Every finding on record at Billings Rehabilitation and Nursing LLC

Based on interview and record review, the facility failed to ensure a thorough investigation of a resident-to-resident physical altercation that was completed for 2 (#s 6 and 8) of 12 residents sampled for abuse. This deficient practice could place the residents involved, or others, at risk for abuse, neglect, and negative physical and psychosocial outcomes from abuse. Findings include:A review of a Facility-Reported Incident submitted to the State Survey Agency on 6/26/26 showed resident #s 6 and 8 were in a physical altercation in the activity room. The report showed resident #6 self-reported slapping resident #8 on the evening of 6/25/26. The Facility-Reported incident showed resident #6 had purchased a couch, and the facility staff placed the couch in a common area, where other residents had access to it. Resident #8 had been lying on the couch and was incontinent of urine. Resident #6 became frustrated with resident #8 for soiling her couch and hit resident #8. Although resident #6 slapped #8, the facility did not substantiate abuse. The initial Facility-Reported Incident showed the immediate actions to be taken would be the completion of:-Injury Assessments -Skin assessments-Psychosocial assessments-Risk assessments-Documentation of a review of behaviors-Care plan reviews and interventions updatedThe Facility-Reported 5-day final report showed the facility would complete:-Nursing Assessments-Psychosocial assessments-Cognitive assessments and- Head-to-toe skin assessmentsReview of resident #6's electronic health records showed the facility did not follow their initial plan as submitted to the State Survey Agency. The facility said resident #6 would have immediate actions of the cognitive assessment, psychosocial assessment, behavior review, care plan updates, a medication review, and a risk assessment. Resident #6's PHQ9 (evaluation for depression) and the BIMS (Brief Interview for Mental Status) were not completed until 7/7/26, four days after the final investigation report was due to the State Survey Agency. Review of resident #6's nursing progress note dated 7/11/26 at 11:47 p.m. showed the facility interdisciplinary review of the resident behaviors included the director of nursing, the social services staff, and the Administrator. The root cause identified for the incident was that resident #6 had a history of generalized anxiety disorder, major depressive disorder, and intellectual disability. The preventative measures put into place included monitoring of the resident's behaviors and documentation of behaviors. Staff were to allow resident #6 to remove herself from situations that were stressful.A review of resident #6's care plan did not include information for the recommended intervention of allowing the resident to remove herself from stressful situations.A review of resident #6's medical record failed to show the facility completed an abuse risk assessment or the identification of the risk she posed to herself or others. Review of resident #8's electronic health record showed the facility did not follow their plan submitted to the State Survey Agency for the Facility-Reported Incident.Review of an interdisciplinary team progress note dated 7/11/26 at 11:35 p.m. showed the team consisted of the director of nursing, social services, and the administrator. The interdisciplinary team reviewed the incident when resident #8 was hit by resident #6. The intervention was to increase the frequency of offering the resident assistance with toileting every two hours. Review of resident #8's electronic health records showed the facility said resident #8 would have the immediate actions of: a cognitive assessment, psychosocial assessment, behavior review, care plan updates, and an abuse risk assessment. Resident #6's PHQ9 (evaluation for depression) was completed 7/23/26, twenty days after the final investigation report was due to the State Survey Agency.Review of resident #8's BIMS (Brief Interview for Mental Status) completed on 5/15/26, which was prior to the altercation with resident #6, but there wasn't one completed after it, as noted by the IDT review.On 7/27/26 at 12:31 p.m., the risk assessments were requested for resident #s 6 and 8. No risk assessment was received by the end of the survey on 7/28/26.During an interview on 7/28/26 at 8:06 a.m., staff member B said all information the facility had for the abuse allegation was included in the folder which was sent to the State Survey Agency. Staff member B said the PHQ9 would be an assessment that monitors depression and should have been completed between the allegation of abuse and the submission of the final report. Staff member B did not know why the assessments (PHQ9 and BIMS) were not completed right away and not done until after the final report was submitted.

Based on interview and record review, the facility failed to report an allegation of resident abuse in the required timeline for 2 (#s 6 and 8) of 12 residents sampled for timeliness of reporting abuse allegations. Findings include: A review of a Facility-Reported Incident for an event that occurred on 6/25/26 was submitted to the State Survey Agency on 6/26/26 after the administration became aware of a physical altercation between resident #6 and resident #8. The incident's five-day final report was not submitted to the State Survey Agency until 7/4/26, reflecting it was reported late.During an interview on 7/28/26 at 8:00 a.m., staff member A said the initial abuse report was submitted on 6/26/26, as soon as the facility became aware of the physical altercation between resident #6 and #8. Staff member A said the event was investigated, and the final report was completed. Staff member A said the company policy was that all abuse reports must be reviewed and approved by the Regional Operations Director and the Regional Nurse. The final report was sent to the corporate regional staff on 7/3/26. Staff member A said the corporate staff approved the report, so it should have been submitted. Staff member A said he was the person responsible for submitting reports and had no idea why the final report was submitted late.

Based on interviews and record review, the facility failed to ensure the physician was notified of a resident's change in condition of her mental status for 1 (#1) of 17 sampled residents. This deficient practice resulted in resident #1 being discharged from the facility involuntarily on 5/18/26 at 9:50 p.m. for behaviors related to threatening others in the building, to an unsafe environment. Findings include:During an interview on 5/20/26 at 1:48 p.m., staff member O stated resident #1 came to her on 5/16/26 and stated, My roommate needs to be out of my room tonight or something's going to happen. Staff member O stated she did not ask any questions or what the statement meant. Staff member O stated resident #1 asked several times if the roommate would be moved and once the staff moved the roommate to another room, resident #1 repeatedly thanked her. Staff member O stated resident #1 seemed to be happy and pleasant on 5/17/26. Staff member O stated staff member U came to her on 5/18/26 at the start of her shift and reported resident #1 had made a threat to staff saying, I need to be moved, or my roommate needs to move or something physical is going to happen. Staff member O stated she did not ask questions as to what the resident's needs were or what the threat meant. Staff member O stated she did not document the behaviors because she did not know where to document them.During an interview on 5/20/26 at 2:57 p.m., staff member C stated she was alerted of resident #1's violent history via text from a staff member on 5/17/26. Staff member C stated resident #1 could not articulate her needs based on her schizophrenia diagnosis and could only state, I'm feeling agitated. Staff member C stated resident #1 had done the right thing by notifying her nurse that something was triggering her by going to the nurse and saying she wanted to hurt someone. Staff member C stated the facility staff had de-escalated, separated and monitored the situation so the physician was not contacted. Staff member C stated the facility was able to maintain safety and a safe environment. Staff member C stated resident had not had threatening behaviors prior to the evening of 5/16/26. Staff member C stated the facility contacted the psychiatrist on 5/18/26. Staff member C stated she had not considered contacting the physician during behaviors because the facility was not sure the behaviors were a change from her baseline. Staff member C stated she had not considered contacting the physician for a medication addition or adjustment to assist with behaviors (threats to harm others).Review of resident #1's Progress Notes, dated 5/11/26 - 5/19/26 showed resident #1 had a BIMS (Brief Interview for Mental Status) of 9 (moderate cognitive impairment). On 5/16/26 the nurse documented resident #1 had moved to a new room and the roommates seemed to be getting along well. On 5/18/26 the progress note showed resident #1 had stated to the medication aide, if my roommate isn't moved out of my room tonight something bad is going to happen. The progress notes showed resident #1 was grateful when her roommate was moved out and repeatedly thanked the staff. On 5/18/26, the progress note showed resident #1, came to her and stated she needed to change rooms because her roommate was a bitch and was threatening the roommate.Review of the facility policy, Notification of Changes, dated 4/4/26, showed:- . The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.- . Circumstances requiring notification include:- . 2. Significant change in resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.

Based on interviews and record review, the facility failed to ensure a resident who was involuntarily discharged was discharged to a safe environment; and failed to ensure the medical record included physician documentation of the dangers of the resident remaining in the facility would pose, interventions attempted, and efforts to meet resident's needs for 1 (#1) of 17 sampled residents. This deficient practice resulted in resident #1 being discharged to a home with a caregiver who had expressed she was unable to care for resident #1. Findings include:During an interview on 5/20/26 at 12:42 p.m., NF2 stated she was contacted by the facility the evening of 5/18/26, and she was told resident #1 was threatening residents and the facility would be calling the police department and resident #1 could no longer stay at the facility and was being discharged . NF2 stated she told staff member C she would drive over immediately. NF2 stated the facility was already aware of resident #1's violent behaviors in the past and NF2 had told the facility she believed resident #1's medications were off (not as high of doses as she previously took at home). NF2 stated she reminded the facility a tree had fallen on her house and it was not a safe place for resident #1 to discharge to, as the roof was caving in. NF2 stated she was given the choice of resident #1 going to jail or taking resident #1 back home so she took her home to her house. NF2 stated she told the facility she could no longer care for resident #1 when she brought her to the facility on admission on [DATE]. NF2 stated nothing had changed in the week since resident #1 came to the facility and she still could not take care of her. NF2 stated she had not received any notifications of behaviors until the morning of the day resident #1 was discharged . NF2 stated she refused to sign the discharge papers because she did not believe it was right to force resident #1 to leave without notice or threaten resident #1 with calling the police if she did not discharge. NF2 stated resident #1 had not been violent since she quit drinking alcohol four years prior and really felt her behaviors were medication related.During an interview on 5/20/26 at 1:09 p.m., resident #2 stated she was roommates with resident #1 before she left. Resident #2 stated resident #1 never threatened her or was mean or nasty towards her.During an interview on 5/20/26 at 1:15 p.m., resident #3 stated she was roommates with resident #1 and they were friends. Resident #3 stated they had meals together and resident #1 was always nice to her. Resident #3 stated resident #1 moved to a different room because she was too noisy, but they remained friends afterwards. Resident #3 stated resident #1 never threatened her.During an interview on 5/20/26 at 1:19 p.m., staff member C stated resident #1 was discharged because she was making threats about her peers (not anyone specific) to staff member O. Staff member C stated resident #1 stated, If someone doesn't leave me alone or go away, something bad is going to happen. Staff member C stated resident #1 was discharged on 5/18/26.During an interview on 5/20/26 at 1:27 p.m., staff member A stated resident #1 had a history of killing her husband, and a history of parole and making threats. Staff member A stated resident #1 was discharged because she was a danger to other residents. Staff member A stated resident #1 and NF2 did not agree to the involuntary discharge. Staff member A stated resident #1 mentioned her feelings (threats) to the staff and did not mention a specific resident.During an interview on 5/20/26 at 1:48 p.m., staff member O stated resident #1 came to her on 5/16/26 and stated, My roommate needs to be out of my room tonight or something's going to happen. Staff member O stated she did not ask any questions or what the statement meant. Staff member O stated resident #1 asked several times if the roommate would be moved and once the staff moved the roommate to another room, resident #1 repeatedly thanked her. Staff member O stated resident #1 seemed to be happy and pleasant on 5/17/26. Staff member O stated staff member U came to her on 5/18/26 at the start of her shift and reported resident #1 had made a threat to staff saying, I need to be moved, or my roommate needs to move or something physical is going to happen. Staff member O stated she did not ask questions as to what the resident's needs were or what the threat meant. Staff member O stated she did not document the behaviors because she did not know where to document them. Staff member O stated she called staff member C, kept the roommates separated, and staff member A arrived at the facility. Staff member O stated she was present during the meeting between staff member A and NF2. Staff member O stated, Unfortunately, after conversations with the staff, we (the facility) are moving forward with discharge. Staff member O stated NF2 was upset and stated, You'll be hearing from our lawyers. This is your plan, not mine. You are using her past against her. Staff member O stated NF2 refused to sign the discharge papers.During an interview on 5/20/26 at 2:57 p.m., staff member C stated she was alerted of resident #1's violent history via text on 5/17/26, from facility staff who had researched her murder case on the internet and sent staff member C a news article. Staff member C stated resident #1 could not articulate her needs based on her schizophrenia diagnosis and could only state, I'm feeling agitated. Staff member C stated resident #1 had done the right thing by notifying her nurses that something was triggering her. Staff member C stated the facility staff had de-escalated, separated and monitored the situation. Staff member C stated the facility was able to maintain safety.During an interview on 5/20/26 at 3:07 p.m., staff member H stated she reached out to resident #1's psychiatrist on 5/18/26 and medication doses were corrected to match doses resident #1 was receiving at home, and face to face was scheduled between the psychiatrist and resident #1.During an interview on 5/20/26 at 3:14 p.m., with staff members A, C, and J, staff member C stated medication changes made by a psychiatrist usually take 14-30 days to take full effect. Staff member A stated he did not offer NF2 the option of an evaluation at the hospital for resident #1. Staff member A stated he told NF2 resident #1 must discharge immediately. Staff member A stated he should have offered NF2 the option of hospital evaluation before discharging resident #1. Staff member C stated when she received staff reports of several threats, it raised her hackles so she escalated the discharge process. Staff member C stated she was not aware of resident #1's criminal history until 5/17/26. Staff member C stated she found out resident #1 had murdered her husband and was charged in 2016 for assaulting NF2 with a knife. Staff member C stated resident #1 had two different roommates, was on 15-minute checks and was discharged . Staff member C stated the facility had not discussed a private room as an intervention for resident #1 and had not used 1:1 staffing as an intervention. Staff member C stated the facility did not have documentation from the physician of the reasons for the need to involuntarily discharge resident #1 because she was a danger to others in the facility. Review of resident #1's Progress Notes, dated 5/11/26 - 5/19/26 showed resident #1 had a BIMS (Brief Interview for Mental Status) of 9 (moderate cognitive impairment). On 5/16/26 the nurse documented resident #1 had moved to a new room and the roommates seemed to be getting along well. On 5/18/26 the progress note showed resident #1 had stated to staff, if my roommate isn't moved out of my room tonight something bad is going to happen. The progress notes indicated resident #1 was grateful when her roommate was moved out and repeatedly thanked staff. On 5/18/26, progress notes indicated resident #1, came to her and stated she needed to change rooms because her roommate was a bitch and was threatening the roommate. On 5/18/26, progress notes showed NF2 refused to sign the notice of discharge form before leaving with the resident. On 5/19/26, progress notes indicated resident #1 had discharged at 9:50 p.m. on 5/18/26 and the on-call physician was notified at 11:10 p.m. On 5/19/26, progress notes indicated a clarification note reflecting, Resident [#1] did not directly threaten roommate, resident [#1] did come to this nurse to inform me of her feelings.Review of resident #1's Notice of discharge, dated 5/18/26, showed resident #1 was being discharged because: The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. The notice stated resident #1 was being discharged without 30-day notice because: The resident poses an immediate danger to the safety of the other individuals in the facility. The notice also stated resident #1 was being discharged , home with friend [NF2]. The resident/resident representative signature line was not signed.Review of resident #1's Care Plan, dated 5/18/26, showed:- Resident #1 admitted on [DATE], and- .Diagnosis: Anxiety disorder, Schizoaffective disorder, Bipolar type, Depression ., - .Focus: The resident has a potential psychosocial well-being problem r/t anxiety, Dependent behavior, Inability to problem solve, alcohol dependence, history of violent behavior,- Interventions: When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings., - .Focus: Mood & Behavior: History for an alteration in mood or exhibition of behavioral symptoms r/t: Anxiety, Depression, Schizophrenia. Resident may have behaviors that include but are not limited to irritability, agitation, anxiousness, verbal or physical aggression. - Interventions: Administer medications as ordered, Allow resident time to calm down and reapproach at a later time, Evaluate for need and refer to psychological counseling as recommended by physician, interact in an empathetic and supportive manner, monitor and document each behavior event, offer 1:1 interaction as needed, offer psychosocial support as needed., and -Focus: Discharge Planning: [Resident #1] will continue to stay in the facility as a long-term care resident due to the inability to care for self outside of this setting.Review of the facility's policy, Transfer and Discharge, dated 3/20/26, showed: - 9. Non-Emergency Transferor Discharges:- c. In situations where the facility determines a resident's clinical or behavioral status endangers the safety or health of individuals in the facility, documentation regarding the reason for the transfer or discharge will be provided by a physician.

Based on interview and record review, the facility failed to initiate and implement a baseline care plan for 1 (#1) of 17 sampled residents. This deficient practice resulted in resident #1's needs not being addressed by staff when resident #1 had behaviors. Findings include:Review of resident #1's medical record showed the record lacked a baseline care plan. A comprehensive care plan was initiated on 5/18/26. Resident #1 was admitted on [DATE].During an interview on 5/20/26 at 3:28 p.m., staff member C stated she was not aware resident #1 did not have a baseline care plan. Staff member C stated resident #1 should have a baseline care plan in place. Review of the facility's policy, Baseline Care Plan, dated 4/4/26, showed:- The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.- 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission.

Based on observation and interview the facility failed to ensure infection control processes were followed during wound care to promote healing of a pressure wound for 1 (#15) of 3 sampled residents. This deficient practice had the potential to increase the risk of infection in the resident's Stage III pressure wound. Findings include:During an observation and interview on 5/21/26 at 8:56 a.m., with staff member T and NF3, staff member T opened resident #15's brief on the left side. Resident #15 was reported to have a Stage III pressure ulcer to her left buttock. Resident #15 had dried feces on the lower left side of her buttocks and had actively started to have a bowel movement. Staff member T cleaned the feces from resident #15. Staff member T cleansed the Stage III pressure wound with Vaish cleanser, and NF3 applied a dressing. NF3 left the room and staff member T requested staff member Q to assist in positioning resident #15 after the wound care. Staff member T and staff member Q placed the dirty brief back on resident #15 after the dressing change and left the dirty bed pad under resident #15. Staff member T and Q positioned resident #15 and covered her with blankets.During an interview on 5/21/26, at 9:29 a.m., staff member T stated, I wasn't even thinking. We put the dirty brief back on her. We will go back and change her (resident #15). I didn't even think.

Based on observations, interviews, and record review, the facility failed to ensure a resident, who was at risk of elopement, was supervised and doors were secured for 1 (#5) of 5 sampled residents. This deficient practice resulted in resident #5 eloping from the facility overnight, and found by police the next day. Findings include:Review of a facility investigation for resident #5's elopement, dated 4/16/26, showed resident #5 exited the facility unattended on 4/16/26 at approximately 10:00 a.m. Resident #5 was identified as a high risk for elopement, and had a WanderGuard device in place. Resident #5 had a BIMS of 7, indicating severe cognitive impairment. Resident #5 was located on 4/17/26 and transported to the hospital for evaluation. Resident #5 was found to have no injuries.Review of the facility's document, Root Cause Analysis, dated 4/21/26, showed the root cause of the elopement was identified as, failure of a staff member to follow established facility policies and procedures related to elopement prevention, resident supervision, and Wander guard monitoring process. The document showed interventions to include a, full system check of all exit doors and Wander guard systems by the Maintenance Director and Nursing Home Administrator.During an observation on 5/20/26 at 8:32 a.m., with staff member C, several exit doors in the facility were tested and the following was revealed. The hall D exit door was tested, and the alarm was sounding so quietly, it could not be heard. The Activities, no smoking exit door, was not sounding when tested with a WanderGuard. The dining room door did not have a WanderGuard alarm but did have a screamer alarm. When testing the dining room exit door, staff member C found the screamer alarm was turned off.During an interview on 5/20/26 at 9:02 a.m., staff member D stated he and staff member A tested the doors last night (5/19/26) and must have forgotten to turn the alarms back on. Staff member D stated he did not know he should be checking the sound on the alarms. Staff member D stated he would walk down the hall and look for the light on the WanderGuard box on the wall to light up, and considered the lights as the alarm system was working. Staff member D stated he used to check the screamer alarms, but he stopped when the task dropped off his work order system.During an observation and interview on 5/20/26 at 9:08 a.m., staff member C tested resident #12's WanderGuard bracelet with the tester box and the bracelet did not work. Staff member C tested resident #18's bracelet and the bracelet did not work. Staff member C took both residents to the door and the alarms went off. Staff member C stated the tester was not working. Staff member C stated the tester was to be used each shift by the floor staff to check the bracelets. Staff member C stated she had not received any reports of the tester not working but would order a new one immediately.During an observation and interview on 5/20/26 at 8:45 p.m., the dining room doors were closed and lights were off. The doors were not locked, allowing residents to enter. Resident #14 entered the dining room at 9:02 p.m. Resident #14 was in the dining room, in the dark for seven minutes when he walked back out of the dining room. Staff member C noticed resident #14 exiting the dining room and assisted him back to his hall. Staff member C tested the dining room door and found the screamer alarm was off. The door did not have a WanderGuard system box on the wall. When the dining room doors were closed, the screamer alarm could not be heard outside the dining room. Staff member C stated the dining room doors were closed because too many residents were congregating in the dining room at night, leading to behaviors. Staff member C stated she had not considered residents wandering into the dining room and exiting the dining room exit door.During an interview on 5/20/26 at 9:12 p.m., staff member V stated it was confusing trying to keep track of which residents were allowed outside because it was continuously changing.During an interview on 5/20/26 at 11:00 p.m., staff member A stated he decided to lock the dining room doors until a WanderGuard could be applied to the exit door or other arrangements could be made.Review of the facility's policy, Elopements and Wandering Residents, dated 4/30/26, showed:- . This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .- . 1. The facility is equipped with door locks/alarms to help avoid elopements.

