on a five liter nasal cannula (normal saturation 95%-100%). The resident's vital signs were temperature 99.1, pulse 104, respiration 30, and blood pressure 104/100. Via a non-rebreather mask, staff set the oxygen tank output at eight liters and the resident's oxygen saturation increased to 90%. Staff used the suction catheter to remove a brown substance. Staff contacted the resident's physician and obtained an order to send the resident to the hospital for evaluation. The ambulance arrived at 7:00 P.M. During an interview on 1/29/15 at 11:50 A.M., CNA C said on 12/18/14, the resident was on hourly checks. The only concern about the resident reported by the outgoing CNA was raspy breathing. Staff administered oxygen and breathing treatments which appeared to help. At the beginning of the evening shift that day, the resident appeared to be experiencing a change in condition related to his/her breathing. CNA C could see the resident struggling to breathe. CNA C went and got Nurse G who assessed the resident and provided notification of the resident's change in condition to the resident's physician and administrative staff. CNAs, certified medication technicians and nurses were in and out of the resident's room at different times for different reasons. The resident was not talking. He/she lay in bed, gazing off into space. CNA C said he/she did not see any food in the resident's room and did not see anyone feed the resident. During interviews on 1/20/15 at 1:31 P.M. and 1/29/15 at 11:41 A.M., Nurse G said he/she was the charge nurse on the resident's hall on 12/18/14. Normally, Nurse G would go in and swab the resident's mouth, but the resident did not need his/her mouth swabbed that day. The dinner service began at around 5:00 P.M. or 5:15 P.M. To Nurse G's knowledge, no one fed the resident. Nurse G attempted to suction out the resident's mucous between 5:00 P.M. and 6:00 P.M. and got nothing back. The suctioning tube did not appear to hit anything when he/she inserted it. When the resident became short of breath, Nurse G checked the resident's oxygen saturation and found that it was low. He/she contacted the resident's physician and received an order for [REDACTED]. Nurse G prepared the transfer paperwork which consisted of POS and a transfer form upon which was documented a body assessment, vital signs and responses to a series of medical questions. When the paramedics arrived, Nurse G walked down the hall to the resident's room with them and discussed the resident's condition. CNA C was present. Nurse G and CNA C helped them transfer the resident to the stretcher. During an interview on 1/22/15 at 3:10 P.M., CNA C said he/she went into the hall when the paramedics arrived and stayed in the hallway attempting to console CNA B. Nurse G remained in the room with the paramedics the entire time, providing them with a report on the resident's condition and transfer paperwork. During an interview on 1/28/15 at 9:34 A.M., the administrator said the facility did not have a transfer sheet on file for the resident's trip to the hospital on [DATE]. Review of the resident's hospital records, dated 12/18/14, included the emergency services pre-hospital care report and all transfer paperwork received from the facility which consisted only of the resident's physician's orders, dated 12/15/14 through 1/14/15. Review of the resident's emergency services patient care report, dated 12/18/14, showed the call for service was received at 6:49 P.M. and the paramedics arrived at the facility at 7:17 P.M. As paramedics entered the room, staff said the resident was having some respiratory distress and was put on 8 liters per mouth of oxygen via a non-rebreather. Staff then exited the room and could not be found again. The resident was semifowlers (lying on the back with the HOB elevated to a 30 degree angle) unable to communicate with the paramedics. Family on the scene reported that the resident's normal mentation was alert and oriented times zero. The resident was alert to voice, but not oriented. A four lead EKG (electrocardiogram) showed sinus/sinus [MEDICAL CONDITION](acceleration of a normal, steady heartbeat) throughout. During an interview on 1/28/15 at 5:00 P.M., the Paramedic said when he and the Medic arrived at the facility, staff gave them paperwork on the resident and directed them to the resident's room. They entered the room and attempted to get report from staff on the resident's condition, but everyone in the room left. Nurse G did not walk down the hallway with them or assist them with transferring the resident from the bed to the stretcher. Due to the resident's condition, he did not want to wait to locate staff. The resident was visibly struggling to breathe. They gave hospital staff all of the paperwork they received from the facility. During an interview on 1/28/15 at 5:05 P.M., the Medic said Nurse G did not walk down the hallway with them or assist them with transferring the resident from the bed to the stretcher. There were family members, but no staff members in the room. The resident was having a pretty tough time breathing. He/she almost appeared to be asleep and was not alert enough to respond to their questions. The resident's eyes might have been open, but he/she was staring off at nothing. Review of the resident's hospital records, dated 12/18/14, showed the resident arrived at the hospital at 7:22 P.M. with a chief complaint of shortness of breath. Staff at the facility was unable to tell the paramedics how long the resident had been short of breath or how long he/she was at his/her current mental status. The resident was breathing at a rate of 40 times per minute, not regarding the examiner or protecting his/her airway. Staff prepared to intubate him/her at 7:27 P.M. Hospital staff found green beans and other food items upon insertion of the airway and orogastric tube (inserted through the mouth to the stomach). The resident also presented with thick, yellow or green sputum upon suctioning. The resident developed unstable vital signs. Hospital staff documented at 9:12 P.M., the provision of approximately 60 minutes of critical care which included providing fluids, vasoactive medications (increases or decreases blood pressure and/or heart rate), oxygen, neuro checks, vent management, interpretation of diagnostic tests, review of nursing home records and discussions with intensive care unit staff. During an interview on 1/29/15 at 9:17 A.M., the emergency room nurse said when the resident arrived in the emergency roiagnom on [DATE], he/she was visibly struggling to breathe with his/her mouth open and audible heavy breathing. The resident's eyes were not open and he/she was not alert. When they attempted to intubate the resident, they discovered a large quantity of soft food consisting of a medley of mixed vegetables which included carrots and string beans. The resident aspirated on the food, which impeded the resident's breath and began drooling out of the resident's mouth. He/she was critically ill and required an advanced airway (stoma device implanted in the windpipe) with large bore access to the central line (vascular access for rapid fluid and blood administration for trauma/resuscitation). The physician and all emergency room nurses had to work on the resident for thirty minutes to an hour in order to get him/her stabilized. The emergency room nurse had to remain at the resident's bedside for at least one hour afterwards in order to attend to him/her and to monitor his/her condition. Review of the facility's menu for the week of 12/14/14 through 12/20/14, showed the following: -On 12/14/14, a lunch side dish of broccoli and dinner side dish of mixed vegetables; -On 12/15/14, a lunch side dish of green beans with onions and dinner side dish of peas; -On 12/16/14, a lunch side dish of carrots; -On 12/17/14, a lunch side dish of lima beans; -On 12/18/14, a dinner entree of chicken pot pie and a side dish of broccoli. Review of the facility's recipe for chicken pot pie showed the following vegetables: peas, carrots and diced potatoes. During interviews on 1/29/15 at 1:58 P.M. and 2/17/15 at 12:21 P.M., the Dietary Manager said the facility served frozen mixed vegetables. The brand currently on hand included green beans, carrots, lima beans, corn and peas. CNAs delivered and passed food trays to the residents. CNAs were allowed to request just a bowl or plate of food without presenting a dietary order ticket. During an interview on 1/20/15 at 11:51 A.M., the Assistant Dietary Manager said the resident's puree diet order was in force for the month of December 2014. The dietary department received a pink dietary communication sheet from nursing staff whenever a resident's dietary order needed to be changed. During an interview on 1/23/15 at 3:56 P.M., the resident's physician said the food that the hospital staff discovered in the resident's throat likely caused the sudden spike in the resident's respiratory symptoms due to aspiration. Anytime someone with difficulty swallowing, who was already evaluated by a SLP and determined not to be capable of eating, was fed they were at risk for aspiration pneumonia. It was very important for staff to give report on a resident's condition to the paramedics they contacted for transport of the resident. The resident more than likely aspirated on 12/18/14. Review of the undated facility policy titled, Resident Transfer to Hospital/Health Care Facility showed direction for staff to utilize a transfer form and document changes occurring within 48 hours which included: abnormal blood sugars, uncontrolled blood pressure, significant changes in vital signs, respiratory concerns, change in baseline functioning, abnormal labs and diagnostic studies, increased confusion, medication issues, complaints of pain/discomfort, falls, as well as signs and symptoms of infection. Staff was to make a copy of the transfer sheet and send it with the resident to the receiving healthcare facility. Staff was to place the original transfer sheet in the box belonging to the Director of Medical Records after the resident's transfer out of the facility. Review of the facility policy titled Abuse, Neglect, Grievance procedures, signed by the administrator on 10/7/11, showed the definition of Class I