Based on interview and record review, the facility failed to report allegations of abuse to the State Survey Agency (SSA) within the required timeframe of an allegation of sexual abuse for 1 (#73); and failed to report the investigative findings for allegations of abuse for 4 (#s 10, 46, 67 and 76) of 25 sampled residents. Findings include:1. Review of resident #73's Behavior Progress Note, dated 12/14/25, showed: Resident has repeatedly been removed from female resident rooms. Resident has also been rubbing legs of other female residents. Resident has been repeatedly corrected by staff and educated on inappropriate behavior. During an interview on 2/24/26 at 4:51 p.m., staff member A stated they were reviewing a former resident's chart (resident #73) who wanted to return to the facility. Upon the review, they noted a progress note which should have been a reportable event, sent to the State Survey Agency, but had not been reported. Staff member A stated they did not know of the incident before the review and would be making a late report to the State Survey Agency regarding the incident. Staff member A stated a staff member noticed resident #73 had his hand on resident #46's thigh while he was assisting the resident to eat. He stated the aide (staff member N) who witnessed the incident and asked the resident to remove his hand from the resident's thigh, which he did, and the aide reported the incident to the nurse on duty (staff member O). Staff member A stated staff member O did not report the incident. He stated the expectation was for staff to report allegations of resident-to-resident abuse or inappropriate contact immediately or within two hours of the incident. During an interview on 2/24/26 at 5:05 p.m., staff member N stated she witnessed resident #73 assisting resident #46 with eating. She stated resident #73 had his hand on resident #46's thigh. She said she did not feel that it was appropriate for resident #73 to have his hand on her thigh, and she asked the resident to keep his hands to himself. Staff member N stated the resident removed his hand from the resident #46's thigh, but he did place his hand again on her thigh. Staff member N stated she asked resident #73 to remove his hand again from resident #46's thigh, which he did. Staff member N stated she did not feel it was appropriate and reported the behavior to the nurse on duty, staff member O. During an interview on 2/25/26 at 11:21 a.m., staff member O stated he was informed by staff member N that resident #73 kept placing his hand on resident #46's thigh while he was assisting her with eating. Staff member O stated he did not observe the behavior but did not feel the behavior was sexual or predatory in nature. He stated he made a note of it in the resident's behavior charting but did not report the incident. He stated he had received Relias training on the different forms of abuse and when and to whom to report any concerns or incidents. 2. Review of a facility reported event dated 1/7/26, showed residents #10 and #76 were involved in a verbal altercation. Investigation findings were due to the State Survey Agency on 1/14/26. The facility reported the investigation findings late on 1/15/26. During an interview on 2/25/26 at 2:58 p.m., staff member A stated the facility had an Administrator in Training who was submitting reportable events and investigation findings to the State Survey Agency. Staff member A stated the investigation findings for the facility reported event on 1/7/26 were due on 1/14/26. Staff member A stated the investigation findings were submitted on 1/15/26. Staff member A stated he received alerts when findings were due and reminded the facility of the due dates. Staff member A did not know why the findings were submitted late. 3. Review of a facility reported event, dated 2/2/26, showed that resident #67 reported verbal abuse by a staff member. Investigation findings of the verbal abuse event were due to the State Survey Agency on 2/9/26. The facility reported the investigation findings late on 2/10/26. During an interview on 2/25/26 at 2:58 p.m., staff member A stated the facility had an Administrator in Training who was submitting reportable events and investigation findings to the State Survey Agency. Staff member A stated the investigation findings for the facility reported event on 2/2/26 were due on 2/9/26. Staff member A stated the investigation findings were submitted on 2/10/26. Staff member A did not know why the findings were submitted late. Review of a facility policy titled, Abuse, Neglect, and Exploitation, implemented 4/11/25, showed: . VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. . B. The Administrator will follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on interview and record review, the facility failed to complete Quarterly MDS assessments in the required timeframe of 14 days after the ARD for 6 (#s 5, 7, 9, 10, 11, and 55) of 25 sampled resident assessments. Findings include:During an interview on 2/26/26 at 8:48 a.m., staff member M stated he started covering as the MDS Coordinator at the end of December 2025. Staff member M stated he believed the facility had Quarterly MDS's that were late when he started. Staff member M stated he was not sure why they were late.- A review of resident #11's medical record showed a Quarterly MDS was scheduled with an ARD of 12/18/25. The Quarterly assessment was due to be completed on 1/1/26. The MDS was completed late on 1/8/26.- A review of resident #55's medical record showed a Quarterly MDS was scheduled with an ARD of 12/23/25. The Quarterly assessment was due to be completed on 1/6/26. The MDS was completed late on 1/8/26.- A review of resident #7's medical record showed a Quarterly MDS was scheduled with an ARD of 1/1/26. The Quarterly assessment was due to be completed on 1/15/26. The MDS was completed late on 1/19/26.- A review of resident #5's medical record showed a Quarterly MDS was scheduled with an ARD of 1/9/26. The Quarterly assessment was due to be completed on 1/23/26. The MDS was completed late on 2/2/26.- A review of resident #10's medical record showed a Quarterly MDS was scheduled with an ARD of 1/15/26. The Quarterly assessment was due to be completed on 1/29/26. The MDS was completed late on 2/2/26.- A review of resident #9's medical record showed a Quarterly MDS was scheduled with an ARD of 1/19/26. The Quarterly assessment was due to be completed on 2/2/26. The MDS was completed late on 2/4/26.A review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, effective 10/1/25, showed: . Chapter 2: Assessments For the Resident Assessment Instrument (RAI). Quarterly (Non-Comprehensive) . MDS Completion Date. No Later Than. ARD +14 calendar days.

Based on interview and record review, the facility failed to complete a Comprehensive MDS assessment in accordance with the required timeframe of the 14th day of the residents stay for 1 (#67) of 25 sampled residents. The failure had the potential to prevent the resident from achieving their highest practicable level of function. Findings include:During an interview on 2/25/26 at 2:58 p.m., staff member A stated the previous MDS Coordinator left the position in late November 2025 or early December 2025, and there was a lapse in coverage of the position duties prior to the current MDS Coordinator starting. Staff member A stated this may have contributed to the MDS's that were completed late.During an interview on 2/26/26 at 8:48 a.m., staff member M stated he started covering as the MDS Coordinator at the end of December 2025. Staff member M stated he believed the facility had MDSs that were late when he started. Staff member M stated he was not sure why they were late.A review of resident #67's medical record showed an admission date of 1/8/26, and an admission MDS was scheduled with an ARD of 1/14/26. The admission MDS was due to be completed on 1/21/26. The MDS was completed late on 1/22/26.A review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, effective 10/1/25, showed: . Chapter 2: Assessments For the Resident Assessment Instrument (RAI). admission (Comprehensive). MDS Completion Date. No Later Than. 14th calendar day of the resident's admission (admission date +13 calendar days) .

Based on observation, interview, and record review, the facility failed to ensure medications to be administered matched the dose on the medication administration record for 2 (#s 14 and 51), and failed to ensure the medication, Voltaren gel, was measured appropriately for 1 (#14) of 25 sampled residents. This deficient practice resulted in a medication error rate of 10.34%. Findings include:1. During an interview and observation on 2/24/26 at 7:32 a.m., staff member I prepared the morning medications for resident #14. Staff member I stated the MAR and the medication bottle did not match for resident #14's glucosamine chondroitin. Staff member I stated the bottle was half empty and facility staff members had most likely been giving this medication in the past. The medication bottle showed Glucosamine Chondroitin Complex and had the following substances: Vitamin C 30 mg, Manganese 2.5 mg, Sodium 20 mg, Potassium 28 mg, Glucosamine Sulfate 250 mg, and Chondroitin Sulfate 200 mg. The MAR failed to show any other substances were ordered by the physician.Review of resident #14's EHR showed a physician order: Glucosamine-Chondroitin Oral Tablet 250-200 MG .2. During an observation on 2/24/26 at 7:49 a.m., staff member I entered resident #14's room with the medication, diclofenac sodium external gel (Voltaren gel). Staff member I squeezed approximately one tablespoon amount of gel into their gloved hands and rubbed the gel onto resident #14's knees. Staff member I did not measure the Voltaren gel.Review of resident #14's EHR showed a physician's order: . apply 2 gm to both knees 3 times a day. 3. During an observation and interview on 2/24/26 at 8:01 a.m., staff member H was preparing the morning medications for resident #51. Staff member H took out the medication magnesium chloride with calcium. On the back of the bottle it showed a serving size of two tablets: calcium 238 mg and magnesium 143 mg. Staff member H stated, The dose does not match up. Staff member H showed the dose on the MAR did not match the dose on the bottle of the medication. Staff member H stated pharmacy was very easy to contact but instead they used ChatGPT to verify if the dose was correct. ChatGPT showed staff member H could give the medication because the dosage was correct. When staff member H calculated the dosage on paper, the dose for one tablet was 119 mg of calcium and 71.5 mg of magnesium. Review of resident #51's EHR showed a physician order: Slow magnesium/calcium oral tablet delayed release 70-117 mg .

Based on interview and record review, the facility failed to develop an individualized care plan reflecting a resident's past trauma, did not address his desire for sexual activities on the individualized care plan, or initiate behavior monitoring for potential sexual behaviors; and the facility did not identify the need for additional mental health trauma-based services timely for 1 (#73) of 25 sampled residents. This deficient practice increased the resident's risk of negative outcomes and or behaviors continuing to be unaddressed or unmonitored, which could affect 2 residents (#s 22 and 46). Findings include:During an interview on 2/24/26 at 5:05 p.m., staff member N stated she witnessed resident #73 assisting resident #46 with eating. She stated resident #73 had his hand on resident #46's thigh. She said she felt it was inappropriate and asked resident #73 to remove his hand. Staff member N stated she was not aware if resident #73 had a care plan or was to be monitored for any sexual behaviors.During an interview on 2/25/26 at 11:21 a.m., staff member O stated he was informed by staff member N that resident #73 kept placing his hand on resident #46's thigh while he was assisting the resident with eating. Staff member O stated he was not aware if resident #73 had a care plan or was to be monitored for any sexual behaviors.Review of resident #73's Psychosocial admission Assessment, dated 5/30/25, showed, The resident has a current BIMS of 9, indicating that there was moderate cognitive impairment. The resident has some confusion and forgetfulness but is usually oriented to person and place. The resident is able to communicate, he at times has difficulty finding words or using correct words but is able to make his needs known and can understand and follow conversation. The assessment showed the following psychosocial categories for which the resident had identified concerns/needs as: Mental health conditions for trauma/PTSD, substance abuse, behavioral issues, self-efficacy deficits, and lack of coping skills, and .desire for physical/sexual intimacy while in the facility. Social Factors that have been identified to affect the resident, showed, The resident made a comment to [social services] that he was engaged to a fellow resident. Does the resident express desire to engage in sexual activity with others, was checked as yes, and complete the Sexual Activity Capacity to Consent Assessment.Review of resident #73's EMR did not show the Sexual Activity Capacity to Consent Assessment was completed by the facility. A facility request for the Sexual Activity Capacity to Consent Assessment was submitted to the facility on 2/24/26 at 5:00 p.m., no additional documentation was provided by the end of the survey on 2/26/26.Review of resident #73's Social Services Progress Note, dated 6/2/25, showed, During a conversation between [social services] and the resident, the resident was telling [social services] that he is recently engaged. When [social services] asked the resident who he was engaged to, he couldn't remember the name but kept looking around him trying to find someone. [Social services] asked if he was engaged to someone in the facility and he said yes. The resident said she lives down B hall - [social services] asked the resident if it was a specific resident to which the resident said 'yes! Yes that's her!' Staff will monitor any increased behaviors relating to this statement from the resident. [sic]Review of resident #73's Behavior Progress Note, dated 12/14/25, showed: Resident has repeatedly been removed from female resident rooms. Resident has also been rubbing legs of other female residents. Resident has been repeatedly corrected by staff and educated on inappropriate behavior.Review of resident #73's Social Services Progress Note, date 12/24/25, showed, [Social services] was informed by staff that the resident reported plans to marry another resident the next day. [Social services] followed up with the resident, who stated that a minister had been arranged to conduct a wedding ceremony on Christmas Eve at the facility with his partner. [Social services] staff identified the minister as another resident currently residing in the facility. Following discussion with management and both residents involved, it was determined that the wedding would not and could not take place in relation to state refollowing. All parties verbalized understanding of the decision. The resident displayed no signs of distress, however, he did express concern regarding his partner's feelings and stated that he wanted her to know that everything was going to be okay. Admin, DON and resident's brother were all notified. [sic]Review of resident #73's Care Plan, failed to show the facility developed a comprehensive care plan to address the resident's past-trauma history and potential for sexual behaviors.Review of resident #73's TAR and Behavioral Monitoring, from 5/30/25 to 2/26/26, failed to show resident #73's potential for sexual behaviors was monitored by staff.Review of resident #73's Initial Psych Evaluation, dated 12/22/25, showed, . Chief Complaint: Initial psychiatric evaluation History of Present Illness: [AGE] year-old male seen for initial psychiatric evaluation with concerns of moderate recurrent major depressive disorder and inappropriate sexual behaviors in the facility setting . Patient exhibits inappropriate sexual behaviors including entering female residents' rooms and inappropriate touching, requiring frequent staff redirection but is typically easily redirectable . The facility failed to timely ensure a behavioral health evaluation was completed for resident #73 at the time of his admission on [DATE]. During an Interview on 2/24/26 at 3:49 p.m., NF1 stated resident #73 no longer resided at the facility, but while he was there, she started seeing him in December of 2025 for mental health services. NF1 stated resident #73 had been in and out of group homes and had been admitted to the facility when his level of care became too much for the group home. NF1 stated resident #73 was flirtatious and a bit of a ladies' man but was not aware of any inappropriate interactions. She stated she noted hypersexuality for resident #73, not because of any inappropriate touching or behavior, but because the staff had noted that he had a girlfriend, identified as resident #22, and they would hold hands and spend time together. She stated residents #'s 22 and 73 were not to be left unattended together since neither resident was capable of providing sexual consent due to their cognition. NF1 stated it would be appropriate to develop a care plan for resident #73 to address his sexual behaviors and provide interventions as well as ensuring behavior monitoring occurred for the behavior.During an interview on 2/25/26 at 11:44 a.m., staff member K stated the Sexual Activity Capacity to Consent Assessment for resident #73 was not completed. She stated it was the expectation that the assessment would be completed during an IDT meeting to determine a resident's ability to consent to sexual activities. She stated residents #'s 22 and 73 were both not able to provide sexual consent. She stated the facility also did not develop a comprehensive care plan to address the resident's past trauma and potential for sexual behaviors. Staff member K stated they also did not include behavioral monitoring for resident #73's potential sexual behaviors.A review of the facility policy and procedure titled, Behavioral Health Services, with an implementation date of 4/1/25, showed, 2. The facility will consider the acuity of the resident population. This includes residents with mental disorders, psychosocial disorders, or substance use disorders (SUDs), and those with a history of trauma and/or post-traumatic stress disorder (PTSD), as reflected in the facility assessment.3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.7. 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.12. The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologists .

Based on interview and record review, the facility failed to thoroughly investigate an unavoidable accident to the level necessary to ensure appropriate measures were implemented to prevent recurrences for 1 (#73) of 25 sampled residents. The resident spilled soup on himself, causing burn(s), but it was unclear (upon watching video footage) who the person was who provided the resident with the hot soup, and or what action was taken to investigate the incident further in an attempt to prevent future recurrences of this nature. The facility treated the resident's burn(s), which did heal. Findings include: During an interview on 2/24/26 at 10:20 a.m., staff member B stated resident #73 sustained a burn injury after spilling hot soup onto himself on 10/30/25. Staff member B stated NF3 reported he had reviewed the facility's video footage of the incident and observed a tall male visitor in street clothes handing resident #73 a container. Staff member B stated NF3 did not offer any additional information on the investigation, including whether there had been a review of video footage near the nourishment room to determine if the visitor accessed the facility microwave or how the soup was heated. Staff member B stated NF3 had determined the burn was not reportable based on the surveillance footage reviewed, and no additional investigative documentation was located for this incident, although it was not clear who exactly provided the resident with the hot soup. During an interview on 2/24/26 at 2:12 p.m., staff member E stated the microwave used to heat resident food was located inside a locked nourishment room, and staff were expected to obtain and document food temperatures when heating food for residents. Staff member E stated she treated resident #73's wound, but did not know exactly how it occurred, stating, I don't know any details, but it blistered and burned.During an interview on 2/24/26 at 3:44 p.m., staff member A stated the facility's video surveillance footage was overwritten approximately every two weeks, and the facility was unable to retrieve or review video footage from the 10/30/25 burn incident involving resident #73. Staff member A stated the facility identified the concerns related to the resident's burn during a chart review three weeks after the incident.During an interview on 2/24/26 at 4:23 p.m., staff member F stated she did not know how a visitor would obtain access to the facility microwave, as the door was secured with a keypad lock. Visitors should not have had access to the locked room. During an interview on 2/26/26 at 9:15 a.m., staff member C stated no additional information was available regarding resident #73's accidental burn. Review of resident #73's physician note, dated 10/31/25, showed, . (Resident #73) was seen today for follow-up at the request of nursing staff for what they report to be burn wound from hot soup. When asked if he had dropped hot soup on himself he did nod yes. [sic]Review of resident #73's physician notes, provider notes, and facility investigative notes for the incident on 10/30/25, showed no documented determination of how or if the visitor accessed the locked nourishment room, whether staff heated the soup, or if the soup came into the facility at the hot temperature, or whether supervision for the resident at the time of the incident was adequate for the resident's safety.Review of a facility policy titled Incidents and Accidents, dated 4/11/25, showed: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Assuring that appropriate and immediate interventions are implemented to prevent recurrences and improve the management of resident care. Conducting root cause analysis to ascertain causative/contributing factors as part of Quality Assurance Performance Improvement (QAPI) to avoid further occurrences . Meeting regulatory requirements for analysis and reporting of incidents and accidents .

Based on observation, interview and record review, the facility failed to adhere to a resident's individualized plan of care regarding repositioning and elevation of the heels to prevent skin breakdown for 1 (#79) of 25 sampled residents. Findings include:During an observation and interview on 2/23/26 at 2:55 p.m., resident #79 was lying flat on her back with a pillow beneath her legs, but her heels and feet were still touching the bed. Resident #79 stated she was never repositioned by staff but would lie flat on her back very frequently. Resident #79 stated, They're (staff) supposed to not let my heels touch the bed, but stated the staff members would often forget to do this task.During an observation and interview on 2/24/26 at 2:12 p.m., resident #79 was lying on her back and had a pillow underneath her legs. Her heels were not elevated but were resting on the pillow's surface. Resident #79 stated she was dependent on staff for help and would rarely get out of bed for activities. During an observation on 2/25/26 at 2:28 p.m., resident #79 was lying on her back and had her heels resting on the pillow's surface. During an observation and interview on 2/25/26 at 3:39 p.m., resident #79 was lying on her back. Staff member L stated resident #79's heels were boggy1. The resident's heels were observed to be slightly red, her entire back was red, and her left arm and fingers were noticeably swollen. Staff member L stated resident #79's left arm needed to be elevated to help reduce swelling and stated, We need to get that (resident #79's arm) up. Review of resident #79's Care Plan, initiated 7/15/25, showed, . Please use heel bilateral suspension boots to float heels while in bed . Staff will assist resident to turn/reposition regularly to offload pressure points . The boots were not observed when the resident was in bed. References:1According to a CMS document, titled Pressure Ulcer/Injury Coding Stages, soft or boggy heels could indicate a concern for a deep tissue injury. Deep tissue injuries can result from prolonged pressure and reduced circulation.Centers for Medicare and Medicaid Services. (2021, November 10). Pressure Ulcer/Injury Coding Stages. Retrieved from Centers for Medicare and Medicaid Services: https://www.cms.gov/files/document/pocket-guidepressure-ulcers-and-injuries-stages-and-definitions.pdf

Based on interview and record review, the facility failed to investigate an allegation of resident-to-resident inappropriate nonconsensual contact for 2 (#s 46 and 73) of 25 sampled residents. Findings include:Review of resident #73's Behavior Progress Note, dated 12/14/25, showed: Resident has repeatedly been removed from female resident rooms. Resident has also been rubbing legs of other female residents. Resident has been repeatedly corrected by staff and educated on inappropriate behavior. During an interview on 2/24/26 at 4:51 p.m., staff member A stated they were reviewing a former resident's chart (resident #73) who wanted to return to the facility. Upon the review, they noted a progress note for a reportable event that was not reported or investigated involving residents #'s 46 and 73. Staff member A stated they did not know of the incident before the review and would be sending a late report to the State Survey Agency regarding the incident and conducting an investigation (See F609 for details of allegation). Review of the facility's reported incidents, sent to the State Survey Agency, did not show that the incident between residents #46 and #73 was reported or investigated by the facility for the event on 12/14/25. Review of the facility's policy and procedure titled, Abuse, Neglect, and Exploitation, with an implementation date of 4/11/25, showed: V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation . 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.

Based on interview and record review, the facility licensed nursing staff, assigned to complete treatments on a resident's burn, failed to provide services in accordance with professional standards of nursing practice related to wound assessments, treatments, and documentation of the wound details and current status, for 1 (#73) of 25 sampled residents. The failure placed the resident at elevated risk for the delayed identification of complications and or ineffective treatments not being addressed promptly, due to the lack of wound information in the resident's medical record. Findings include:During an interview on 2/24/26 at 11:12 a.m., staff member B stated resident #73 had obtained a burn injury to his lower abdomen, groin, and right hip on 10/30/25, after accidentally spilling hot soup onto himself. The right hip wound was a second-degree burn with blistering, and the lower abdomen and groin were first-degree burns. Staff member B stated wound treatments were initiated on the notification to the provider about the burns, which was on 10/30/25, and the burn treatments were completed as ordered until the wound healed.During an interview on 2/24/26 at 1:34 p.m., staff member G stated that the previous wound management nurse left the facility unexpectedly two weeks earlier. Staff member G stated she was unaware of the resident's wound until that time. Staff member G stated she assessed the wound for the first time on 11/21/25 and noted it had resolved. Staff member G stated a wound's progress (healing) should be assessed routinely by the nurse, who then documents the status and evaluation of the effectiveness of the wound treatments provided. Review of resident #73's nursing progress note, dated 10/30/25 at 2:31 p.m., showed: Resident sustained a burn to right upper thigh, groin, and low abdomen during early morning hours. Burn on thigh is 5 1/2 by 5 inches with a large blister which has since broken and drained serous fluid. The abdomen has several small burns the blistering to this area has resolved. The groin has 2 red areas without blistering. There are 41/2 by 2 3/4 inches and 2 1/4 by 1 1/2 inches. Burns had been covered with loose ABD dressings for protection from rubbing. Provider did evaluate and gave instruction to ADON for new orders. Dressing will be applied as instructed . [sic]Review of resident #73's nursing progress note, dated 11/1/25 at 5:36 a.m., showed: area of burn cleaned and Bacitracin applied- covered with abd- tolerated well-N/S of infection. [sic] Review of resident #73's nursing progress note, dated 11/3/25 at 2:25 a.m., showed: area of burn cleaned and Bacitracin applied- covered with abd- tolerated well-N/S of infection. [sic]Review of resident #73's nursing progress note, dated 11/6/25 at 12:54 a.m., showed: Bacitracin applied as ordered to burn on right hip. Resident tolerated well. Wound bed pink/red in color. No signs of infection. Minimal drainage noted. Dressing applied to area. Scant serous drainage noted. [sic]Review of resident #73's nursing progress note, dated 11/21/25 at 7:09 a.m., showed:Area to right hip checked- no open areas-clean dry and skin is intact-resolved. [sic]Review of resident #73's nursing progress notes failed to show a wound status note on 10/31/25, 11/2/25, 11/5/25, and 11/7/25 through 11/20/25, and the notes that were completed did not address all the areas of the burn(s), the status of the burns, location, classification, measurement, burn assessment, the status of the wound edges, if there was any odor, if the resident had pain or if there were signs of infection, or if the treatment at the time was beneficial or not. Review of resident #73's physician order, dated 10/30/25, showed: Adaptic or Optifoam dressing with daily dressing changes to right lateral hip burn site. One time a day for second degree burn of right lateral hip. Notify provider of any worsening. [sic]Review of resident #73's Medication Administration Record for November 2025 showed the dressing change was not documented as completed on eight out of 21 days.Review of a facility policy titled Wound Treatment Management, dated 4/11/25, showed: . 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record .8. The effectiveness of treatments will be monitored through ongoing assessment of the wound .Review of a professional standard titled, Principles for Nursing Documentation, published by the American Nurses Association, accessed online on 3/2/26 at https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/ana-principles/, showed: Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice.

Based on observation, interview, and record review, the facility failed to revise a resident's care plan, based on the resident's refusal to wear a [NAME] brace, and the staff's application of a compression wrap to maintain stump positioning on the wheelchair leg rest, for 1 (#4) of 6 sampled residents. The care plan did not reflect the restraint assessment findings, risks, or resident preferences related to the refusals of the [NAME] brace. Findings include:During an observation on 11/3/25 at 4:04 p.m., resident #4 was sitting in a wheelchair by the nursing station. Resident #4 had a left below the knee amputation that was tied to the left footrest of the wheelchair with a tan colored compression wrap. Resident #4 was pulling at the compression wrap and was unable to remove it. When resident #4 was asked if he could remove the compression wrap, he shook his head no.During an interview on 11/4/25 at 7:50 a.m., staff member G stated staff tied resident #4's stump to the leg rest on the wheelchair because, His stump will not stay on the leg rest, and he will not wear his [NAME] brace. Staff member G stated she was not aware if staff were documenting the refusal of the [NAME] brace. Staff member G stated the use of the compression wrap for resident #4's stump was not on his care plan. Staff member G stated staff had been using the compression wrap for quite a while.During an interview on 11/4/25 at 12:25 p.m., staff member L stated she had not documented or reported when resident #4 refused the [NAME] brace. Staff member L stated she had not checked resident #4's care plan about the use of the compression wrap and was told by other staff it was ok to use.Review of resident #4's comprehensive care plan, with a date of 7/29/25 showed: Focus: Potential for altered skin integrity related to: limited mobility. diabetes. poor wound healing.Goals: No goals were placed on the care plan for potential for altered skin integrity.Interventions: [NAME] Brace. Monitor under brace. [sic]Review of resident #4's comprehensive care plan, dated 9/21/25, showed: No focus, goals, or interventions for the use of a compression wrap to tie resident #4's stump to the wheelchair leg rest. The facility did not revise resident #4's comprehensive care plan to include resident #4's refusal to wear the [NAME] brace or the use of the compression wrap as a restraint, when it was implemented, during the Quarterly assessment period between 7/29/25 and 9/21/25.Review of a facility policy titled, Comprehensive Care Plans, dated 4/11/25, showed: . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team.Review of a facility policy titled, Restraint Free Environment, dated 4/11/25 showed: . 6. The care plan be updated accordingly to include development and implementation of interventions, to address any risks related to the use of the restraint.

Based on observation, interview, and record review, the facility failed to complete a baseline care plan within the 48-hour required time frame, that included resident specific needs for activities of daily living for 1 (#3) of 6 sampled residents. This deficient practice had the potential to affect all new admissions into the facility. Findings include:During an observation and interview, on 11/4/25 at 1:41 p.m., resident #3 was standing at the nursing station. Resident #3 had on a red colored t-shirt and a pair of jeans. Resident #3's shirt had dried food debris on it, and the jeans had dried brown stains consistent with what appeared to be coffee. There were multiple spots noted on resident #3's jeans. Resident #3 stated he needed assistance at times with dressing and hygiene because of his wound. Resident #3 stated he had been wearing the same pair of jeans for multiple consecutive days.During an interview on 11/4/25 at 2:58 p.m., NF6 stated resident #3 had some forgetfulness and confusion at times and would not always remember to ask for assistance if he needed it.During an interview on 11/4/25 at 3:15 p.m., staff member F stated there was not a baseline care plan completed for resident #3, but staff member E was completing it, . right now.Review of resident #3's electronic medical record showed he was admitted to the facility on [DATE].Review of resident #3's activity of daily living documentation, dated 11/1/25 - 11/4/25, showed resident #3 was independent for personal hygiene two times out of the six documented encounters, required supervision or touching assistance two times out of six documented encounters, required partial to moderate assistance one time out of six documented encounters, and required substantial to maximum assistance one time out of six documented encounters.Review of resident #3's activity of daily living documentation, dated 11/1/25 - 11/4/25, showed resident #3 was independent for dressing three times out of seven documented encounters, required supervision or touching assistance two times out of seven documented encounters, and required substantial to maximum assistance two times out of seven documented encounters.Review of resident #3's open baseline care plan in the resident's electronic medical record, showed the baseline care plan was blank.Review of a facility policy titled Baseline Care Plan, dated 4/23/25, showed: The facility will develop and implement a baseline care plan for each resident.1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident.

Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from physical restraints for 1 (#4) of 6 sampled residents, when the resident's stump was secured to the wheelchair with an elastic compression wrap that the resident could not release. There was no physician's order authorizing the use of the restraint, no assessment of the resident's need or risk for the restraint, and no monitoring for the restraint was documented. This deficient practice had the potential to cause an increased risk for impaired skin integrity, falls, and injury. Findings include:During an observation on 11/3/25 at 4:04 p.m., resident #4 was sitting in a wheelchair by the nursing station. Resident #4 had a left below-the-knee amputation that was tied to the left footrest of the wheelchair by a tan colored compression wrap. Resident #4 was pulling at the compression wrap and was unable to remove it. When resident #4 was asked if he could remove the compression wrap, he shook his head no.During an interview on 11/4/25 at 7:50 a.m., staff member G stated staff tied resident #4's stump to the leg rest on the wheelchair and stated, His stump will not stay on the leg rest, and he will not wear his [NAME] brace. Staff member G stated she was not aware whether staff were documenting the refusal of the [NAME] brace. Staff member G stated staff had been using the compression wrap for quite a while. Staff member G stated there was no physician's order for the compression wrap to be used as a restraint. Staff member G stated she had not been assessing the area where the compression wrap was tied to the stump and was not sure if the compression wrap was released other than when resident #4 was not in his chair.During an interview on 11/4/25 at 1140 a.m., staff member I stated she had seen staff tie resident #4's stump to the leg rest. Staff member I stated, We are not allowed to tie up limbs, that is very much as restraint. Even if a resident or family member requests it, we can't do that. I know there is adaptive equipment that can be ordered by therapy to help with stump positioning. I have told the staff that using the wrap was not allowed, but they continued to use it.During an interview on 11/4/25 at 12:01 p.m., staff member J stated, I thought you could tie the stump to the wheelchair to keep the stump in place. I told staff it was ok to do that. Staff member J stated, Looking back at it now, it is considered a restraint, it could have caused major harm or injury. Obviously, we need some education, not only for myself, but for all staff. Staff member J stated she had not done an assessment or evaluation on resident #4 before the use of the compression wrap.During an interview on 11/4/25 at 12:15 p.m., staff member K stated she had not completed any type of assessment on resident #4.During an interview on 11/4/25 at 12:25 p.m., staff member L stated she was told by other staff it was ok to tie the stump to the wheelchair. Staff member L stated she was told resident #4 wanted the compression wrap but knew it was a type of restraint. Staff member L stated she had never seen resident #4 remove the compression wrap and did not feel he would remove it on his own.Review of resident #4's physicians orders, dated 9/1/25 - 11/6/25, showed no physician's order for the use of a compression wrap to secure the resident's leg stump to the wheelchair.A review of resident #4's nursing assessments, dated 9/1/25 - 11/6/25, showed no assessments for the use of the compression wrap to secure the leg stump to the wheelchair, or any documentation showing the compression wrap had been released and or the skin assessed.A review of resident #4's ADL documentation from 9/1/25 - 11/6/25 showed no documentation for the use of the compression wrap or release of the compression wrap.A review of resident #4's physical therapy and occupational therapy evaluations, dated 8/21/25, showed no documentation of an evaluation for the use of the compression wrap to secure resident #4's leg stump to the wheelchair.Review of a facility policy titled, Restraint Free Environment, dated 4/11/25, showed: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints. Physical restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily. 5. Before a resident is physically restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine:How the use of restraints would treat medical symptomsThe length of time the restraint is anticipated to be used . who may apply the restraint, and time and frequency that the restraint will be released 8. The resident/resident's representative may request the use of a physical restraint; however, the facility is responsible for evaluating the appropriateness of the request. The facility shall explain to the resident/resident's representative the potential risks and benefits of using a restraint, not using a restraint, and alternatives to restraint use. Potential negative outcomes should also be explained, including, but not limited to: . e. Pressure ulcers/injuries . g. Agitation . i. Accidents such as falls, strangulation, or entrapment .

Based on observation, interview, and record reviews, the facility failed to develop and implement a person-centered, comprehensive care plan that assessed the dental status for 1(#4) of 6 sampled residents. This deficient practice had the potential for resident needs to be unmet by staff. Findings include:During an observation on 11/3/25 at 4:04 p.m., resident #4 was sitting in a wheelchair by the nursing station. Resident #4 was noted to be lacking teeth.During an interview on 11/4/25 at 7:50 a.m., staff member G stated resident #4 had dentures and was seen at a dental clinic last week. Staff member G stated family had provided resident #4 with another pair of dentures because his had been lost.During an interview on 11/4/25 at 12:25 p.m., staff member M stated resident #4 had dentures and most mornings he already had them in place when staff member M arrived on shift. Staff member M stated if the dentures were already in resident #4's mouth oral care did not need to be done. Staff member M stated all staff have access to the resident care plan. Staff member M stated there was no information about resident #4's oral status on his care plan, prior to his dental appointment, in October.During an interview on 11/4/25 at 2:15 p.m., NF4 stated the facility had lost resident #4's upper dentures, and the facility was supposed to have them replaced but had not replaced them. NF4 stated a family member had gone to resident #4's home and picked up an old pair of dentures and took them to him. NF4 stated, At least he could eat something with the old dentures, he was not wanting to eat without any dentures. NF4 stated every time she was in the facility she had to remove resident #4's dentures to clean them because staff were not cleaning them. NF4 stated, I would have to pry his teeth out because they were so full of food debris. They were gross. This is part of their job, I thought.During an interview on 11/4/25 at 4:04 p.m., staff member O stated oral care and denture care is to be completed in the mornings and in the evenings. Staff member O stated if a resident refused any type of care, staff are supposed to reapproach in a little bit or ask another staff member to assist the resident. Staff member O stated the nurse should be notified, and all refusals should be documented.Review of resident #4's comprehensive care plan, dated 9/21/25, showed, resident #4 . needs assistance with oral care. The care plan did not identify if the resident had no teeth or dentures, or what kind of oral care resident #4 required.Review of a facility policy titled, Comprehensive Care Plans, dated 4/11/25, showed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.3. The comprehensive care plan will describe, at minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.f. Resident specific interventions that reflect the resident's needs. [sic]