neglect as failure of an employee to provide reasonable and necessary services to maintain the physical and mental health of any resident when that failure presented either imminent danger to the health, safety, or welfare of a resident, or a substantial probability that death or physical injury would result. Class II neglect was defined as failure of an employee to provide reasonable or necessary services to a resident according to the individualized treatment/habilitation plan, if feasible, or according to acceptable standards of care. This included action or behavior, which might cause psychological harm to a consumer due to intimidating, causing fear or otherwise causing undue anxiety. The facility was to provide interventions in situations in which abuse, neglect or misappropriation of resident property was more likely to occur. The supervisor was to identify inappropriate behaviors such as derogatory language and neglectful care. Prevention was to also include assessment care planning and monitoring of residents with needs or behaviors which may lead to conflict or neglect. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had i

Based on observation, interview and record review, facility staff failed to supervise one of four sampled residents (Resident #1) who eloped from an outing. Resident #1 had a mental health diagnosis, which required daily medication management by nursing staff. He/she was missing for seven days and had decompensated such that visual and auditory hallucinations became more severe resulting in agitation, paranoia and threatening behavior, requiring an acute psychiatric hospitalization . Facility staff failed to document permission from all four residents' physicians regarding outside facility trips and supervision during outside facility trips, and also failed to document the residents left the facility. (Residents #1, #3, #4 and #5). The census was 133. 1. Review of Resident #1's psychiatric progress note, dated 9/30/11, showed staff reported he/she fixated on thinking he/she was dead or someone was trying to kill him/her. He/she was delusional, had poor insight due to his/her illness, and exhibited disorganized thought processes. The psychiatrist reviewed the resident's lab work, increased the resident's dosage of Haldol (medication used to treat psychotic disorders) to 15 milligrams (mg) twice a day, and instructed staff to monitor the resident's mood and behavior. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/08/11, showed: -[DIAGNOSES REDACTED]. -Independent ambulation; -Required no assistance for transfers; -Brief Interview for Mental Status (BIMS) was 10 points out of 15 total, indicating moderate cognitive impairment; -Disorganized thinking and delusions; -Two physician visits and one change in medication over the last 14 days. Review of the resident's Elopement Risk Assessment, dated 10/21/11, showed the resident was not physically able to leave the building, exhibited impaired decision making and was not at risk for possible elopement. Review of the resident's psychiatric progress note, dated 10/25/11, showed: -Affect was blunted; -Oriented times two (to self and place); -Limited and impaired insight; -Auditory hallucinations, but he/she was not responding to the internal stimuli of voices telling him/her they were going to kill him/her. Review of the resident's nurse's notes, dated 10/28/11 at 6:00 A.M., showed he/she became agitated and physically aggressive. Staff called "Code Green" (an announcement for available staff to report to a location for assistance in calmly physically restraining a resident, if staff could not calm the resident verbally). The resident did remain calm and did not require physical restraint. Review of the resident's care plan, updated on 11/3/11, showed the following: -He/she exhibited delusional behavior, responded to internal stimuli and had an aggressive and intimidating tone and mannerisms; -Goal: no harm to self or others; -Staff instructions: -Redirect resident to become as calm as possible; -Encourage participation in constructive activity; -Notify the physician of behaviors; -Monitor and report behaviors, remembering safety first. -He/she had dyskinesia (involuntary movements); -Goal: dyskinesia would not affect his/her swallowing; -Staff instructions included: -Monitor for signs of aspiration; -Administer medications. Review of the resident's nursing Monthly Summary, dated 11/20/11, showed: -[DIAGNOSES REDACTED]. -Hallucinations and delusions; -Memory problems; -Little interest or pleasure in doing things; -Transferred and ambulated independently. Review of the resident's Physician's Order Sheet (POS), dated 12/15/11 through 1/14/12, showed: -[DIAGNOSES REDACTED]. -Independent ambulation; -May attend planned home activities as tolerated; -No physician's order or guardian's instructions about attending activities, with or without supervision, held outside of the facility; -Aspirin 325 mg, daily; -Benztropine Mes (reduce the side effects of antipsychotic treatment) one mg, daily; -Divalproex SOD (seizure medication) 500 mg, daily; -Levothyroxine (thyroid medication) 50 mg, daily; -Seroquel XR (antipsychotic) 200 mg, daily; -Sertraline HCL (antidepressant)100 mg, daily; -Haldolperidol (antipsychotic) 5 mg, take three tablets, twice a day; -Lorazepam (antianxiety) one mg, twice a day; -Seroquel XR (antipsychotic) 400 mg, take two tablets, daily; -Lorazepam 2 mg every four hours, as needed, for agitation; -Trazodone 50 mg at bedtime, as needed, for insomnia. Review of the resident's and nurse's notes (which was marked error and crossed out), dated 12/18/11, showed: -At 10:45 A.M., the resident was alert and oriented times one to two. Certified Medication Technician (CMT) M granted the resident permission to leave the secured unit with the activity department escort (AD) D, gave verbal instructions and several reminders to AD D the resident should remain with the escorts AD D and Activity Aide (AA) B at all times. AD D acknowledged his/her understanding. The resident was in stable condition. -At 1:20 P.M., CMT M received a call from Transportation Employee (TE) C that the resident was not at the church building (the site of the outing). -At 1:40 P.M., CMT M called and informed the resident's Public Administrator of the resident's elopement, who instructed CMT M to notify the police department. Review of another nurse's note, dated 12/18/11, showed: -At 10:45 A.M., the resident was alert and oriented times two, quiet and with no present behaviors. The resident was granted permission by the unit CMT to ride with the facility activity department to escort others to church. (The record did not show CMT M's instructions to AD D and the resident.) During an interview on 12/18/11 at 4:45 P.M. and on 12/19/11 at 2:30 P.M., the Director of Nurses (DON) said: -Between 11:00 A.M. and 11:30 A.M. (on 12/18/11), the resident left the facility with Activity Aide B, AD D and Residents #3, #4 and #5 to go to church. AA B and AD D dropped off the residents at the church building. The resident left the service, returned, left again and then did not return. Services end at 1:00 P.M. -At 1:00 P.M., AA B and AD D returned to the church building and the resident was not there. -The resident missed his/her morning medications. Staff did not consider the resident at risk of elopement. -The resident did not attend church every Sunday, but did occasionally attend. -The police began searching at about 3:00 P.M. During an interview on 1/5/12 at 12:38 P.M., CMT M said on 12/18/11, he/she was assigned the role of Team Leader of the secured unit on 12/18/11. The Team Leader was expected to make decisions regarding outside facility trips based upon the resident's care plan. The "error" nurse's note written on 12/18/11, was factual. The administrator told him/her to strike through the notes and write "error," then rewrite the note leaving out conversation with AD D and the resident prior to the outside facility trip. At approximately 10:05 A.M., AD D asked CMT M if the resident could go with the activity staff on an outside facility trip to church. The resident's care plan showed he/she could go to activities, but did not show the resident could stay at an outside activity with or without supervision. The POS did not show authorization from the resident's guardian or physician affording the resident the right to go on outside facility trips. CMT M told AD D the resident could ride in the van, but could not get out of the van or stay at the church building. CMT M repeated and stressed the instructions to AD D. At approximately 1:30 P.M., TE C called CMT M and reported the resident eloped from the church building. CMT M paged AD D and AA B and told them the resident eloped. AD D said, "are you serious?" AD D said he/she forgot about the resident and said AA B was supposed to stay with the residents. AA B said he/she, "had no part in it," but AD D was responsible. CMT M did not know the social services progress notes showed documentation of the resident's guardian's wishes. CMT M did not know nursing staff were expected to contact the social worker about guardianship. Review of AD D's written statement, dated 12/18/11, showed he/she and CMT M told the resident he/she could ride to church. While on the van, the resident was quiet and AD D "didn't even know he/she (the resident) was there." AD D assisted a wheelchair bound resident, Resident #5, out of the back of the van. AD D and AA B left the church building. Because the resident had never ridden to church, AD D and AA B did not realize the resident was not on the bus. AD D and AA B returned to the facility. CMT M told AD D the resident eloped. During an interview on 1/4/12 at 2:15 P.M., AD D said on 12/18/11, he/she asked CMT M if the resident could go to church. AD D did not recall seeing CMT M look in the resident's medical record. CMT M said the resident could go, but if no activity staff were staying, the resident could not stay. CMT M told the resident not to get off the van. Upon arrival at the church building, AA B assisted the ambulatory residents out of the van. AD D assisted a wheelchair bound resident from the back of the van and assumed all the ambulatory residents went into the building. AA B and AD D went