Based on observation, interview, and record review, the facility failed to prevent Immediate Jeopardy level neglect by refusing to allow a resident re-entry to the facility after transferring to the hospital, then he went AMA, and attempted to return to the facility, which resulted in the resident sitting outside of the facility for several hours in inclement weather, and placing the resident at high risk of a serious adverse outcome, for 1 (#1) of 3 residents sampled for discharge. On 6/6/24 at 1:06 p.m., the facility Administrator and administrative staff were notified of an Immediate Jeopardy involving resident #1, pertaining to F600 - Freedom from Abuse and Neglect. The facility provided an acceptable plan to remove the immediacy for the resident involved, and the time the immediacy was removed was at 4:58 p.m. on 6/6/24. The surveyor was onsite verified the removal of immediacy by observations, interviews, and record reviews. The Severity and Scope of the Immediate Jeopardy was identified to be at the level of J, and upon removal of immediacy, lowered to G. Findings include: During observations, interviews, and record reviews, the following was found: Resident #1 was denied entry to the facility on two separate occasions during one shift on 5/23/24, despite an administrative directive relayed to staff member D at 1:14 a.m. to allow the resident entry to the facility. The denial of entry resulted in resident #1 sitting in the parking lot for approximately four hours overnight in inclement weather. Details of the observations, interviews, and record reviews included: During an interview on 6/3/24 at 3:48 p.m., staff member C stated, staff member D contacted her by phone at approximately 12:15 a.m. to report resident #1 had signed out of the hospital against medical advice (AMA). Resident #1 had taken a cab to the facility, and the cab driver was requesting entry for resident #1. Staff member C reported being called into the facility at approximately 12:30 a.m. at the request of staff member D. On arrival at the facility, staff member C messaged staff member A and also left a message for the on-call provider. Staff member C stated resident #1 had left the facility with the cab driver, on another run by the time of her arrival. Staff member D told staff member C the cab driver left his phone number and was waiting for instructions on where to leave resident #1. Staff member D did not have instructions from administration or admitting orders at that time. Staff member C stated she received a text from staff member A on 5/23/24 at 1:14 a.m., instructing the staff to, Let him (#1) rest at the facility for the night, and we can figure this out in the morning. Staff member C reported she told staff member D about staff member A's instructions. Staff member C stated she left the facility to return home at approximately 1:30 a.m. on 5/23/24, and resident #1 had not returned to the facility while staff member C was there. Staff member C stated she did not see resident #1 in the parking lot, or on the bench near the entrance, as she left the parking lot to return home. Staff member C stated, He's a problem. By 4:00 a.m., (resident #1) would be throwing things if he didn't get his medicine. Staff member C did not know if anyone from the facility assessed resident #1 at any time or confirmed his identity. Staff member C stated she did not follow-up with the on-call provider before or after returning home related to #1's need to return to the facility. During an interview on 6/4/24 at 5:18 p.m., staff member D stated, I got a call from the hospital, I think it was about 12:15 a.m. (on 5/23/24), and the nurse said (resident #1) had decided he didn't want to be there anymore, and he was on his way back in a cab. The first thing I did was call (staff member C) to see what I should do, because he was discharged from our facility when he went to the hospital. Then the cab driver came to the door and said he had (resident #1) out in his cab, and I hadn't heard back from anyone yet. (The cab driver) said he would just keep (resident #1) in the cab, and said he had another call to go on. (The cab driver) gave me his phone number and said to call him when I knew what we were going to do. When I heard back from (staff member C), she said she was on her way in, and we decided the best thing to do, because I didn't have any orders or anything, was to let him go back to the ER because that's where he needed to be because he was sick. I called the cab driver around 1:15 a.m. and asked (the taxi driver) to take (resident #1) back to the emergency room . Staff member D stated she did not follow-up with the hospital or the on-call provider, and did not call resident #1's primary physician, stating, . because there is no doctor in the middle of the night who is going to give (physician) orders, and this man was a heavy narcotic user, and I knew that as soon as he came in the door he was going to want narcotics. Around 4:00 a.m., someone came to the door, and they (the CNAs) said it was a lady, and she was not very nice. (The lady) said that there was an old man sitting out on the bench. I had no idea who she was or that it was (resident #1), and so she just went away. There was no conversation. The lady was outside yelling and said she was going to call the police, and there's an old man sitting (outside the facility), and then she left. She did not say his name, and I was certain it was not (resident #1) . We have video cameras, but there was no camera in that (front entrance) area. I was certain it was not my resident because he could have come to the door. He was able to walk to the door, and I thought if that was my resident he would have come to the door himself. When the police came, the police officer said that this old man was out there, and nobody ever said his name, and I just told her when someone leaves the facility and goes to the hospital they're discharged until they're readmitted . (The police officer) didn't know it was a resident, or didn't say it was. (The police officer) was only there a minute, and then she just left, and took him (#1) with her . all I know for sure is that I was positive that it wasn't (#1). During an interview on 6/4/24 at 7:20 p.m., staff member I stated, I think the lady that was here around 3:00 or 4:00 a.m. (on 5/23/24) called the cops. I think so, because the nurses kept telling them that they couldn't take him (#1) back in because of no (physician) orders. I think that's why the lady called (the police), and that made a big old stink about it, because we couldn't let him back in. In the back of my head, I was wondering why (the nurses) didn't just let him back in. (Staff member E) was working that night and kept saying that (#1) had to have an (physician) order before they could let him back in. They knew who he was, definitely. After the cop left, then everybody came back up to the nurse's station, and started talking about it. During an interview on 6/5/24 at 8:00 a.m., staff member A stated he probably should have reported the incident. Staff member A stated he did obtain statements from some of the staff that were working on 5/23/24, but did not complete a thorough investigation. During an interview on 6/5/24 at 11:50 a.m., staff member A reported the facility video footage from the front entrance camera, as requested by the surveyors, was being deleted due to space capacity as administrative staff were reviewing it. (The facility) would therefore be unable to provide video footage for surveyor review. Staff member A stated the staff took notes and would provide written statements of what they had observed on video for the early morning hours of 5/23/24. During an interview on 6/5/24 at 11:11 a.m., NF2 stated, I picked (#1) up in my cab at [Hospital]. He wanted to go to the nursing home. I went to the (facility) door and they told me he couldn't come in. I was kind of sad about how that all happened . because I don't know why they didn't want him to have a place to stay another day. It was a nursing home decision they couldn't have a place for him to stay. [Resident #1] had to go to the hospital first and talk to the doctor, and he didn't want to go, and it's kind of sad all the way around. [Resident #1] was so weak, but I just had to leave him there (at facility). [Resident #1] said the last thing he wanted to do was go to the hospital, and I couldn't convince him to, so I just helped him get in his truck at the nursing home. During an interview on 6/5/24 at 4:20 p.m., staff member J stated, Around 11:30 a.m. (on 5/23/24), one of the CNAs came and got me and told me [Resident #1] was in his truck. I went out there because he just found out he had cancer and was so weak. He told me he wanted to smoke a few cigarettes, and so I said I'd be back in about 20-30 minutes, because I knew he was going to need a wheelchair. I don't even know how he got into his truck, because he was that weak. I brought him back to his room, and I asked him what happened, and he said he came here in a cab and [Staff member D] told the cab driver the facility could not accept the resident again as they didn't have (physician) orders, and he needed to go back to the hospital. The cab driver said he'd take him back to the hospital, so I asked him if he went back to the hospital, and he said, 'No, I stayed right here (in the parking lot) until the newspaper lady found me on the bench.' You could just tell he knew he was dying. I think he was just so much thinking about that and what he found out in the hospital. We put him in bed, got him blankets from the (blanket warmer). He just stayed in his room, you know, that's how we knew he was going downhill over the last couple weeks, but he was so stubborn he didn't want to go to the hospital. He just looked so tired and defeated like he was in a lot of pain. During an interview on 6/5/24 at 4:42 p.m., staff member E stated, (On 5/23/24), a lady came, and said there was a man on the bench outside, and she was going to call the cops and why won't we let him (Resident #1) in. I wasn't there, but they didn't reiterate to me that they said it was resident #1, because if they said it was resident #1, that would have been a completely different course of action that would have happened. The police showed up and it was a woman cop, and when she came in she said that (Resident #1) said he was a resident there and that his name was [Resident #1]. At that point, we were all shocked because we had believed that he was back at the hospital. Then she asked for our administrator's phone number and left. During an interview on 6/5/24 at 4:48 p.m., NF4 stated, When I first arrived on-scene, [NF3] was still standing with him (the resident), and told me she tried to talk to them (facility staff), and they yelled at her and told her he (resident #1) was not their problem anymore. NF4 stated NF3 reported disbelief that the facility staff were not concerned there was an old man outside in the weather. NF4 talked to the facility staff, and they told her He left AMA. NF4 stated that the staff responded to her questions with short, dismissive answers. NF4 stated, They (facility staff) were incredibly rude. Not even one person there was surprised or concerned at all about the resident after being told he was out there. During an interview on 6/5/24 at 6:09 p.m., Staff member G stated, I remember around three or four in the morning (on 5/23/24), the lady that brings the newspaper said that [Resident #1] was out there (outside), and then Staff member E told us that he couldn't come in because he wasn't discharged from the hospital yet. I know one of the girls went to go talk to the newspaper lady by the front doors. I think it was either [staff member K] or [staff member H] that checked to see if it was [Resident #1], and told [staff member E]. [Staff member E] said we couldn't let him in because he wasn't discharged (from the hospital). Three message requests for interview were left on NF3's phone during the survey period and a return call was received on 6/10/24. During an interview on 6/10/24 at 11:17 a.m., NF3 stated, At around 4:15 a.m. (on 5/23/24), [Resident #1] was sitting on the bench near the front of [Facility], and as I delivered the newspaper, I heard yelling, Help me, help me, help me! I saw [Resident #1] sitting on the bench waving his arms. It was raining and cold out, so I stopped and asked him what was going on. [Resident #1] said he could not stand up. I got out of my car and tried to help him. I was not strong enough to help him up because it is like dead weight when somebody can't lift themselves off a bench. [Resident #1] said he had been stuck sitting there on the bench for a long time. He asked if I could please help him get up because he can't on his own. He had a cane with him and did not have a coat. I tried to help him up three times and was unable to. I then said, let me go and ask the nurses for help. I rang the doorbell. I could see the staff sitting at the nurse's station. Eventually three staff members got up and came over to the inner door, but they did not want to open the door. There were two sets of doors with a space between maybe six feet or so. I had to talk to the staff through both glass doors, so I was talking pretty loudly. One of the staff, she was young and had pink hair, she cracked the door and said, 'He [Resident #1] doesn't stay here so it's not our deal.' I said excuse me? The same person said, 'Yeah, he doesn't stay here, so we're not going to help him.' I said, well OK, so will you please then call the non-emergency (police) number because I'm not strong enough to get [Resident #1] to stand on my own. The staff refused. I was floored by their complete lack of caring. I said this is an older gentleman, and he cannot stand on his own. I asked if they would please call the non-emergency (police) number, and the staff member said no, and repeated it several times. I was not cool, calm, or collected, because I was getting very upset with the way they were handling the situation. I said to the staff, to be clear, you are refusing to call the non-emergency (police) number to help an old man in need that's trapped on your bench in front of your facility. The staff member said yes. I said alright, and went and called the non-emergency (police) number to report it. [Resident #1] was still on the bench in the rain without a coat. [Resident #1] said, 'Well maybe if I scoot to the very edge of the bench, you'll be able to get more leverage and help me.' I said OK, and tried a fourth time to help him and was not able to. At that point, I told [Resident #1] they're not going to help you because you don't live here, and he said, 'Yes, I do live here. My name is [Resident #1] and I live in room [room #]. My name is on the door. I was just released from the hospital and dropped off here.' At that point, I went back to the doorbell and told the nurses who the gentleman was, and they all looked up at me, but no one even got up or came to the door that time. When the police arrived, one officer asked [Resident #1] some questions, while the other officer went inside the building. [Resident #1] seemed a little flustered and anxious, maybe a bit confused during questioning. He was weak, cold, and he just got out of the hospital. It was a pretty overwhelming situation. He looked like he was in pain. While the officer asked questions, I went and got a blanket from my car and wrapped him in it. I gave the police officers my card, and told them if they needed any more information, I would be happy to give it to them. The nursing staffs' behavior was unacceptable. They have taken an oath as healthcare providers, and that's something that they should uphold whether it's somebody that lives in the facility or not. My concern was [Resident #1]. To leave somebody who has just been discharged from the hospital sitting outside in the rain and cold without a coat is very concerning. Older people are so susceptible to pneumonia or other types of infections. I'm very happy that I came along when I did, because I normally don't start that route first. So it was just happenstance that I was in the right place at the right time. How long would he have been out in that weather if I hadn't come by? Review of resident #1's progress notes, showed the following entry, signed by staff member D, and dated 5/23/24 at 6:23 a.m.: Received call from [Local Hospital] (12:00 a.m.) stating this resident had left hospital AMA and was heading back to facility in a cab. Called administration to ask what to do. ADON attempted to call administrator and DON, then came to facility. Resident is outside in the cab, and when we had not heard back from administration told cab driver to take him back to the ER. Cab left with resident inside. Later, a girl rang the door bell and stated there is an old man sitting on the bench, and she was going to call the police. police arrived, explained to her this resident was discharged from the facility, he left the hospital AMA, and we have no idea how he got back here and on the bench. Police left with resident. [sic] Review of resident #1's progress note, showed the following late entry, signed by staff member C, and dated 5/23/24 at 6:32 a.m.: Called by NOC nurse (staff member D) at approx. 0015 (12:15 a.m.) - stating that hospital called to say resident had checked himself out AMA and was heading back to facility by cab. Notified Admin of above and for advice- called (Hospital) on call- to attempt to get order to readmit- no return call from [provider name] the on-call provider. Cabby told [staff member D] that resident could not even walk, I told [staff member D] to have cabby take resident back to the hospital, with him being that sick. Cabby told [staff member D] that he would keep resident with him for another run. After this discussion, Administrator text back to keep the resident here util morning and we would then figure this out. I told [staff member D] on the advice of the Administrator; we were to keep resident, and we could figure this out then. Nothing more was heard from the cabby and or resident until about 0430 (4:30) a.m., when [staff member D] called back to say that someone from the outside had called the police because we were not taking care of our residents and he had been sitting outside. Police asked who the administrator was and gave them his name and number. When I got here this am, [staff member D] told me that the police took him with them. [sic] Review of the hospital on-call provider call log and audio recording, dated 5/23/24 at 12:39 a.m., showed one call was placed to the on-call provider line regarding resident #1. On the call recording, the operator is heard telling staff member C, They should call you within ten minutes, if not give us a call back, and we will reach out to her cell phone. Review of resident #1's MDS Discharge Assessment, with an ARD date of 5/21/24, showed resident #1's discharge coded as an unplanned discharge, Short-Term General Hospital, and return anticipated. Review of resident #1's medical record showed a signed Bed Hold, dated 5/21/24. Review of a police report, dated 5/23/24 at 4:38 a.m., showed the weather conditions were raining, 46 degrees Fahrenheit, and 93% humidity. Two officers responded to the call at [Facility name]; NF4 and NF5. Review of NF4's body camera footage showed an on-scene arrival at the facility at 4:23 a.m. on 5/23/24. The footage showed NF4 talking with the facility staff. NF4 stated, Do you have a [Resident #1] listed here at all? Staff member D stated, He's in the hospital. NF4 stated, He's been released, he's sitting on the curb right now. Staff member E stated, He left AMA. Staff member D stated, He left here in a cab. He was on his way to the ER. NF4 stated, So does he not have a room here, then? Staff member D stated, No he was discharged . Staff member E stated, As far as we're concerned, he's just somebody, who, like anybody walking in off the street and saying, yeah I have a room here. Staff member D stated, How he got out of the hospital and got back here, nobody called us, nobody told us, but we couldn't let him in here anyway because he was dismissed. NF4 left the facility parking lot in route to the hospital at 4:37 a.m. At no time in the video footage, did any facility staff express concern for resident #1's health or well-being, and no facility staff went outside with the officer to identify, assess, or assist resident #1. Review of NF5's body camera footage, showed an on-scene arrival at the facility at 4:23 a.m. on 5/23/24. Resident #1 was observed sitting outside of the facility on a bench talking with NF3. Resident #1 was wearing a lightweight button-up shirt with T-shirt underneath, and lightweight pants. Resident #1 was in the rain and his clothes were wet. He was attempting to protect his face and head from the rain and cold with his shirt collar. Resident #1 appeared weak and frail. He was grimacing in obvious discomfort and was having difficulty breathing. NF3 told resident #1 she was going to get him a blanket, and she is observed in the background wrapping the resident in a blanket. The officer asked if resident #1 would like to get into the patrol vehicle to warm up and resident #1 said Yes. You're going to need to help me up. Once upright, resident #1 walked to the patrol vehicle with a slow, shuffling gait and using a cane for support. His breathing was labored, and he was in obvious discomfort. NF5 stated, Are you supposed to be on oxygen? Resident #1 stated Haven't been, but . I told them regularly that they should put me on some . Resident #1 is heard moaning in the backseat of the patrol vehicle, as he tried to find a comfortable position, and he was heard coughing. NF5 asked resident #1 if his belongings were still in the facility, to which he replied, yes. NF5 arrived at the hospital at 4:42 a.m. Resident #1 was polite and appreciative of the officers' assistance and thanked them at the hospital. Review of resident #1's Emergency Department Report, dated 5/23/24, showed the following: This is a [AGE] year-old male presenting to the emergency department via (local police). Patient was admitted to the hospital, left AMA last night May 22, 2024 at approximately midnight. He returned to his . facility ., however he was not allowed back into the building stating that he needed medical evaluation . As result he was left on the bench outside. Police found the patient sitting on the bench in the rain. As (a) result, they brought him back to the emergency department for evaluation . wishes to return back to the rehab facility where all of my stuff is. [sic] Based on the information above in the observations, interviews, and record reviews, facility staff continued to deny the resident entry, stating he did not have a room there, and they could not let him in. None of the facility staff that were observed on police body camera video showed concern for resident #1's well-being, and no facility staff were observed going outside with the officer to identify, assess, or assist the resident. No follow-up call was placed to a provider for admission orders. Resident #1 was in fragile health, and the refusal of the staff to allow the resident to enter the facility put resident #1 at high risk of a serious adverse outcome due to his health and general safety.

Based on observation, interview, and record review, facility staff failed to protect 2 (#s 15 and 66) of 9 residents sampled for abuse and neglect; and #66 had extended fear due to conflicts with the room mate, and #15 incurred a fall due to neglect by the staff member. Findings include: 1. During an observation and interview on 9/11/23 at 3:25 p.m., resident #66 was sitting in his room on the 400 hall. Resident #66 stated he did not get along very well with his roommate, and it had been that way for months. During an observation and interview on 9/12/23 at 8:17 a.m., resident #66 had been moved to a room on the 500 hall. Resident #66 stated, I had been having problems with my roommate. He is mean to me and verbally abusive, he pushed me to the floor the other day, and it hurt my bottom and back. I had to ask for some extra Tylenol. Resident #66 stated his roommate would block his way to his closet or sink so he could not use them. Resident #66 stated his roommate would also go through his things and take them from his closet or nightstand. During an interview on 9/12/23 at 8:23 a.m., staff member D stated, [Resident #66's] roommate had the potential to be aggressive with resident #66. During an interview on 9/12/23 at 4:10 p.m., resident #66 stated, I told multiple CNAs and nurses, and just about anybody that I talked to, about what my roommate was doing to me, and nobody helped me. I was scared of him. I was scared to close my eyes some nights. I feel better now that I do not have to be in the room with him. During an interview on 9/12/23 at 4:47 p.m., NF2 stated, I had told the facility a few months ago that there were problems with the roommate and that me and [family member] were unhappy in that room. I talk to my [family member] daily and come up when I can. I tried to call the facility last week and could not get anyone to answer the phone. I finally heard back from them on Monday. I know that my [family member] had complained to staff many times about what his roommate was doing to him. During an interview on 9/13/23 at 8:20 a.m., staff member H stated, I was made aware of the issues between resident #66 and his roommate by staff member D a couple of months ago, I think in June. I know that the resident wanted to move rooms at that time. During an interview on 9/13/23 at 8:30 a.m., staff member D stated, I was aware resident #66 and his roommate were having problems, I just did not know the extent of the problem. I did not do any type of investigation at that time or talk with resident #66. It was brought up again at resident #66's care conference in June 2023 by resident #66's family member. I did not document the complaint or speak with resident #66 about his concerns. Staff member D stated, I should have done more and looked into it more at that time, but I didn't. I guess we should have moved him then. During an interview on 9/13/23 at 9:21 a.m., staff member A stated, I guess the abuse coordinator would be me and staff member B. I reported the incident as soon as staff member D informed me. Staff member A stated abuse training was done at least yearly and the last one was in November 2022. A review of a document from resident #66, dated 9/4/23, showed: - .I have to get up at about 5:00 am to use the sink to wash my hair. He [roommate] didn't like me washing my hair so he got up and turned off the water and took my Purell shampoo that my [family member] had sent me and won't give it back to me. I had to get the soap out of my hair my putting my head in the toilet. - .he tries to control the room and make it all for himself. He thinks he owns the room. He's a big bully. - .He came over and went through all my drawer taking everything out and leaving my stuff all over the floor. - he doesn't like me to shut the main door for me to get into my closet so he will come over and try and pull me away by the waist band on my shorts, and then close my closet and open the door. If I am in his way he will try and grab my waist band on my shorts to move me away. He made me fall over by doing this . [sic] A review of resident #66's electronic medical record, from June 2023 through September 14, 2023, failed to show documentation from social services, nursing, or administration regarding the complaints voiced by resident #66. No social services notes or assessments were completed addressing resident #66's psychosocial well being after the allegation was submitted. A review of a facility document titled, Abuse Policy, with a revision date of 6/14/23, showed: Every resident has the right to be free from all forms of abuse . 1. Resident abuse: the willful infliction of an injury, unreasonable confinement, intimidation or punishment of a resident resulting in physical harm or pain, mental anguish or deprivation of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being . 32997 2. During an observation and interview on 9/13/23 at 10:36 a.m., resident #15 was lying in bed. His hair was dishelved, his facial hair was unkempt, and his sheets were soiled. Resident #15 said he remembered the incident when a staff member left him on the toilet. He said the incident had happened in June. Resident #15 said he was on the toilet for at least two hours. Resident #15 said he tried to reach for the call light, but he slid off the toilet. Resident #15 said staff eventually heard him calling out, Help, help. Resident #15 said the CNA who put him on the toilet and left him there was terminated after the incident. Resident #15 said the facility acted like it was no big deal, and no facility staff followed up with him after the incident. Review of a facility reported incident, dated 6/11/23, showed resident #15 was placed on the toilet around 3:00 p.m. by a CNA, and a nurse heard the resident yelling out for help during her medication pass at 5:00 p.m The report showed the CNA had placed resident #15 on the toilet then left for her lunch break. The CNA failed to notify other staff of resident #15 being on the toilet. The facility report showed the CNA's employment with the facility was terminated. The facility did substantiate neglect had occurred to resident #15. The facility reported incident failed to show the facility had followed up with resident #15, failed to re-educate staff on abuse and neglect, and failed to add abuse and neglect to their quality assurance program for quality improvement.

Based on observation, interview, and record review, the facility failed to follow dietician recommendations for a weekly weight related to weight loss for 1 (#4) of 4 sampled residents. This deficient practice caused a lack of monitoring for a resident with significant weight loss. Findings include: During an interview on 9/12/23 at 9:47 a.m., resident #4 stated he had lost some weight, but the food was better and that will help with his appetite. A review of resident #4's documented weights, from 5/1/23 through 8/14/23, show a weight loss of 8.84% in a three-month period. A review of resident #4's progress notes, dated 8/17/23, showed: Resident discussed during Nutrition-At-Risk meeting. Resident is triggering for a significant wt. loss.RD recommends to increase supplements to 2x more/day.RD to notify physician of conversation with resident today and significant wt. loss.Recommending weekly weights for close monitoring. RD and IDT to monitor/follow closely. [sic] A review of resident #4's weights showed the last documented weight was on 8/14/23. Resident #4's weight at that time was 133.0 pounds. No additional weights had been documented after the recommendation for weekly weights. A review of resident #4's nutritional assessment, dated 6/28/23, showed resident #4's weight was stable and to monitor. There was no current assessment completed after the weight loss was identified on 8/14/23. During an interview on 9/13/23 at 2:10 p.m., staff member B stated she was part of the interdisciplinary team, and nutrition at risk committee. Staff member B could not describe the process of the interdisciplinary team or the nutrition at risk process. Staff member B stated, I have not been here very long. The dietician was unavailable for interview during this time. A review of a facility policy titled, Weight Assessment and Intervention, with a revision date of September 2008, showed: 1. Residents shall be weighed in accordance with the facility's weight protocol, physician's order, or Nutrition at Risk (NAR) committee recommendations. .c. If, after achieving a stable weight trend, a resident is identified to have a significant weight change, the resident shall be weighed weekly for 4 weeks or until a stable trend is achieved . [sic]

Based on observation, interview, and record review, the facility failed to implement measures to mitigate the spread of COVID-19 within the facility. The facility had 38 out of 73 residents contract COVID-19, and 4 (#s 1, 4, 5, and 7) of 17 sampled residents were sent to the hospital, and after evaluation were diagnosed with COVID-19 related illnesses. Staff were observed going in/out of at least 12 resident rooms without following proper infection control prevention measures. On 2/15/23 at 1:45 p.m., the facility Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations were informed an Immediate Jeopardy existed for F880, Infection Control. The severity and scope for the immediate jeopardy was determined to be at a level K, and would be lowered to an H, after the removal of immediacy. The alleged removal date/time was 12:30 p.m. on 2/16/23. Prior to the end of the survey, the verification of the removal of immediacy was verified to be 2/16/23 at 12:30 p.m. Findings include: 1. During an observation on 2/13/23 at 4:03 p.m., staff member J entered room A-2. The door had a transmission-based precaution sign posted. There was a biohazard waste receptacle outside the room, located next to the supply cart. The door to the resident's room was partially open. Staff member J put on PPE outside the room, prior to entrance, into the room. Upon exit from the room, staff member J brought the isolation gown and gloves out of the room, and put them into the waste receptacle. The PPE was not removed prior to the employee leaving the resident's room. Staff member J did not clean or disinfect the face shield being worn upon exit from the resident's room. 2. During an observation on 2/13/23 at 4:08 p.m., staff member J donned a gown and gloves. Staff member J had an isolation mask and face shield on. Staff member J entered the resident's room. Staff member J exited the resident's room, wearing a gown, gloves, face shield, and mask. Staff member J removed the gown, and gloves outside the resident's room (rather than inside the room) and placed the PPE in the waste receptacle, then sanitized her hands. Staff member J did not replace or clean the face shield. 3. During an observation on 2/14/23 at 5:26 a.m., staff members D, F, and G were noted to don (put on) their gowns and gloves in the hallway. Staff members D, F, and G had on masks and face shields. The trash can for room B-5 was located in the hall, outside of the resident's room. Staff members D, F, G were observed exiting room B-5 with full PPE on, removed the gowns and gloves, and placed them in the waste receptacle. Staff members D, F, and G did not clean or discard their face shields, and did not remove the PPE prior to leaving the resident's room. During a group interview on 2/14/23 at 5:28 a.m., staff members D, F, and G stated there was annual training completed on infection control. 4. During an observation on D hall, there were two red biohazard waste receptacles in the hall, and three yellow bins, labeled linen. There were no biohazard waste or linen bins observed inside rooms D6, D7, or D8. Rooms D6, D7, and D8 had signage posted on the doors showing transmission-based precautions were in place. 5. During an observation on 2/14/23 at 10:16 a.m., there were transmission-based precaution signs posted on the doors to rooms E1, E2, E4, E5, E10, E11, and E12. There were four waste receptacles located in the hall, with seven rooms identified to have transmission based precautions in place. 6. During an observation on 2/14/23 at 10:30 a.m., staff members E and F entered room E-10 with full PPE on (gown, gloves, mask, and face shield). Staff members E and F exited the room and removed the gown and gloves in the hall, and placed them in a waste receptacle. Staff member E and F did not clean or discard their face shields. During an interview on 2/14/23 at 10:31 a.m., staff members E and F stated they have annual training on infection control, which was completed in the Relias (computer based) training system. 7. During observations on 2/13/23 and 2/14/23, of halls A, B, D, and E, it was noted all rooms with designated transmission-based precautions in place, to include having infection control signage on the doors, had the room doors partially opened or fully opened, and the waste and linen receptacles were in the hallway, not in the resident rooms, as to be available for staff to use prior to exiting the resident room when a resident was on transmission-based precautions. 8. During an interview on 2/14/23 at 2:53 p.m., staff member B stated the expected process for doffing PPE was, remove the gown by rolling it away from the body, and wrap the gloves in the gown, then put it in the trash. Staff member B stated staff should also clean the face shield, and put on a new mask. Staff member B stated the facility used bleach wipes or the purple topped cloths for cleaning. 9. During an observation and record review, on 2/16/23 at 2:20 p.m., resident #7 was observed ambulating in the hall with a walker. He had a face mask on, which only covered his mouth, and a face shield. Review of the facility outbreak sheet showed resident #7 was on transmission-based precautions until 2/22/23. 10. Review of the facility outbreak sheet showed resident #1 tested positive for COVID-19 on 2/3/23, and the resident was placed on transmission-based precautions. Review of resident #1's hospital records showed the resident was admitted to the hospital on 2/4/23, with severe COVID Pneumonitis. Review of resident #1's nurse's progress note, dated 2/4/23, showed the resident was sent to the [Hospital] on 2/4/23, due to low oxygen saturations of 42% on room air, which increased to 70% with supplemental oxygen in place. Review of resident #1's hospital discharge documentation, showed he was discharged on [DATE], and the resident returned to the facility. On return, the resident was placed on transmission-based precautions until 2/15/23. 11. Review of the facility outbreak sheet showed resident #4 tested positive for COVID-19 on 2/3/23. Review of resident #4's nurse's progress note, dated 2/3/23, showed the resident was sent to the emergency room . Review of resident #4's hospital discharge paperwork, dated 2/3/23, showed the resident was admitted on [DATE] and diagnosed with a fall, COVID-19, and hypoxia. The resident discharged the hospital and returned to the facility on [DATE]. On return, the resident was placed on transmission-based precautions, which continued until 2/16/23. 12. Review of the facility outbreak sheet showed resident #5 tested positive for COVID-19 on 1/28/23. Review of resident #5's hospital discharge paperwork showed he was admitted to the hospital on 1/29/23 and discharged on [DATE]. The resident's primary diagnosis at the time of admit was Acute Respiratory Failure, with Hypoxemia and Pneumonia, due to the COVID-19 Virus. The resident later returned to the facility and placed on transmission-based precautions until 2/10/23. Review of a facility document, titled Course Completion History, showed: - staff member D completed donning and doffing PPE education on 9/21/22, - staff member E completed donning and doffing PPE education on 11/17/22, - staff member G completed donning and doffing PPE education on 1/31/23, - staff member J completed donning and doffing PPE education on 11/25/22. The facility did not provide requested documentation showing staff members F and K received education for donning/doffing PPE. A request was made for the facility policies and procedures for donning and doffing PPE on 2/13/23. At that time, staff member A stated the facility follows CDC (Centers for Disease Control) guidelines for donning and doffing. Staff member A stated the staff complete online training on donning and doffing PPE through Relias (computer based) learning. Review of the CDC's Sequence for Putting on PPE, provided by the facility, showed PPE to be worn for transmission-based precautions included a gown, mask or respirator, goggles or face shield, and gloves. The documents also showed staff were to Remove all PPE before exiting the patient room. Throughout the survey, management or oversight staff were not observed monitoring or correcting staff on the improper use of PPE, to include donning/doffing, the PPE. The facility provided a list of residents who had tested positive for COVID-19. The list showed there were 38 out of 73 of the residents at the facility who tested positive for COVID-19.

Based on observation, interview, and record review, the facility neglected to ensure sufficient staff were available and working on the secure unit to supervise, protect, prevent, or intervene in resident to resident physical, sexual, and psychosocial abuse involving 9 (#s 14, 16, 17, 32, 35, 48, 50, 53, and 58) of 15 sampled residents, as evidenced by ongoing resident to resident abuse incidents, and these events caused physical injury, residents had fear of others, or were targeted by other residents, and some continued to be at risk for ongoing abuse; and, 4 (#s 30, 31, 34, and 55) residents were identified to need more than supervisory assistance of the facility staff when it was not provided sufficiently by the facility. The deficient practices were a system failure specifically identified for the secure unit, and the lack of staff, resident oversight, thorough and effective investigations of the abuse incidents, identification and evaluation of root causes for ongoing incidents, and the lack of the identification and implementation of individualized resident interventions based on incident findings and root cause analysis were all contributing factors to the failure(s). These failures increased the risk for abuse for all residents residing on the secure unit. IMMEDIATE JEOPARDY On 11/21/22 at 1:54 p.m., the facility management team was notified that an Immediate Jeopardy existed in the area of F600. The Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of a K. Findings include: 1. During an observation on 11/19/22 at 1:28 p.m., resident #53 was wandering in and out of various resident rooms and closing the doors behind him. There were no staff in the vicinity to redirect his behavior. Resident #53's room was at the end of the hall, furthest from the nursing station, and adjacent to resident #32's room. Review of a facility reported incident, dated 11/23/21, showed, [Resident #53] had his hand in [Resident #32's] shirt. Appeared that he (#53) was attempting to put his other hand down her (#32's) pants when they were separated. Review of facility investigation files on 11/20/22, showed a copy of the statement made by the staff member who had been working the date of the incident (11/23/21), and a copy of the reportable information submitted to the State Survey Agency. There was no information on how the facility intended to keep residents safe during the investigation. Review of resident #32's care plan, most recent revision dated 11/7/22, did not address her vulnerability for ongoing sexual abuse. Review of resident #32's nursing progress notes, dated 12/10/21, showed, [Resident #53] found laying in [Resident #32's] room under her covers while [Resident #32] layed in only her underwear with shirt pulled up and breasts exposed. [Resident #53's] hand was on one of [Resident #32's] breasts .Later in the shift [Resident #53] was found again sleeping in [resident #32's] bed with no pants on. [sic] Review of facility investigation files on 11/20/22, showed a copy of the statement made by the staff member working the date of the incident (12/10/21) and a copy of the reportable information submitted to the State Survey Agency. There was no information on how the facility intended to keep residents safe during the investigation. Review of resident #32's nursing progress notes, dated 12/10/21, showed no nursing assessment of the resident for physical or psychosocial harm. Review of resident #53's nursing progress notes, dated 12/10/21, showed he was removed from resident #16's bed and educated not to lay in her bed before he was found there again later that same night. Review of resident #53's care plan, dated 9/29/22, revealed a lack of interventions or monitoring to prevent him from wandering into other residents rooms. Review of resident #32's EHR, accessed on 11/20/22, failed to show a completed Sexual Consent Capacity Assessment for resident #32. A request was made for the Sexual Consent Capacity Assessment on 11/20/22 at 11:00 a.m. The assessment requested was completed on 11/20/22 at 11:10 a.m. and was not provided prior to the end of the survey. During an interview on 11/20/22 at 9:39 a.m., NF1 stated, There is only one person back there (on the secure unit) working on nights with fourteen people (residents) walking around. During an interview on 11/21/22 at 9:29 a.m., staff member G stated, I'm not gonna lie there is only one CNA back here (on the secure unit) at night. She stated it (resident care) was too much for one person. Staff member G stated, You're basically running the unit. They put someone with you now, but the other person (PCA-care assistant) is not hands on and can only hand out waters. Review of the facility document, Care Assistant SNF Temporary Position, dated 7/1/18, showed the duties and responsibilities included, .to provide support and assistance to the nurses and certified nursing assistant with non-direct resident care needs. 2. Review of a facility reported incident, dated 5/28/22, showed, [Resident #53] wandered into [resident #58's] room. [Resident #58] took a gait belt and struck [resident #53] across face with the buckle end. Review of two witness statements regarding an incident between resident #58 and resident #53 on 5/28/22 showed resident #58 had attacked resident #53 with a gait belt and hit him in the face repeatedly when resident #53 had walked into her room and got into her roommate's bed. Review of the facility reported incident submitted findings, dated 5/31/22, showed, A mesh/Velcro belt that can be attached to the sides of the door frame with the big stop sign in the middle has been ordered to deter residents from going into her room. During an observation 11/19/22 at 1:28 p.m., there was no such sign to deter resident #53 or anyone else from wandering into resident #58's room. During an interview on 11/21/22 at 9:29 a.m., staff member G stated resident #58 got along with the other men on the unit, it was just resident #53 that she targeted. Staff member G stated she was getting off shift and throwing trash away (on 5/28/22) when the incident with the gait belt occurred. Staff member G was able to run in and help the single night aide by taking the gait belt away. Staff member G stated resident #53's face was bleeding, and the scar was still visible. During an interview on 11/21/22 at 10:32 a.m., staff member H stated the licensed nurse from one of the outside halls in the facility was responsible for assessments and behavior monitoring (associated with prn medications) for residents on the secure unit. Review of a facility reported incident, dated 8/12/22, showed a nurse was called to the unit after resident #58 was the aggressor striking resident #53. Findings were a minor injury to resident #58's hand and none to resident #53. Review of facility investigation files and the care plans of residents #53 and #58 show a lack of specific interventions to protect the residents from further altercations. Review of a facility reported incident, dated 8/19/22, showed resident #53 was again attacked by resident #58. This incident resulted in resident #53 receiving lacerations to his right cheek and along his neck. Review of a facility reported incident, dated 10/3/22, showed resident #53 received a bite mark from resident #58 during an altercation. Both residents were scheduled for a tele psych appointment. Review of resident #58's care plan, dated 10/31/22, showed a lack of interventions to address the incidents between these two residents in a 5-month span, from 5/28/22 to 10/3/22. Review of resident #53's care plan, date initiated 11/2/21, showed, Verbally aggressive, physically aggressive. Four interventions were listed: - Requesting a psych to psych encounter to billings clinic and med increase (11/17/22), - Resident has had 2 med adjustments made by psych provider (2/3/22), - SW has made a referral for [Facility Name] (2/3/22), - Staff will monitor and intervene when my behaviors occur (11/2/21) The interventions include: redirect me and offer private conversation. Review of resident #53's care plan, dated 9/29/22, showed a lack of new interventions or non-pharmacological attempts to prevent further incidents of abuse. Resident #53's care plan failed to address he was vulnerable to being a victim of abuse in addition to an aggressor. During an interview on 11/21/22 at 9:29 a.m., staff member G stated resident #s 16, 35, 53, and 58 did not get along. Resident #s 16 and 58 targeted resident #53 calling him a child molester. Staff member G stated she tried to remove resident #53 from the situation, but resident #s 16 and 58 would walk past resident #53 and say things to [NAME] him up. Staff member G stated she had seen resident #53 crying when he was singled out by other residents. During an observation on 11/19/22 at 1:32 p.m., resident #16 was walking the hallways with her walker visually policing resident #53's movements. She went to the dining room and was whispering to other residents to notify them that resident #53 was now up and walking in the hallway. Resident #16 appeared tense. 3. Review of a facility reported incident, dated 1/23/22, showed, [Resident #53] was inappropriately touching a female resident. The staff separated both residents .[Resident #53] then entered several female's rooms, pulling their covers off and attempting to touch them inappropriately .[Resident #53] was removed by 911 police department and taken to E.R. [sic] Resident #s 16 and 35 were listed as victims of this incident. The facility investigation file, reviewed 11/20/22, contained a witness statement from the staff member working that day and a copy of the reportable information submitted to the State Survey Agency. No documentation of steps taken to protect residents during the investigation was included. Review of resident #35's care plan, revision date 9/8/21, showed, I am a vulnerable adult and at risk for dangerous situations due to my cognition . Interventions: Staff to redirect away from other residents that are exhibiting behaviors/agitation for her safety. The resident's care plan failed to show any updates or new interventions after the 1/23/22 incident. Review of resident #35's nursing progress notes, dated 1/23/22, showed a lack of resident physical or psychosocial assessment immediately after, or in the days following, the incident. Review of resident #16's nursing progress notes, dated 1/23/22, showed a lack of resident physical or psychosocial assessment immediately after, or in the days following, the incident. During an observation on 11/21/22 at 11:15 a.m., the staffing schedule for the night showed one CNA scheduled on the secure unit oversight of all the residents. 4. Review of resident #48's nursing progress notes, dated 11/13/22, showed, Upon entering room, pt was getting hit on the back of his head by another resident [Resident #53]. [sic] Review of a facility reported incident, dated 11/13/22, showed when the nurse opened the door to resident #48's room, resident #48 was on the floor with resident #53 on top of him. The residents were striking each other. During an observation and interview on 11/19/22, resident #48 was sitting in his wheeled walker just inside the doorway of his room, directly across the hallway from resident #53's room. Resident #48 was closely watching resident #53 who was walking in the common hallway. Resident #48 pointed at resident #53 and stated, He hurt me bad. 47003 5. Record review of 14 facility reported resident to resident and staff to resident incidents from 11/23/21 to 11/13/22 for the secure unit which showed four incidents occurred between 2:50 p.m. and 6:30 p.m., and nine incidents occurred between 6:30 p.m. and 9:15 p.m. Review of the facility provided schedule showed that night shift worked from 6:00 p.m. to 6:30 a.m. Review of facility investigation documents into an incident with resident #50, and a staff member, on 8/1/22 showed, resident #50 ripped a closet door from its hinges and became physically aggressive towards staff member N who was aiding another resident with changing their clothes. This resulted in a physical and verbal altercation between resident #50 and staff member N. Staff Member N had to lock herself and the resident she was aiding in a bathroom until resident #50 stopped banging on the door to the bathroom. The investigation documents provided showed only staff member N had a direct interaction with resident #50 and gave a statement regarding the incident. The statement from staff member L relayed the events after she relieved staff member N from the secure unit. There were no other staff member statements regarding having directly witnessed the actual incident. 6. During an observation on 11/19/22 at 3:22 p.m., resident #30 was in the TV room and picked up an unplugged electronic device below the TV. Resident #30 carried the electronic device around the room, with the cord dangling for several minutes. There were two other residents in the room at that time. Resident #14 became agitated and told resident #30 to put the device down. There were two staff members present in the secure unit assisting other residents, neither staff member entered the TV room and redirected resident #30 from picking up or replacing the device on the table, nor noticed resident #14's increased agitation. During an interview on 11/20/22 at 2:14 p.m., staff member G stated the facility expectation was the CNA assigned to work on the secure unit would watch all residents all the time. Staff member G stated it was not possible when several of the residents required direct CNA or nursing assistance with toileting or dressing, as well as the frequent redirection required for most of them. Review of the current care plans for 4 residents residing on the secure unit, and included in the immediate jeopardy situation, showed: - Resident #14 care plan, dated 11/10/22, required 1:1 staff supervision for aggressive/anxious behavior, monitor for rummaging through other's belongings, and assistance with ADLs, - Resident #17 care plan, dated 10/7/22, required extensive assistance of one staff for dressing, bathing, grooming, and toileting, - Resident #50 care plan, dated 10/11/22, required supervision to limited assistance with dressing, bathing, grooming, and toileting, and - Resident #58 care plan, dated 10/31/22, required assistance of one staff for transport to group activities and location checks for wandering/elopement and assistance of two staff for relocation to other areas of unit for aggressive behavior, Review of the current care plans and MDS information of four sampled residents on the secure care unit, but not part of the immediate jeopardy, were included to show additional staffing concerns due to increased care needs showed: - Resident #30 care plan, dated 8/27/22, needed monitoring for seizure activity and required limited to extensive assistance with bathing and dressing, and assistance with oral care, - Resident #31 care plan, dated 8/24/22, required supervision to extensive assistance with toileting and ambulation, extensive assistance with transfers, and assistance with oral care, - Resident #34 care plan, dated 10/20/22, required monitoring for sexually inappropriate behavior, supervision with transfers, bed mobility and ambulation, supervision with toileting, and assistance with oral care, and - Resident #55 Admission MDS, with an ARD of 8/28/22, required a one person physical assistance with his activities of daily living, and was frequently incontinent of bowel and bladder. During an interview on 11/21/22 at 9:26 a.m., staff member G stated she usually worked on the secure unit, and in the time she had been employed at the facility, the night shift frequently had only one CNA working on the secured unit without a PCA or second CNA. Regarding an incident with resident #50 which happened on the night shift on 8/1/22, staff member G stated there had only been one CNA on the shift with no other CNA or PCA. Staff member G stated when working alone, during an emergency situation there was no way for a CNA to request help from other staff members outside the secure unit other than using the telephone or yelling very loudly so other staff could hear. The main nurse's station was approximately 30 feet from the closed double doors leading to the secure unit. During interviews on 11/21/22 at 8:20 a.m. and 10:03 a.m., staff member B stated two staff members were scheduled for the secure unit at all times, either two CNAs or a CNA and a PCA. The PCA was only allowed to do activities and non-direct patient care. If a staff member assigned to the secure unit called in ill, the facility used a call list to find another staff member to come in to fill the shift. If no one was found, it was up to the remaining staff in the facility to ensure at least two staff members were in the secure unit at all times. Staff member B was unsure why there was only a statement from one CNA regarding direct contact with resident #50 on the night of the incident on 8/1/22. Staff member B stated beyond going through the call list to find another staff member to fill in, there was no actual policy or procedure for ensuring the secure care area had two employees working every shift. Staff member B stated the cause for the majority of the incidents occurring later in the day was most likely due to sundowning, and they had been trying to get more PCAs trained to do activities as the facility was trying to move away from hiring contract staff, but they had not specifically looked at adding additional resident supervision during that time. During an interview on 11/21/22 at 9:20 a.m., staff member M stated she was unsure where to find care plan interventions for resident behaviors or how to redirect specific residents on the secure unit if the CNA was with another resident and she had to intervene in an altercation between residents. Staff member M stated she would have to leave her area or room to find the CNA to ask her what to do. 7. During an interview on 11/19/22 at 3:43 p.m., NF3 stated resident #58 had experienced a lot of traumatic events in her past, and she specifically had difficulties with men. NF3 stated that the facility had not really done anything to make the situation (between resident #58 and resident #53) safer, and it will probably happen again. During an interview on 11/20/22 at 2:14 p.m., staff member G stated resident #53 was not usually the aggressor in situations with resident #58, and resident #53 seemed to trigger resident #58's violent behavior. During an interview on 11/21/22 at 1:29 p.m., NF4 stated during the initial admission care conference for resident #58, the history of trauma and abuse was a main topic of the conversation. Review of facility reported incidents for resident #58 from 5/19/22 to 10/7/22 showed she had four physical resident to resident altercations and all of them involved resident #53. Review of a provider psychology telehealth encounter for resident #58, dated 8/24/22, showed, .[Resident #58] attacked another resident. She sharpened her fingernails so she could scratch him. She is afraid of one of the residents, calls him a rapist and this is the resident she attacked Social history: hx of sexual abuse and hx physical abuse .resident is aggressive, combative, and has assaulted another resident. [sic] During an interview on 11/21/22 at 8:20 a.m., staff member B stated many of resident #58's behaviors toward resident #53 were due to her history of PTSD and the facility monitored as closely as they could to keep resident #58 and resident #53 seperated. Review of resident #58's care plan, last reviewed 10/31/22, showed, I will have staff order mesh stop signs to prevent others from entering into my room. There were no interventions related specifically to monitoring resident #58 to direct her away from contact with males, especially resident #53. A mesh stop sign was never observed across the doorway to resident #58's room when resident #53 was observed walking in the hallways. 8. Review of the facility's investigation for the facility reported incident into bruising of unknown origin on resident #50's hip, dated 5/13/22, and bruising of unknown origin on resident #50's bicep, dated 5/19/22, both showed a list of staff with the word no written next to staff member names. No other investigative paperwork was provided for the incidents, aside from the copy of the reported information submitted to the State Survey Agency. The information reported showed the resident frequently likes to throwing herself on the bed and swinging at objects. [sic] Review of resident #50's Admission MDS, with an ARD 3/28/22, Section E, showed the resident exhibited no behaviors. Review of resident #50's care plan, dated 10/11/22, failed to show any behaviors or interventions as described in the incidents reported on 5/13/22 and 5/19/22. 9. During an observation and interview on 11/19/22 at 1:42 p.m., resident #14 was noted to have bruising around her right eye. The resident stated she got the black eye when the tall man punched her. She indicated the tall man was resident #53. Resident #14 was unsure why resident #53 had punched her. During an observation on 11/19/22 at 1:46 p.m., resident #14 became nervous and scared when she saw an unfamiliar female standing in the hallway outside of resident #53's room. Resident #14 called out to the unfamiliar female in an attempt to direct her away from resident #53's room. During an observation on 11/20/22 at 2:14 p.m., resident #14 walked into her room, then walked down the hall into and out of another resident's room, while staff were busy assisting other residents. Review of resident #14's care plan, dated 11/10/22, showed, resident #14 required 1:1 staff supervision for aggressive/anxious behavior, monitor for rummaging through other's belongings, and assistance with ADLs, I often go into other resident's rooms . The interventions listed were both for staff to redirect, and were last revised on 8/13/21. 32997 During an interview on 11/21/22 at 3:20 p.m., staff member I entered the conference room and said she did not know how the facility would remove the immediate jeopardy. Staff member I said the facility could not get any more staff for the secure care unit. Staff member I stated This close to the holiday we can't get any contract staff either. Staff member I stated We are going to have to call the families and tell them to come get their residents. If they won't take their residents home, we are going to have to transfer them to the hospital and refuse to take them back. During an interview on 11/21/22 at 5:36 p.m., staff member N said he was going to write discharge orders and send two residents to the hospital. Staff member N stated It sounds like the facility can't get any additional staff until December 2nd, and it appears the only way to address this situation is to send these residents to the hospital. One resident can go to [Hospital name] and the other resident can go to [hospital name]. Review of a facility document titled, Abuse Prevention Plan, review date November 2022, showed: Neglect - .The failure of a caregiver to supply a resident with the care or services, including but not limited to food, clothing, shelter, health care or supervision which is reasonable and necessary to obtain or maintain the resident's physical and mental health or safety, considering the physical or mental dysfunction of the resident which is not the result of an accident or therapeutic conduct. and - .The absence or likelihood of absence of care or services necessary to maintain the physical and mental health of the resident and which a reasonable person would deem essential to obtain or maintain the Resident's health, safety and comfort, considering the physical and mental capacity of the resident. and - .Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances . lack of sufficient staffing to be able to provide the services.