back to the facility. It did not dawn on AD D that the resident was not on the bus. It was not routine for the resident to ride to church. The resident did not talk while on the bus. Normally the resident was very talkative. The resident just slipped AD D's mind. Approximately 45 minutes after AA B and AD D returned to the facility, AA B and AD D noticed their error. It was not up to AD D to determine which residents go on outside facility trips. It is up to the activity staff. If AD D transported a group of residents, it was the activity aide's responsibility to stay with the residents and assure all residents got back onto the van. Review of AA B's written statement, dated 12/18/11, showed he/she let the residents out of the van to go into the church. He/she was not used to the resident riding along. During an interview on 1/4/12 at 1:40 P.M., AA B said on 12/18/11, before the van left for the church building, he/she asked AD D why the resident was going with them. When they arrived at the church building, AA B was not paying attention to the resident. AA B had quit staying with the residents who regularly attended, but said he/she should have stayed to supervise the residents. It was really bad and a terrible mistake. The resident was supposed to ride the van, stay on the van and return to the facility. The resident did not attend church. AA B did not take the resident, but rather AD D took him/her. The activity staff were supposed to get permission from the nurse for residents to attend outside facility trips and sign out the resident. AD D was the transporter and AA B was the staff member who collected the residents for outside facility trips. The Activity Director told activity staff which residents were allowed to go out. At the time of each outside facility trip, the nurses were to advise the activity staff if the resident should not attend, based upon the resident's current condition. Review of Resident #3's Quarterly MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -Understood by others and understands; -BIMS scored 15 out of 15 total points, indicating no cognitive impairment; -Lived on the secured unit. During an interview on 12/22/11 at 12:45 P.M., Resident #3 said the residents sat together during church services. Resident #1 left, returned, left again and did not come back. Resident #3 and another member of the church noticed Resident #1 was gone a long time. The church member told TE C. Resident #1 was not on the van when returning to the facility. Resident #1 had not previously ridden the van to church. Review of Resident #4's quarterly MDS dated [DATE], showed: -[DIAGNOSES REDACTED]. -Understood by others and understands; -BIMS scored 15 out of 15 total points, indicating no cognitive impairment; -Lived on the secured unit. During an interview on 12/22/11 at 1:15 P.M., Resident #4 said AA B and AD D took the residents to church. Resident #1 was not, "a church person." Resident #4 was Resident #1's close friend. Resident #4 knew Resident #1 heard voices and missed his/her family. Resident #1 was a talker, but did not talk on the van trip and had not previously gone to church with the facility. It was very strange that Resident #1 got on the van. He/she could not believe that AA B did not stay with Resident #1. During an interview on 12/22/11 at 2:35 P.M., TE C said he/she was not on duty. At approximately 11:20 A.M., he/she first saw the resident seated in the services and saw the resident leave the services and return. Approximately 30 minutes into the services, TE C did not see the resident get up a second time. One of the church members told TE C the resident left and did not return. TE C searched for the resident around the building, then notified the facility. He/she knew the resident and did not think it was appropriate to take the resident out of the facility to attend church. He/she did not know AA B did not stay at the church building. Residents were not to leave the facility without an escort. Review of the police report, dated 12/18/11, showed: -At approximately 1:00 P.M., AA B arrived at the facility after transporting residents back from a church service and staff discovered the Resident #1 was missing. AA B returned to the church building in search of the resident and arrived back at the facility at 2:30 P.M. -At 2:37 P.M., AA B notified the police department the missing resident left the church building. Police Officer A responded to the facility and interviewed AA B, who said the resident was last seen at 12:00 P.M., described the resident's appearance, said his/her [DIAGNOSES REDACTED]. Review of mapquest, showed the distance between the facility and the church building was 4.11 miles. Review of Weather Underground, showed from 12/18 through 12/25/11, the highest temperature was 57 degrees Fahrenheit (F) and the lowest temperature was 27 degrees F. During an interview on 12/22/11 at 9:15 A.M., front desk attendant F said he/she did not know of a list of residents at risk for elopement. During an interview on 12/22/11 at 9:30 A.M., the administrator and the DON said: -In 2009, on more than one occasion the resident left