Based on observation, interview, and record review, the facility failed to ensure there were sufficient staff members present on the secure care unit to assist with resident care and supervision of residents, to include those with behavioral needs, for 11 (#s 14, 16, 17, 30, 31, 34, 48, 50, 53, 55, and 58) of 14 sampled residents. This failure led to repeated incidents of resident-to-resident abuse, and one incident of staff to resident abuse. Findings include: During an observation on 11/19/22 at 1:28 p.m., resident #53 was walking in and out of other resident rooms and closing the doors behind him. Staff were not around to be able to intervene or redirect resident #53's behavior. Review of facility reported incidents, dated 11/23/21 to 11/13/22, showed a pattern of resident to resident interactions on the secure care unit. During an incident on 12/9/21, resident #53 wandered into another room and inappropriately touched resident #16. During an incident on 5/28/22, resident #53 wandered into resident #58's room and was struck several times across the face with a gait belt buckle. During an incident on 11/13/22, resident #53 was found in resident #48's room with the door closed while they were lying on the ground striking each other. During an interview on 11/20/22 at 9:39 a.m., NF1 stated he didn't believe there were enough staff working on the secure care unit. He was angry about an incident that had happened to his family member. He stated, There's only one person back there [on the secure care unit] on nights (on shift working) with fourteen people (residents) walking around. During an interview on 11/21/22 at 9:29 a.m., staff member G stated, I'm not gonna lie there's only CNA back here at night. She then stated she felt it was too much (resident care) for one person. Staff member G stated they (facility) would give you another person (a PCA), but they are not hands on and can only hand out waters. Review of a facility staffing document, for 11/21/22, showed only one CNA was listed as working on the secure care unit that evening. 47003 During an observation on 11/19/22 at 3:22 p.m., resident #30 was in the TV room of the secure unit, and picked up an unplugged electronic device below the TV. Resident #30 carried the electronic device around the room, with the cord dangling for several minutes. There were two other residents in the room at that time. Resident #14 became agitated and told resident #30 to put the device down. There were two staff members present in the secure unit assisting other residents, neither staff member entered the TV room and redirected resident #30 from picking up or replacing the device on the table. Neither staff member noticed resident #14's increased agitation. During an observation and interview on 11/20/22 at 2:14 p.m., staff member G stated the facility expectation was the CNA assigned to work on the secure unit would watch all residents all the time. Staff member G stated it was not possible when several of the residents required direct CNA or nursing assistance with toileting or dressing, as well as the frequent redirection required for most of them. When staff member G left to aid another resident with ambulation, resident #14 was observed walking out of her room on the secure unit, and across the hall and into and out of another resident's room. No staff member observed or redirected resident #14. During an interview on 11/21/22 at 9:26 a.m., staff member G stated she usually worked on the secure unit, and in the time she had been employed at the facility, the night shift frequently had only one CNA working on the secured unit without a PCA or second CNA. Regarding an incident with resident #50 which happened on the night shift on 8/1/22, staff member G stated there had only been one CNA on the shift with no other CNA or PCA. Staff member G stated when working alone, during an emergency situation, there was no way for a CNA to request help from other staff members outside the secure unit other than using the telephone or yelling very loudly so other staff could hear. The main nursing station was approximately 30 feet from the closed double doors leading to the secure unit. During interviews on 11/21/22 at 8:20 a.m. and 10:03 a.m., staff member B stated two staff members were scheduled for the secure unit at all times, either two CNAs or a CNA and a PCA. The PCA was only allowed to do activities and non-direct patient care. If a staff member assigned to the secure unit called in ill, the facility used a call list to find another staff member to come in to fill the shift. If no one was found, it was up to the remaining staff in the facility to ensure at least two staff members were working on the secure unit at all times. Staff member B was unsure why there was only a statement from one CNA regarding direct contact with resident #50 on the night of the incident on 8/1/22. Staff member B stated beyond going through the call list to find another staff member to fill in, there was no actual policy or procedure for ensuring the secure care area had two employees working every shift. Staff member B stated the cause for the majority of the incidents occurring later in the day was most likely due to resident sundowning (typically a late day increase in confusion/behavior), and they had been trying to get more PCAs trained to do activities as the facility was trying to move away from hiring contract staff, but they had not specifically looked at adding additional resident supervision during that time. During an interview on 11/21/22 at 9:20 a.m., staff member M stated she was unsure where to find care plan interventions for resident behaviors or how to redirect specific residents on the secure unit if the CNA was with another resident and she had to intervene in an altercation between residents. Staff member M stated she would have to leave her area or room to find the CNA to ask her what to do. Review of 14 facility reported resident to resident and staff to resident incidents from 11/23/21 to 11/13/22 for the secure unit, which showed four incidents occurred between 2:50 p.m. and 6:30 p.m., and nine incidents occurred between 6:30 p.m. and 9:15 p.m. Review of the facility provided schedule showed that night shift staff worked from 6:00 p.m. to 6:30 a.m. Review of facility investigation documents into an incident with resident #50, and a staff member, on 8/1/22 showed, at 9:22 p.m., resident #50 ripped a closet door from its hinges and became physically aggressive towards staff member N who was aiding another resident with changing their clothes. This resulted in a physical and verbal altercation between resident #50 and staff member N. Staff Member N had to lock herself and the resident she was aiding in a bathroom until resident #50 stopped banging on the door to the bathroom. The investigation documents provided showed only staff member N had a direct interaction with resident #50 and gave a statement regarding the incident. The statement from staff member L relayed the events after she relieved staff member N from the secure unit. There were no other staff member statements regarding having directly witnessed the actual incident, as staff member N was working on the secure unit by herself. Review of the current care plans and MDS assessments for eight residents residing on the secure unit, showed: - Resident #14 - care plan, dated 11/10/22, required 1:1 staff supervision for aggressive/anxious behavior, monitor for rummaging through other's belongings, and assistance with ADLs, and showed, I like to go into other resident's rooms and attempt to help or comfort them . Interventions- Staff will redirect [Resident 14] away from entering other resident's rooms; - Resident #17 - care plan, dated 10/7/22, required extensive assistance of one staff for dressing, bathing, grooming, and toileting; - Resident #50 - care plan, dated 10/11/22, required supervision to limited assistance with dressing, bathing, grooming, and toileting; and, - Resident #58 - care plan, dated 10/31/22, required assistance of one staff for transport to group activities and location checks for wandering/elopement and assistance of two staff for relocation to other areas of unit for aggressive behavior; - Resident #30 - care plan, dated 8/27/22, needed monitoring for seizure activity and required limited to extensive assistance with bathing and dressing, and assistance with oral care; - Resident #31 - care plan, dated 8/24/22, required supervision to extensive assistance with toileting and ambulation, extensive assistance with transfers, and assistance with oral care; - Resident #34 - care plan, dated 10/20/22, required monitoring for sexually inappropriate behavior, supervision with transfers, bed mobility and ambulation, supervision with toileting, and assistance with oral care; and, - Resident #55 - Admission MDS, with an ARD of 8/28/22, required a one-person physical assistance with his activities of daily living, and was frequently incontinent of bowel and bladder.

Based on observation, interview, and record review, the facility failed to prevent and protect residents from ongoing sexual, physical, or emotional abuse for 6 residents residing on the secure care unit (#s 8, 16, 32, 35, 53, and 58) of 29 sampled residents. This deficient practice allowed residents to continue to be at risk for further abuse, and resident #53 had multiple injuries, to include stitches, female residents exhibited fear, and were risk for sexually inappropriate touching. Findings include: 1. Review of a facility reported incident, dated 11/23/21, showed, [Resident #53] had his hand in [resident #32's] shirt. Appeared that he (resident #53) was attempting to put his other hand down her (resident #32's) pants when they were separated. Review of the facility investigation file, on 11/20/22, showed a written statement from the staff member working the night of the alleged sexual abuse (11/23/21), involving resident #32 and 53, and a copy of the reported information submitted to the State Survey Agency. There was a lack of root cause analysis or information about how the facility intended to protect resident #32 from further sexual abuse. Review of resident #32's nursing progress notes, dated 12/10/21, showed, [Resident #53] found laying in [resident #32's] room under her covers while [resident #32] layed in only her underwear with shirt pulled up and breasts exposed. [Resident #53's] hand was on one of [resident #32's] breasts . Later in the shift [resident #53] was found again sleeping in [resident #32's] bed with no pants on. [sic] Review of the facility investigation file, on 11/20/22, revealed a written statement from the staff member working the night of the second alleged sexual abuse (12/10/21), and a copy of the reported information submitted to the State Survey Agency. There was a lack of root cause analysis or information about how the facility intended to protect resident #32 from further sexual abuse. During an interview on 11/21/22 at 9:29 a.m., staff member G stated she could not speak to a specific plan or process to keep specific residents separated. 2. Review of the facility reported incidents, dated 5/28/22 to 10/3/22, showed resident #53 had been physically abused by resident #58 on four different occasions. Consequences of these altercations included being hit across the face with a gait belt buckle, scratched along his face and neck with fingernails, and being bitten hard enough to leave a bite mark. Review of the facility investigation files, viewed on 11/20/22, for the abuse events between resident #53 and 58, showed a lack of information on how the facility intended to prevent ongoing abuse while determining the root cause of the separate incidents. Review of the facility reported incident findings, submitted to the State Survey Agency, dated 5/31/22, showed, A mesh/Velcro belt that can be attached to the sides of the door frame with the big stop sign in the middle has been ordered to deter residents from going into her [resident #58] room. During an observation on 11/19/22 at 1:28 p.m., there was no mesh/velcro belt sign to deter resident #53 or any other residents from wandering into resident #58's room. 3. Review of a facility reported incident, dated 1/23/22, showed, [Resident #53] was inappropriately touching a female resident. The staff separated both residents .He (resident #53) then entered several female's rooms, pulling their covers off and attempting to touch them inappropriately .[Resident #53] was removed by 911 police department and taken to E.R. Resident #16 and #35 were listed as victims of this incident. The facility investigation file, related to the abuse events on 1/23/22, reviewed on 11/20/22, contained a witness statement from the staff member working the day of the alleged sexual abuse (1/23/22), and a copy of the reportable information submitted to the State Survey Agency. No documentation of steps taken to protect resident #16 or #35 from further abuse by #53, while the investigation was ongoing were included. 41652 4. Review of the investigation of an incident reported to the State Survey Agency, which occurred on 2/12/22, involved an allegation of verbal abuse by staff member C towards resident #8. The investigative documents showed staff member C was prohibited from caring for resident #8 but was allowed to care for other residents without continuous supervision. During an interview on 11/21/22 at 1:35 p.m., staff member B stated she performed the investigation of the incident between resident #8 and staff member C. Staff member B stated resident #8 was protected from further abuse during the investigation. However, staff member B stated she did not protect other residents during the investigation as staff member C was allowed to continue working with other residents without direct supervision.

Based on observation, interview, and record review, the facility failed to provide a safe and secure environment with sufficient supervision to prevent elopement for 1 resident (#32) of 3 sampled residents, which resulted in a hospitalization for the resident. Findings Include: Review of a Facility Reported Incident, dated 10/7/21, showed resident #32 eloped from the facility on 10/7/21 at 11:40 a.m., and was found on 10/8/21 at 9:28 a.m., at his son in-law's home, asleep on the couch. Resident #32 was taken to the hospital by police and admitted for dehydration and altered mental status. The Facility Reported Incident included documentation showed the resident was missing for 18 hours, and did not show resident #32 had altered mental status or dehydration at time of the elopement. Resident #32 returned to the facility on [DATE]. Review of resident #32's Elopement Risk Assessment, dated 9/29/21, showed the resident had eloped from a the previous facility, less than 30 days prior to admission to current facility. The document also showed a care plan intervention of needs monitored by staff, wander guard ordered and placed. Review of an un-titled and un-dated facility document showed, Patio door was locked. [Staff member] was told she could let the residents out on patio if she stayed with them. The fence was down at the time. [Staff member] took residents out on the patio; however, did not lock the door again after she brought them in. The document showed after reviewing the cameras, resident #32 stood in the activities room by a pillar and walked out to the patio when he saw no staff was watching. He sat on a patio chair for a while then walked off the patio as the fence/gate was down. Review of a un-titled and un-dated facility document showed, Floor staff had witnessed [Resident #32] standing in the Activity room near a pillar . Staff were not checking residents as frequently as needed . Review of resident #32's [Entity Name] report, dated October 2021, showed an order for, Wander guard in place for safety-please check function and placement q shift every shift for elopement risk, start date 9/30/21 and D/C date 10/12/21. Documentation for shift checks on 10/1/21, 10/3/21 and 10/6/21 were not present on the [Entity Name] report. A second order showed Wander guard in place for safety- please check function and placement q shift. Wander guard expiration date 4/2024. Every shift for elopement risk, start date 10/12/21 and D/C date 11/22/21. Documentation for shift checks on 10/14/21, 10/18/21, and 10/20/21 were not present on the [Entity Name] report. During an interview on 11/23/21 at 12:42 p.m., staff member E stated there were cameras at the doors, and a main screen was located at the nurse's station. The cameras could also be accessed by cell phone or other facility computers. The screens at the nurse's station are not monitored. During an interview on 11/23/21 at 12:54 p.m., staff member F stated the fence was down on the non-smoking area, and there was a delay with the fencing company in putting it back up. Staff member F stated the door to the smoking patio contained an alarm, and a lock with a code for entry, and exit. Staff member F said the door on the non-smoking patio door did not have an alarm and was locked with a key. Staff member F said resident #32 was discovered missing when the nurse went into his room for the afternoon med pass at 2:10 p.m., and found his lunch tray had not been touched. A code pink was then called and a search by staff was initiated. Staff member F stated resident #32 was initially admitted for the secured unit. The facility did not have any openings at that time in the secured unit, and the facility placed resident #32 in a non-secured room. Staff member F stated, The Administrator wanted him taken anyway (accepted for admission), social services wanted a wander guard placed and resident watched closely. Review of document titled, Elopement of [Resident #32] dated 10/8/21, showed the facility did not discover resident #32 was missing for 2.5 hours. During an observation on 11/23/21 at 1:35 p.m., the smoking door was propped open with a towel, the door alarm was sounding, but couldn't be heard over the noise of the heater running. During an observation on 11/23/21 at 1:36 p.m., the alarm system at the nurse's station was noted to make the same alarm sound for both the door alarm, and the resident call lights. No staff members were present at the nurse's station to hear the door alarm had been activated. Review of facility policy titled Elopement Risk, with a revision date of March 2019 showed .6. Following are possible individualized interventions which may include, but are not limited to: a. Account for residents at risk for elopement every 30 minutes .

Based on interview and record review, the facility failed to ensure residents were adequately assessed for changes in their physical and neurological condition after an unwitnessed fall, for acute pain after an unwitnessed fall, and for deterioration in functional ability; the facility failed to notify the medical provider when a diagnostic x-ray was not completed as ordered, resulting in a delay in treatment; and the facility failed to update the resident care plan with interventions related to monitoring and documentation of changes in physical, mental, and psychosocial status, management of acute pain, and when to notify a medical provider, for 1 (#1) of 5 sampled residents. Findings include: During an interview on 5/11/21 at 2:25 p.m., resident #1 stated she remembered the circumstances of her fall but did not remember much about the days which followed because she was, kind of in a daze, and did not remember many details. Resident #1 stated she was trying to get something out of her clothes closet, lost her balance, and fell backwards hitting her left hip and her head. She stated she needed help getting up and took pain pills for her hip pain. Resident #1 stated she had the pain pills for use after having a tooth pulled approximately a week earlier. Resident #1 was found to be alert and able to answer general questions easily. Resident #1 was not able to recall specific details regarding her pain or ability to move around in the days after her fall. During an interview on 5/11/21 at 10:10 p.m., staff member F stated although resident #1 was in a lot of pain and did not want to logroll or get out of bed during his shifts on 4/2/21 and 4/3/21, resident #1 had been examined by a provider on 4/2/21 and he (staff member F) did not feel there was anything new to tell the provider. Staff member F stated resident #1 yelped when her leg or hip was touched, but when she was asleep, she was able to cross her legs without waking up. Staff member F stated despite her pain and reluctance to move, he believed her flexibility when sleeping confirmed there was no reason to be concerned. During an interview on 5/12/21 at 9:50 a.m., staff member G stated she was the nurse on duty when resident #1 was found on the floor in her room. Staff member G stated she believed neurological checks were started after resident #1's fall on 4/1/21. Staff member G stated neurological checks were indicated because resident #1 had hit her head during the fall. and it was an unwitnessed fall. When staff member G was told there was no documentation of neurological checks in resident #1's medical record, she was not able to explain why. Staff member G stated the neurological checks should have been continued on the night shift. During an interview on 5/12/21 at 10:10 a.m., staff member C stated when a Medication Aide was assigned to administer medications to residents on a specific wing, a nurse was assigned to complete any assessments or other nursing duties for the residents. After consulting the assignment sheet for 4/1/21, the date of resident #1's fall, staff member C stated staff member G had been responsible for any assessments and documentation required after resident #1 fell . During an interview on 5/12/21 at 10:39 a.m., staff member B stated it was the facility's expectation nursing was supposed to perform a resident assessment, including their neurological status at least once a shift for 72 hours after an unwitnessed fall. Staff member B stated sometimes the neurological checks were documented on a paper form first and then transferred to the electronic medical record later. Staff member B stated it was the responsibility of the nurse assigned to the resident to complete all necessary post-fall documentation. Staff member B stated he was told the neurological checks were documented on paper, but no one was able to locate the document. Staff member B stated he was not aware of resident #1's fall on 4/1/21 and subsequent hospitalization on [DATE] for a left hip fracture until he returned from vacation. Staff member B stated he talked with the resident's primary provider as part of his post-fall investigation. Staff member B was told, by the primary provider, the provider who saw resident #1 on Friday, 4/2/21, called the facility on Monday 4/5/21 at 1:21 p.m. to check on resident #1's condition. Staff member B was told the staff felt she was worse and an x-ray of resident #1's left knee and hip was requested. The primary provider also told staff member B he was not aware resident #1 had refused the hip x-ray until after she had already been admitted to the hospital. Staff member B stated care plans were updated by the IDT after an event, and any nurse was also able to update care plans. The resident's primary provider was not available for direct interview during the survey. During an interview on 5/12/21 at 11:22 a.m., staff member A stated the IDT reviewed the circumstances and documentation related to resident #1's fall on the following day, 4/2/21. Staff member A stated it was the facility's expectation neurological checks and an overall assessment was required at least once a shift for 72 hours after an unwitnessed fall or a fall with a head injury. Staff member A stated a thorough assessment of the resident included the interventions implemented, the response to the interventions, the resident's physical and neurological condition, and pain. Staff member A stated the IDT was not aware there were no neurological checks or thorough resident assessments present for resident #1 following her fall on 4/1/21. A review of resident #1's nursing progress note, dated 4/1/21 at 6:03 p.m., showed resident #1 had been found on the floor at 4:50 p.m. by a CNA. The note showed resident #1, . felt dizzy from hitting her head. and Left hip is causing pain however is still able to rotate and extend her legs. CNA and I had to use a hoier [sic] to pick her up. Neuros will be monitored. The note showed no evidence of a thorough physical or neurological assessment. A review of resident #1's IDT progress note, dated 4/2/21 at 9:30 a.m., showed, IDT reviewed incident Re: 4/2/21 [sic] Fall without injury, Resident is occasionally incontinent of Bowel and Bladder, but takes herself to the bathroom. Staff to check resident during care rounds, and offer toileting and assistance. The note showed no evidence of a loss of balance being part of the root cause for the fall, as reported by resident #1 during an interview on 5/11/21. A review of resident #1's nursing progress note, dated 4/3/21 at 3:49 a.m., showed, Resident reluctant to do activities. She states she fell two days ago and she is sore. [MEDICATION(S)] given for pain with some relief. The note showed no evidence of the location of resident #1's pain or an assessment of her overall condition. A review of resident #1's nursing progress note, dated 4/5/21 at 5:25 p.m., showed, Provider ordered an Xray of pts (patient's) L hip and knee. Mobile imaging was only able to get pts knee and not hip, they will be back tomorrow to get an image of pts hip. The note showed no evidence a provider was notified regarding the inability to obtain the hip x-ray as ordered. A review of resident #1's Change in Condition progress note, dated 4/5/21 at 10:16 p.m., showed the resident was found to have an oxygen saturation reading of 52%, and was to be transferred to the emergency room per the on-call provider. The note showed no documentation related to the resident's recent fall with left hip pain. A review of resident #1's medical record failed to show any neurological checks documented between her initial fall on 4/1/21 and 4/5/21 when resident #1 was transferred to the hospital. The medical record showed no evidence of a physical assessment, including the location and quality of her pain, and her response to non-pharmacological interventions other than the brief nursing notes on 4/1/21 at 6:03 p.m., 4/2/21 at 9:30 a.m., 4/3/21 at 3:49 a.m., 4/5/21 at 5:25 p.m., and 4/5/21 at 10:16 p.m., referenced above. A review of resident #1's CNA Task Completion records, dated March 2021, showed the resident's functional ability and assistance required before the fall on 4/1/21 to be the following: -Bed Mobility, primarily independent to limited assistance of one staff member -Dressing, primarily limited assistance of one staff member -Personal Hygiene, primarily limited assistance of one staff member -Toileting, primarily limited to extensive assistance of one staff -Transferring, primarily independent to supervision with setup help only -Walk in Room, primarily independent to supervision without assistance A review of resident #1's CNA Task Completion records, dated April 2021, showed the resident's functional ability and assistance required after the fall on 4/1/21 to be the following: -Bed Mobility, primarily extensive assistance of one to two staff members -Dressing, primarily extensive assistance of one staff member -Personal Hygiene, primarily extensive assistance of one staff member -Toileting, primarily extensive assistance of one staff -Transferring, refused or extensive assistance of two staff members -Walk in Room, activity did not occur until after surgical repair of fracture A review of resident #1's Fall Care Plan, initiated 4/16/20 on admission, showed no revisions or updates related to the fall which occurred on 4/1/21. The revisions noted occurred on 4/8/21 when resident #1 returned from a hospital stay where she had a surgical repair of her fractured left femur. The care plan showed no evidence of interventions related to neurological checks, assessment of physical condition, pain management, new fall prevention precautions, or to notify the resident's medical provider of worsening of her condition. A review of the facility's policy titled, Fall Prevention and Response Policy, dated April 2020, showed the following, . 3. Initiate Neuro checks if resident hit head or if unwitnessed fall. 6. Post-fall documentation includes . interventions, response to interventions, effectiveness of interventions, and injuries noted. 7. Documentation of post-fall status will occur in progress notes q (every)-shift for at least 72 hours and as needed. A request for any documentation of Neurological Checks for Resident #1 was requested on 5/11/21 at 2:00 p.m. Nothing was received prior to the end of the survey.

Based on interview and record review, the facility failed to ensure a resident experiencing a sudden onset of pain after a fall had a comprehensive nursing assessment and ongoing monitoring intended to provide necessary resident information leading to an effective pain management plan for 1 (#1) of 4 sampled residents. The deficient practice resulted in a decline in functional ability and potentially resulted in a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: During an interview on 5/11/21 at 11:30 a.m., staff member D stated resident #1 was, difficult to read. Staff member D stated resident #1 would sometimes say her pain was okay and rate it as a 7 on a 1 to 10 scale. Staff member D stated she used more non-verbal indicators for resident #1. She stated this was due to resident #1's dementia and contradictory statements associated with pain. During an interview on 5/11/21 at 2:25 p.m., resident #1 stated she remembered the circumstances of her fall but did not remember much about the days which followed because she was, kind of in a daze, and did not remember many details. Resident #1 stated she was trying to get something out of her clothes closet, lost her balance, and fell backwards hitting her left hip and her head. She stated she needed help getting up and took pain pills, originally ordered for tooth pain, for her hip pain. During an interview on 5/11/21 at 10:07 p.m., staff member F stated resident #1 was in a lot of pain and tried to refuse cares which involved rolling from side to side or getting out of bed during his night shifts on 4/2/21 and 4/3/21. Staff member F stated he did not think resident #1's level of pain or inability to perform ADL's was a reason for concern because the provider had examined her the day after she fell (4/2/21) and did not think there was a fracture. Staff member F stated resident #1 would yelp when her hip or leg was touched. He stated the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1's hip pain as well. During an interview on 5/12/21 at 9:50 a.m., staff member G stated other than her single nursing progress note identifying the resident's fall, dizziness, and hip pain, she did not have any specific memories related to resident #1's fall on 4/1/21. Staff member G was assigned to nursing assessments for resident #1 on 4/1/21 and 4/5/21. Staff member G had no memory of resident #1 having pain or demonstrating behaviors associated with pain on 4/5/21. Even though she was assigned to resident #1, staff member G stated she believed someone else had given resident #1 pain medication during the day shift on 4/5/21. Staff member G was not able to explain why there was no pain assessment for resident #1 on 4/1/21 or 4/5/21. Although staff member G entered the verbal order and documented the hip x-ray was not obtained on 4/5/21, she could not remember what precipitated the order for a knee and hip x-ray, or if she notified the provider about the hip x-ray not being obtained. A review of resident #1's nursing progress note, dated 4/1/21 at 6:03 p.m., written by staff member G showed no description of the resident's left hip pain following an unwitnessed fall. The note showed a mechanical lift was required to get resident #1 off the floor and back in bed. A review of resident #1's nursing progress note, dated 4/3/21 at 3:49 a.m., written by staff member F showed the resident was reluctant to do activities, and she was sore. [MEDICATION(S)] was given with some relief of her pain. The note showed no evidence of a pain assessment which should have included the intensity, pattern, location, frequency, timing, and duration of her pain. A review of resident #1's CNA Task Completion records, dated March and April of 2021, showed a decline in her functional abilities, and an increased need for assistance. Please refer to F689 for additional detail related to this documentation. A review of resident #1's Medication Administration Records, dated March and April of 2021, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The following showed the administration of [MEDICATION(S)] and follow-up evaluation of effectiveness: -3/30/21 at 8:44 p.m., [MEDICATION(S)] 50 mg given for post tooth extraction pain rated as a 6 on a 1 to 10 scale. This was the last dose given until after resident #1's fall on 4/1/21. -4/1/21 at 5:31 p.m., [MEDICATION(S)] 50 mg given for pain rated as 8 on a 1 to 10 scale. No documentation of the characteristics of the pain except it was in her left hip. -4/1/21 at 7:37 p.m., effective, rated as a 4 on a 1 to 10 scale, no documentation of location or any other pain characteristics found. -4/2/21 at 3:12 a.m., [MEDICATION(S)] 50 mg given for pain rated as a 5 on a 1 to 10 scale, no documentation of location or any other pain characteristics found. -4/2/21 at 6:29 p.m., effectiveness unknown -4/2/21 at 8:47 p.m., [MEDICATION(S)] 50 mg given for pain rated as a 3 on a 1 to 10 scale, no documentation of location or any other pain characteristics found. -4/3/21 at 3:49 a.m., effective, no rating on 1 to 10 scale documented. -4/3/21 at 10:46 a.m., [MEDICATION(S)] 50 mg given for pain rated as an 8 on a 1 to 10 scale, no documentation of location or any other pain characteristics found. -4/3/21 at 7:01 p.m., effectiveness unknown -4/5/21 at 8:28 p.m., [MEDICATION(S)] 50 mg given for pain rated as a 5 on a 1 to 10 scale, no documentation of location or any other pain characteristics found. A review of resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The day shift monitoring documentation was blank from 4/1/21 through 4/5/21. The night shift monitoring documentation showed a rating of 6 for 4/1/21 and a 5 for 4/5/21. The night shift pain monitoring documentation for 4/2/21 through 4/4/21 showed a rating of 0. A review of the facility's policy titled, Pain Assessment and Management Policy, dated March 2019, showed a comprehensive pain assessment should include the resident's history of pain and its treatment, characteristics of pain which include intensity, descriptors, patterns, location, frequency, timing, and duration of pain, impact of pain on daily life, triggers, and accompanying symptoms. The policy showed a resident's pain is monitored to determine if it is being adequately controlled, if interventions are effective, and for how long.

Based on observations, interviews, and record reviews, the facility failed to ensure staff were performing protective measures to prevent the transmission of infectious diseases and failed to implement the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices in preparation for COVID-19 virus. Specifically, the facility failed to: -Ensure all staff were adhering to personal protective equipment (PPE) upon entry into the facility -Ensure staff were performing hand hygiene -Ensure staff were donning (PPE) upon entry into resident rooms for residents with a positive [DIAGNOSES REDACTED].>-Ensure doors in residents' rooms were kept close upon entry and exiting when staff were providing nursing cares to residents with a [DIAGNOSES REDACTED].>These failures place staff, residents, and visitors as risk for acquiring infectious diseases. Immediate Jeopardy (IJ) called on 11/18/20 at 1:15 PM for 42 CFR §483.80 Infection Control regulations. A removal plan for the Immediate Jeopardy was accepted and the IJ was removed on 11/18/20 at 5:50 PM after the implementation of the plan was verified by the surveyor. After removal of the Immediate Jeopardy, the scope/severity of this citation is level F (widespread with the potential for more than minimal harm). Findings include: On 11/18/20 at 1:15 PM, an observation revealed that the Infection Preventionist (IP) was in a resident's room, sitting down in chair near the resident's bedside without a gown, disconnecting the resident from the tube feeding machine. The resident tested positive for COVID-19 and droplet precautions were indicated from the signage on the door. Within minutes, another nurse entered a COVID-19 positive room with a face shield, gown, gloves, and did not have a respirator mask (KN95 or N95) or any mask protecting nose or mouth. These observations resulted in an immediate jeopardy determination. I. Observation on 11/17/20 at 1:43 PM, greeted by Chief Operating Officer (COO) without PPE (no mask, no goggles, no face shield, and no gown). After the introduction as to why this surveyor was here, the COO stated she was without a mask because she was eating lunch. She then walked approximately 50 feet where she donned a mask and a face shield. When asked why she was not wearing a mask, she stated, well, this is not a patient care area ; informed her of the signage upon entry into the building that specifies all staff are required to wear a mask, and that this building has an outbreak of COVID-19 cases, the COO acknowledged. Record review of the Infection Prevention and Control Policies and Procedures Interim Policy for Suspected or Confirmed Coronavirus (COVID-10) dated March 2020; Revised March 18, 2020; on page three of 26, under subheading Policy reads in pertinent part, It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents and employees with clinical features and an epidemiological risk for the COVID-19 and to adhere to Federal and State/Local recommendation that protect our residents and employees from the spread of infectious disease, including COVID-19. Professional reference by CMS reads, Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE. · For the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility. Retrieve online at: https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf Professional reference by the CDC reads, HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. Retrieved online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html Professional Reference by the CDC: The CDC defines Healthcare Personnel (HCP) to include but not limited to emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, volunteer personnel). Retrieved online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assessment-hcp.html II. Observation on 11/17/20 at 2:38 PM, the Housekeeping Supervisor (HK2) exited a resident room, doffed gown and gloves, balled them up in hand, then picked up clipboard and ink pen without hand hygiene after the removal of gloves. Then HK2 walked 14 feet up the hall to discard the PPE that was balled up. In subsequent interview, when asked why hand hygiene was not used upon removal of the gloves, HK2 stated, The gown was inside out, continued to state he wished he could discard them in the room, instead of leaving the room and discarding in the common area. Following a discussion with HK2, HK2 verbally acknowledged that immediately after the removal of gloves, it is a best practice is to perform hand hygiene before picking up the clipboard. Record review of Handwashing/Hygiene policy effective date of 2010; revision date [DATE]; Policy Number: NS342 page two number six reads, In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visible soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: (j.) After removing gloves; and number seven reads, Hand hygiene is always the final step after removing and disposing of personal protective equipment. Professional reference by the CDC indicate to use an alcohol-based hand sanitizer immediately after glove removal. Retrieved online at: https://www.cdc.gov/handhygiene/providers/index.html III. Observation on 11/17/20 at 2:56 PM, in the secured unit, HK1 donned gloves before the gown, and entered the droplet precautions room. Upon exiting the room, he removed his gown and gloves with hand hygiene and placed the used gown and gloves in the trash on his housekeeping cart, he then donned one glove, again without hand hygiene and proceeded to exit the locked unit. During subsequent interview, when shared observation with HK1 in regards to the sequencing of donning PPE (Putting gloves on before the gown) and not using hand hygiene after glove removal. HK1 stated, I had two pairs of gloves on when asked about the donning correctly, meaning the gloves are the last item of PPE, HK1 stated I forgot .I know, I had COVID-19 before. HK1 was observed to be wearing two pair of gloves. Less than six feet from where HK1 was cleaning was signage for donning PPE listing the following: 1. Gowns, 2. Masks, 3. Goggles, and 4. Gloves. Record review of Handwashing/Hygiene policy effective date of 2010; revision date [DATE]; Policy Number: NS342 page two number six reads, In most situation, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visible soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: (j.) After removing gloves; and number eight reads, The use of gloves does not replace handwashing/hand hygiene. Professional reference by the CDC indicates to use an alcohol-based hand sanitizer immediately after glove removal. Retrieved online at: https://www.cdc.gov/handhygiene/providers/index.html Professional reference for donning PPE list the following: 1. Gown; 2. Mask or Respirator; 3. Goggles or Face Shield; 4. Gloves Retrieved online at: https://www.cdc.gov/HAI/pdfs/ppe/ppeposter148.pdf IV. Observation on 11/18/20 at 12:45 PM, noted door open in the COVID-19 + room, with the IP/ADON sitting on a chair at the resident's bedside disconnecting the feeding tube, the IP/ADON did not have a gown on. The resident's room had signage outside the door illustrating Droplet Precautions and PPE, including gowns, gloves, mask , and goggles are to worn upon entry. Upon exiting the room, the IP/ADON was asked was the resident positive for COVID-19, the IP/ADON looked at the precautions on the door that remained open, and said, I don't know if she is; the NHA joined this surveyor and the IP/ADON and stated, Yes, she is positive for COVID-19. The IP/ADON then stated, Well, I did not do patient care, I only came in the shut the alarm off. When shared with the IP/ADON that the observation revealed that she was sitting down at the bedside, with the door open and not wearing PPE. She was asked when does she wear full PPE, the IP/ADON stated, When I do patient care. When shared the signage on the door illustrates the resident is on Droplet Precautions, the IP/ADON walked away. Subsequent interview with NHA, when informed of the outbreak in the facility and not adhering to CDC guidelines of prevention strategies places everyone at risk. The NHA stated, yes I know .especially since she (IP/ADON) has had COVID-19, and then stated he will educate the IP/ADON. Record review of policy titled, Infection Prevention and Control Policies and Procedures Interim Policy for Suspected or Confirmed Coronavirus (COVID-19); Dated March 9, 2020, revised March 18, 2020; on page number ten of 26, on the fifth bullet point it reads, The facility will re-educate and reinforce: -Diligent hand-hygiene practices including correct handwashing and the use of ABHG -Cough/respiratory etiquette -Respiratory hygiene -Transmission Based Precautions -Appropriate utilization of PPE's as indicated -Current CDC, CMS, state and local requirements for all levels of living. Professional reference by CMS reads, Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected of COVID-19 per CDC guidance on conservation of PPE. · If COVID-19 transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 [DIAGNOSES REDACTED].cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf Professional reference by the CDC reads, Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Retrieved from: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html V. Observation on 11/18/20 at 1:06 PM, LPN1 had a face shield on, no mask or respirator covering mouth or nose, LPN1 donned gowns, then gloves and proceeded into a COVID-19 + room to give medications. The door was remained open. Upon exiting the room, asked why she did not wear a mask in the room. LPN1 stated, I have a medical release associated with trauma, I was victimized when the assailant covered my mouse and nose. She states further, that wearing any mask over mouth and nose associates her with the trauma. Subsequent interview with NHA, when asked why is LPN1 is in patient care areas if she cannot wear PPE. The NHA states she cannot wear the alternatives such as a helmet or hooded respirator, because she tears up like she is being victimized again. Professional reference by CMS reads, Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE. and to include but not limited to , Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE. · If COVID-19 transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 [DIAGNOSES REDACTED].cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf Professional reference by CDC: HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also: -Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. -Wear an N95 or equivalent or higher-level respirator, instead of a facemask, for: ?Aerosol generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings FAQ) and Surgical procedures that might pose higher risk for transmission if the patient has COVID-19 (e.g., that generate potentially infectious aerosols or involving anatomic regions where [MEDICAL CONDITION] loads might be higher, such as the nose and throat, oropharynx, respiratory tract) (refer to Surgical FAQ). Retrieved online at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html On 11/18/20 at 6:10 PM, in an exit interview with the NHA, COO, and the VPO/DON, when shared Observation number I, the COO stated, This was my first break after working 36 hours .and I heard the doorbell, and I had to answer the door. Informed the COO, that the CDC/CMS suggest wearing masks throughout the facility, and especially during an outbreak. The VPO/DON and the NHA states, we have been working 16 hour days with no breaks. Asked the VPO/DON about the surveillance for hand hygiene, the VPO/DON stated, Our goal is 100%. When asked what were the results last month, the NHA replied, We did 97%. Shared observation number II and III , the NHA says the HKS has only been the supervisor for about three days. The NHA says HK1 recently returned from recovery with COVID 19. When shared observation number IV, the NHA stated I have educated her. When reminded she is the Infection Preventionist for the facility, the NHA and the VPO/DON acknowledged. When shared observation number V, the COO says she is no longer involved in patient care, when asked when did this happen. The COO said when the IJ was called, we removed her from patient care. The COO stated LPN1 will now be in staff education, in a room large enough for social distancing. Encouraged to submit any additional items during this survey period via email.