his/her previous residence, a residential care facility, and did not return for days such that this facility admitted the resident from a psychiatric center, to the locked unit of the facility, because of his/her psychiatric [DIAGNOSES REDACTED]. -The resident's physician and guardian gave permission for him/her to attend activities outside the facility with staff supervision. -The resident resided on the secured unit in the facility and was independently ambulatory. -On 12/18/11, the resident eloped from the church building. Resident #3 and another church member were the first to notice the resident did not return to the church services. While services continued, the church member notified an off-duty employee of the facility, TE C, who called the facility. -The facility did not in-service nursing staff and activity aides since the resident's elopement regarding facility protocol on all residents that participate in activities outside the facility. During an interview on 12/22/11, at 3:30 P.M., the activity director said she gave AA B permission to leave residents unattended at the church building one time for one occasion. AA B said because AD gave AA B permission to leave residents unattended at the church building one time, AA B thought he/she could continue leaving the residents at the church building without supervision. AA B admitted to AD he/she should have stayed. AA B and AD D did not count the residents when loading and unloading the van. During an interview on 12/22/11 at 3:40 P.M., the social services director did not know if the facility kept a list of residents who were at risk for elopement. During an interview on 12/22/11 at 3:45 P.M. and on 12/29/11 at 3:30 P.M., the admissions director (AD) (previously Social Services Director) said she kept records of conversations with guardians in each resident's social service progress notes. The resident's social service progress notes, showed his/her guardian gave permission for the resident to attend activities outside the facility with the activity staff. She compiled and kept a list of residents who were at risk for elopement, which was current as of three months ago. She added residents to the list if they had previously attempted to elope from the facility. She did not have the resident on the list because he/she had not previously attempted to leave the facility. The resident had not gone on outside facility trips to church. She was responsible for calling a resident's guardian regarding permission for outstrip activities. If nurses wanted to know about a guardian's permission regarding outside facility trips, she expected the nurses to ask her. She did not know of facility policies and procedures regarding procuring information from guardians or communicating that information to facility staff. During an interview on 12/22/11 at 12:45 P.M., nurse P said the resident's baseline behavior included talking about him/herself as being dead, because someone tried to killed him/her. All residents must have an escort to go on outside facility trips, unless due to their behavior, they have been assessed to safely leave the building unescorted. Nurse P did not know what the resident's POS showed, but said in his/her opinion, the resident could leave the building with staff supervision. He/she did not have a list of residents at risk for elopement, but knew the residents, did not know the social worker or anyone in the facility had a list of residents at risk for elopement, did not know the social worker documented this information in social services progress notes and did not know to contact the social worker regarding permission for outside facility trips from a guardian. During an interview on 12/22/11 at 4:00 P.M., AA G said the resident sang, danced and talked a lot, enjoyed the privilege of leaving the secured unit with supervision to smoke. AA G did not recall instructions from the activity director about getting permission from nurses to take residents on outside facility trips, but thought he/she should. When taking residents on outside facility trips, AA G got permission from each resident's nurse, then each nurse recorded that resident's absence on a 15 minute report sheet. Activity staff were to sign out each resident at the front desk. AA G did not know the determining factors a nurse would use regarding outside facility trip privileges. Activity aides were to stay with residents on outside facility trips. The resident had previously gone on van rides, but was not privileged to get off the van at any time during the ride. During an interview on 12/22/11 at 4:15 P.M., AA H said activity staff were expected to ask a charge nurse for permission regarding a resident's attendance on an outside facility trip, but did not know how a charge nurse made that determination. On outside facility trips, activity staff were expected to stay with residents who had psychiatric [DIAGNOSES REDACTED]. During an interview on 12/22/11 at 4:30 P.M., AA J said he/she thought nurses called a resident's guardian regarding that resident's outside facility trip privileges, allowed residents to go on outside facility trips based on their knowledge of a resident's behavior and did not know each resident's POS showed physician's permission regarding outside facility trip attendance. He/she did not know facility expectations regarding supervision of residents on outside facility trips. During an interview on 12/29/11 at 3:40 P.M., staff member (SM) K said on 12/25/11 between 4:00 P.M. and 5:30 P.M., he/she saw the resident at a bus stop. SM K called 911 and the administrator. The resident had known SM K for years; however, the resident did not show signs he/she recognized SM K and acted suspicious. The police and ambulance workers picked up the resident and took him/her to the hospital. Review of the resident's hospital medical records showed: -On 12/25/11 at 5:30 P.M., the physician's emergency room assessment showed the resident's psychotic symptoms were disorganized, suspicious, had loose associations, paranoid delusions, heard voices and reported attempts to kill him/her, his/her body was being grabbed and his/her feet were being stabbed. -On 12/26/11 at 9:00 A.M., the resident was admitted to the psychiatric unit with the [DIAGNOSES REDACTED]. He/she would not allow nurses to perform an assessment. The hospital was unable to obtain medical records from the facility. The psychiatrist ordered Haldol 5 mg, every four hours and Ativan 2 mg every four hours for breakthrough symptoms to promptly control the resident's acute agitation. -On 12/27/11, the psychiatrist's Mental Status Exam showed the resident's chronic paranoid schizophrenia presented with acute exacerbation and personality disorder. The psychiatrist's recommended the resident stay in the psychiatric unit for seven to ten days to try to stabilize him/her. Review of mapquest showed the distance between the facility and the location where the resident was located, was 1.36 miles. During an interview on 12/27/11 at 1:00 P.M., the DON said on 12/25/11, SM K called 911 when he/she saw the resident. The resident would not go willingly with facility staff. The police and an ambulance crew picked up the resident and took him/her to a hospital where he/she was admitted to an acute psychiatric center for stabilization. During an interview on 1/5/12 at 1:00 P.M., the DON said on 1/2/12, the resident returned to the facility. Prior to the resident's elopement, it was not normal for him/her to pace the hallways; however, since his/her return, he/she has been pacing. During an interview on 1/4/12 at 12:10 P.M., Advanced Practice Registered Nurse Board Certified, (APRN) L, who worked under the resident's psychiatrist, said prior to the resident's elopement, he/she was always delusional and responded to internal stimuli and he/she got along with others. Since he/she was off of his/her medication for seven days, his/her delusions, hallucinations and agitation increased. On 1/3/12, APRN L called the facility and received report the resident was pacing the hallways since his/her readmission. The resident needed his/her medications adjusted due to his/her pacing, with the hope the resident would not have to return to the acute psychiatric unit. APRN L expected the facility would have policies and procedures in place to address protective oversight of residents who are at risk for elopement. During an interview on 12/29/11 at 12:36 P.M., physician N said while the resident was in the emergency room , he/she experienced visual and auditory hallucinations that his/her body was being grabbed and there were attempts to kill him/her. His/her thinking was disorganized and his/her verbal responses were not on subject. When the resident was admitted to the acute psychiatric unit, the resident became defensive and agitated, yelling he/she wanted to go to work and would not allow the nursing staff to assess his/her condition. He/she had been without medication for seven days causing decompensation (psychological term used when a person is showing signs of deterioration). He/she expected the facility to have orders from psychiatrists for residents with psychiatric [DIAGNOSES REDACTED]. During an interview on 12/29/11 at 2:40 P.M., the resident's public administrator (legal guardian) said he/she allowed the resident to go with staff supervision on outside facility trips. Facility staff failed to execute those instructions. During an interview on 12/22/11, at 3:30 P.M., AD expected activity staff to provide supervision to residents when on outside facility trips and to follow procedures. She did not have a written policy and procedure, did not have a list of residents at risk for elopement and did not know facility nursing staff completed an elopement risk assessment for each resident. She expected each resident's POS to show whether or not the resident's physician and guardian gave permission for outside facility trips, the activity staff to ask each resident's charge nurse for permission for each resident to go on an outside facility trip, the charge to make a judgement call, based on the resident's behavior, and the activity staff to count residents while loading and unloading the van to assure they have all the residents. Review on 1/9/12, of the facility's residents on elopement precaution list, dated 1/6/12 did not include Resident #1. During an interview on 1/6/12 at 12:00 P.M., the DON said she instructed CMT M to strike through and write, "error" on the nurse's note dated 12/18/11; however, that nurse's note was accurate. CMT M did not write the nurse's note according to the DON's telephone instructions; therefore, the DON instructed CMT M to rewrite the nurse's note. During interviews on 12/22/11 at 9:30 A.M. and 5:30 P.M., the administrator said she expected nursing staff to refer to a resident's POS to determine if the physician and a resident's guardian gave permission for outside facility trips with activity staff and expected activity staff to stay with all residents while attending activities outside the facility. The administrative staff had not provided in-services to staff since the resident's elopement on 12/18/11 and she did not have written policies and procedures regarding protective oversight for residents at risk for elopement or activity staff supervision of residents when on outside facility trips. During an interview on 1/9/12, at 4:30 P.M., the administrator said she expected nursing staff to complete the Elopement Risk Assessment to show an independently ambulatory resident as physically able to leave the building on his/her own even if he/she lived in the secured unit of the facility. 2. Review of Resident #3's Quarterly MDS dated [DATE], showed: -[DIAGNOSES REDACTED]. -Understood by others and understands; -BIMS scored 15 out of 15 total points, indicating no cognitive impairment; -Lived on the secured unit. Review of the residents current POS dated 12/15/11 through 1/14/12, showed no documentation the resident's physician granted outside facility trip privileges. The resident's most recent care plan provided by the DON, dated 1/28/04 and not updated, showed no documentation instructing staff regarding outside facility trips. 3. Review of Resident #4's quarterly MDS dated [DATE], showed: -[DIAGNOSES REDACTED]. -Understood by others and understands; -BIMS scored 15 out of 15 total points, indicating no cognitive impairment; -Lived on the secured unit. Review of the residents current POS dated 12/15/11 through 1/14/12, showed no documentation the resident's physician granted outside facility trip privileges. The resident's most recent care plan provided by the DON, dated 3/17/11 and updated on 5/11/11, showed no documentation instructing staff regarding outside facility trips. 4. Review of Resident #5's Quarterly MDS dated [DATE], showed: -[DIAGNOSES REDACTED]. -Understood by others and understands; -BIMS scored 14 out of 15 total points, indicating minimal cognitive impairment; -Transferred with the assistance of one staff person; -Non-ambulatory, but independent with a wheelchair. Review of the residents current POS dated 12/15/11 through 1/14/12, showed no documentation the resident's physician granted outside facility trip privileges. The resident's care plan, dated 1/14/10 and updated on 12/7/11, showed no documentation instructing staff regarding outside facility trips. 5. Review of the facility's Resident Sign-in/out Sheet kept at the front desk and dated 12/18/11, showed Residents #1, #3, #4 and #5 names listed with the destination of church; however, did not show the time the residents left or returned. Review of Residents #1, #3, #4 and #5's current Sign-in/Sign-out Sheets kept in their medical records showed on 12/18/11, no documentation the residents left the building, nor a signature of a person accepting responsibility for the resident. NOTE *At the time of the abbreviated survey, on 01/06/12, the violation's grid placement was "J" immediate and serious jeopardy level. Monitoring visits were conducted on 1/06 and 1/09/12. Based on observation, interview, and record review completed during the onsite visits, it was determined the facility implemented corrective action to address and lower the violation at this time. Per the facility's plan of correction, the DON immediately in-serviced all currently working nursing staff and began the process of inservicing all oncoming nursing staff such that no nursing staff member would work without first receiving instructions to assure no residents, including Resident #1, left the facility without approval from each resident's physician and approval from a guardian (if a resident had a guardian). The instructions included the locations of a Residents on Elopement Precautions list and a photograph of each resident at risk for elopement located at the front desk These lists included Resident #1. Staff interviewed on 01/09/12, were aware of the policies and procedures as described in the immediate in-service information. The Residents on Elopement Precautions list and the photographic list of each resident at risk for elopement was observed at all of the facility instructed locations and at the front desk. Additional in-services are planned to address the full extent of the deficiency. Staff plan to review and update all residents' medical records regarding elopement. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations. MO 706