Based on observation, interview, and record review, the facility failed to prevent the development of two avoidable pressure ulcers on the resident's heels and one avoidable pressure ulcer to the left great toe; failed to identify timely, assess adequately, and document the status of the wounds; and failed to prevent the worsening of the pressure ulcers, and all three pressure were Unstageable at the time of the survey, for 1 (#13) of 23 sampled residents. Findings include: During an observation and interview on 12/22/19 at 10:20 a.m., resident #13 was wearing a green Podus boot (for pressure relief) on each foot. Resident #13 stated she got pressure sores on her heels from walking barefoot, up and down the hallway. Resident #13 stated one ulcer had healed, and she sure was glad, and she was being treated at the wound clinic for the pressure ulcers. She stated the ulcers did not hurt. Review of resident #13's eMar progress note, dated 4/12/19, showed the physician had evaluated the resident regarding feet issues. He noted a blood blister to the left great toe and lateral heel. Daily skin checks were ordered, and a foam dressing was ordered for the left toe ulcer. The feet issues were not documented in resident #13's medical record prior to the physician visit. During an interview on 12/23/19 at 12:09 p.m., staff member B stated the facility had no documented daily skin checks for resident #13, as ordered by the physician on 4/12/19. During an interview on 12/22/19 at 10:30 a.m. staff member B stated the ulcers were not facility acquired, and at one point, a wound vac to the resident's heels was implemented. Staff member B stated resident #13's comorbidities included a special kind of [MEDICAL CONDITION], and she was being treated at the wound clinic. Review of resident #13's admission skin assessment, dated 3/16/19, showed no presence of pressure ulcers. Review of resident #13's Admission MDS, dated [DATE], showed no risk for the development of, or presence of, pressure ulcers. Review of resident #13's 30-day MDS, dated [DATE], did not identify the presence of the pressure ulcers. Review of resident #13's Quarterly MDS, dated [DATE], showed the presence of two Stage I pressure ulcers and one Stage II pressure ulcer, present at admission, and two deep tissue injuries were present on admission. Resident #13's Quarterly MDS also showed a Multi Resistant Organism infection, and the resident required a two person assist for bed mobility. Review of resident #13's eMar progress note, dated 4/24/19, showed Resident in bath house receiving a shower this morning and was noted by bath aide black tissue on back of heels bilaterally (sic). No orders for pressure ulcer treatments, interventions, or assessments were included in the progress note. Review of resident #13's initial wound clinic note, dated 4/25/19, showed, Initial wound healing center evaluation for 3 wounds. The onset of these was sometime before 4/12/2019. These wounds were noted by her (name) provider on that day. She has bilateral Unstageable heel ulcers and an ulcer of the left great toe also Unstageable at this time. Both heel ulcers are involved with a dry hard eschar, black in color . To this point it does not sound like much offloading has been attempted to protect the wounds. (sic) Review of resident #13's (MONTH) 2019 Medication Administration Record, [REDACTED]. The worsening and development of the Unstageable toe ulcer was not documented in the Medication Administration Record. Review of resident #13's nursing progress note, dated 6/18/19, showed a wound vac was implemented to both heels to promote wound healing, and recommended by the wound clinic. Review of resident #13's nursing progress note, dated 6/18/19, showed continues to struggle with having the bilateral [DEVICE] to her heels. Review of resident #13's Provider Wound Care orders, dated 6/28/19, showed, Please schedule MRI ordered on [DATE]. Review of the provided MRI document from the facility, showed it was completed on 7/30/19. Review of resident #13's physician visit note, dated 7/22/19, showed two Stage IV pressure ulcers to the resident's heels. The visit note showed, Recent MRI of right heel is consistent with osteo[DIAGNOSES REDACTED]. The great left toe ulcer was not addressed in the physician note. Review of resident #13's Care Plan, for Skin Issues and interventions, was initiated on 4/26/19. It did not include the three pressure ulcers. A second Care Plan provided by the facility was initiated on 6/4/19. It showed I have skin issues: bilateral pressure ulcers on my heels. The great left toe pressure ulcer was not included in the care plan. Review of resident #13's Comprehensive Skin Inspection, dated 4/24/19, showed the two heel pressure ulcers, and the left toe ulcer with no description. Review of resident #13's Comprehensive Skin Inspection, dated 8/23/19, showed the presence of two Stage IV pressure ulcers to the heels. The great toe wound was not included. Measurements of each wound were not documented. Review of resident #13's Comprehensive Skin Inspection, dated 9/17/19, showed the presence of two pressure ulcers to the heels. The stage and measurements were not documented. The status of the great toe ulcer and treatment were not identified in the documents provided by the facility. During an interview on 12/23/19 at 11:20 a.m., staff members B and C stated the procedure for updating care plans was a daily team effort at the morning meeting. Staff member C stated she could not speak to the events of the development and worsening of resident #13's wounds. Staff member C stated she was a floor nurse at that time, and only remembered the resident went to the wound clinic. Staff member B stated she had been the Director of Nursing since (MONTH) 2019, and was not able to determine how the facility failed to treat the wounds when identified on 4/12/19. Staff member B stated she should be in the loop for all wounds, and the wounds are communicated to the team by reading the daily progress notes. When asked about root cause analysis for wound development, staff member B stated the facility had a Performance Improvement Plan in place for pressure ulcers, and were educating the nurses. Staff member A stated the goal was to have every resident to have a skin evaluation by staff member C. Review of the facility Skin Program Policy, dated (MONTH) 2019, showed, To provide care and services to prevent pressure ulcer development, to promote the healing of pressure ulcers that are present and prevent development of additional pressure ulcers . and a comprehensive wound assessment will be completed: When a skin ulcer is identified. This assessment will include, a) Site, stage, size, appearance of wound bed, undermining, depth, and drainage.

Based on observation, interview, and record review, the facility failed to provide oxygen to a resident which resulted in the resident having insufficient oxygen saturations and caused the resident to fear for his life; and failed to provide a resident with his call light in order to reach staff when having breathing difficulties for 1 (#36) of 19 sampled residents. Findings include: During an observation on 12/10/18 at 4:45 p.m., resident #36 was observed sitting in his wheelchair at a table in the dining area of the memory care unit. His oxygen cannula was not placed in his nose; it was on his face, but the nasal ports were to the left side of his nostrils. Resident #36 was observed with one oxygen cylinder, which was attached to the back of his wheelchair. The gauge showed the oxygen cylinder was empty. During an interview on 12/10/18 at 4:46 p.m., resident #36 stated, I need oxygen all the time. If I don't have it for two hours, I will die. During an interview and observation on 12/10/18 at 4:46 p.m., staff member E was asked to assist resident #36 with his oxygen needs. Staff member E stated resident #36 needs continuous oxygen. She stated resident #36's oxygen cylinder was empty. Staff member E was observed leaving the memory care unit, and returned five minutes later with a new oxygen cylinder and exchanged it with resident #36's empty cylinder. Staff member E was observed setting the flow rate on the oxygen cylinder to two liters. She did not inform nursing staff of the need to assess resident #36 and no nursing assessment was completed or on file. During an observation on 12/11/18 at 12:31 p.m., resident #36 was observed sitting in his wheelchair at a table in the dining room of the memory care unit. His oxygen cannula was wrapped around the left handle of his wheelchair. The oxygen cylinder that was attached to resident #36's wheelchair was empty. During an observation on 12/11/18 at 12:32p.m., staff member H was asked to assess resident #36's O2 saturations. She retrieved a pulse oximeter and placed it on resident #36's right pointer finger. The pulse oximeter showed that resident #36's oxygen saturation was 87%. During an interview on 12/11/18 at 12:34 p.m., staff member H stated, (Resident #36) had his oxygen on earlier. She stated, I'm bad. Staff member H stated resident #36 is supposed to have oxygen, In his room, all the time, otherwise when he needs it. She stated, It's supposed to be set at two, when asked how many liters of oxygen he is supposed to have. Staff member H did not inform nursing staff of the need to assess resident #36 and no nursing assessment was completed or on file. During an observation on 12/11/18 at 12:40 p.m., staff member I was observed changing the oxygen cylinder on resident #36's wheelchair. She set the flow rate of the oxygen cylinder to two liters. During an interview on 12/11/18 at 12:40 p.m., resident #36 stated, Oh it is nice to be able to breathe. I had trouble breathing without my air. He stated, I don't know how long it has been off. My lungs are clearing now. Ma'am if I am without this for 86 minutes I am going down the shoot! During an interview on 12/12/18 at 10:18 a.m., staff member B stated, If a resident is supposed to have oxygen continuously and their oxygen has set parameters, then we should be monitoring oxygen regularly, at least every shift. She stated, We need to see if we have a variance. Staff member B stated resident #36 had orders for continuous oxygen. She stated a licensed nurse is supposed to oversee the use of oxygen and is supposed to set the flow rate on the oxygen cylinders. During an interview on 12/12/18 at 10:42 a.m., staff member G stated, Based on (resident #36's) care plan, he should have oxygen on all the time. Per his doctor's orders, it looks like oxygen should be on all the time. During an observation on 12/13/18 at 8:21 a.m., resident #36 was observed lying in his bed. His bed was placed in the lowest position and a fall mat was observed next to him, on the floor, on the left side of his bed. Resident #36 was lying flat in his bed and his head was not elevated. Resident #36 did not have a blanket covering his body. He was observed wearing a disposable brief which was saturated in urine, and the sheets of his bed were soaked. Resident #36's oxygen cannula was not placed correctly on his face; it was removed from his left ear and lying on his chin. His call light was observed wrapped up and attached to the wall, and was not within resident #36's reach. Resident #36 stated, Please help me, I can't breathe. During an observation and interview on 12/13/18 at 8:22 a.m., staff member O entered resident #36's bedroom. She assisted resident #36 with getting changed and dressed. Staff member O stated she started her shift at 6:00 a.m. She stated, (Resident #36's) call light should not be pinned to the wall. Staff member O stated resident #36 should have his head elevated and his oxygen cannula should be placed in his nose correctly. During an interview on 12/13/18 at 8:28 a.m., staff member D stated he administered medications to resident #36, About a half an hour ago. He stated he sat him up in his bed, then laid his bed down flat. Staff member D stated, I did not see his call light or that he did not have it. He stated he did not turn the lights on in resident #36's room because his roommate was sleeping and he wanted to be respectful. Staff member D stated, (Resident #36) was up when I went in there. He didn't say that he wanted to get up. I didn't know he was wet because the lights were off. He stated he thought his oxygen cannula was on his face and placed correctly, but he could not be sure because the room was dark. During an interview on 12/13/18 at 8:29 a.m., staff member G stated staff member D passed medications to resident #36 at 7:47 a.m. She stated, Call lights should be within reach for all residents, when asked what the call light procedure was for the facility. During an interview on 12/13/18 at 8:30 a.m., staff member A and staff member B stated resident call lights should be within reach at all times for all residents. Staff member A stated call lights should not be pinned to the wall. Staff member B stated, Call lights should not be pinned to the wall. Some residents prefer that they are, but not (resident #36). It needs to be within reach. During an observation on 12/13/18 at 8:36 a.m., resident #36 was observed sitting in his wheelchair at a table in the dining room of the memory care unit. His oxygen cannula was not on his face and was observed wrapped around the left handle of his wheelchair. Resident #36's oxygen cylinder was empty, and he was observed coughing several times. During an observation on 12/13/18 at 8:38 a.m., staff member N was asked to assess resident #36's O2 saturations. He retrieved a pulse oximeter and placed it on resident #36's right index finger. The pulse oximeter showed that resident #36's oxygen saturation was 80%. During an interview on 12/13/18 at 8:39 a.m., staff member N stated resident #36 is supposed to have oxygen, When he has issues. He stated he does not need it all the time except for when he is in his bed. During an observation on 12/13/18 at 8:39 a.m., staff member N asked resident #36, Feeling okay (resident #36)? Resident #36 responded, No, I am feeling like I am drunk. During an interview on 12/13/18 at 8:40 a.m., resident #36 stated, I feel like there's a black spot in the back of my head. It is clouding my brain. He stated he needs his oxygen to survive and without it, I'll die. During an interview and observation on 12/13/18 at 8:43 a.m., staff member O stated, Yes, (resident #36) is supposed to have his oxygen on all the time. Staff member O was observed exchanging the empty oxygen cylinder that was attached to resident #36's wheelchair. Neither staff member reported the incident to a member of nursing and no nursing assessment was completed or on file. During an interview on 12/13/18 at 9:10 a.m., staff member M stated, I don't know, when she asked who was responsible for supervising the memory care unit. During an interview on 12/13/18 at 9:11 a.m., staff member N stated he and staff member O were responsible for the memory care unit. Staff member N stated, I am reporting to (staff member D), the nurse who is working this hall. During an interview on 12/13/18 at 9:13 a.m., staff member O stated staff member D was the nurse assigned to the memory care unit. She stated if there was a resident emergency she would call staff member D to come down. Staff member O stated, I would call (staff member D) if someone coded. Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #36's physician orders, dated (MONTH) (YEAR), showed he had an order for [REDACTED]. Review of resident #36's care plan, last revised 11/5/18, showed, Focus, I have a respiratory condition that requires assistance in breathing: [MEDICAL CONDITION], sleep apnea. Goal area showed, I want to keep my O2 saturation's 88-95%. Interventions section for the focus area showed, I require O2 per nasal cannula at 2 Liters/minute. Review of resident #36's progress notes, dated 12/13/18 at 10:43 a.m., showed, (NF1) contacted with details that he was found by surveyor, wet, call light out of reach, 02 saturation was 80%. Clarified with her the interventions that facility has taken and will continue to keep her informed. Review of resident #36's progress notes, dated 12/13/18 at 9:37 a.m., showed, MD notified that resident was found soaked, call light not within reach and that his oxygen was not on. Sat's were 80%. Review of resident #36's medical chart showed nursing staff did not asses the residents O2 saturations on every shift. For the month of (MONTH) (YEAR), O2 saturation documentation was on file for two days, 12/5/18 and 12/6/18. For the month of (MONTH) (YEAR), O2 saturations were documented on: -11/29/18; -11/27/18; -11/22/18; -11/21/18; -11/20/18; -11/10/18. Review of resident #36's progress notes, dated 11/03/18, showed, Pt up all night very agitated stating 'I am gonna (sic) die I cannot feel my pulse and nobody cares, I think I need to go to the hospital.' Checked radial pulse it was strong and bounding at normal rate attempted to assure pt that he was fine and that he is not going to die. No assessment of resident #36's O2 saturations were documented or on file for this incident. Review of resident #36's medical chart showed resident #36 had O2 saturations of 67% and 71% (Oxygen via Nasal Cannula) on 10/29/18. No nursing assessment was on file for the resident and the residents progress notes did not reflect interventions or notifications made to the resident's doctor about the resident's status. Review of the facility policy, Oxygen Usage, last revised on (MONTH) (YEAR), showed, Licensed nurses shall be in charge of the administration of oxygen .A nursing assistant is not to set the oxygen flow rate, initiate the use of oxygen or assess the need for usage .nursing assistants should check amount of oxygen in resident's tank at the beginning of their shift and as needed .If a resident is up and out of their room for long periods of time, a good practice would be to have 2 portable tanks on the chair for ease of switching and confidence for the resident of continued O2. Review of the facility Abuse Prevention Plan (MT), effective 2012, last revised (MONTH) of (YEAR), identified neglect as: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Further, the policy defined active neglect as, Putting call light out of reach, and passive neglect was defined as, Forgot to place within reach. The facility failed to administer necessary oxygen to resident #36 and failed to provide adequate nursing supervision, assessment, intervention, and documentation. Further, the facility failed to ensure that the resident was provided his call light so that he could alert staff in the event that he was having difficulty breathing, which caused the resident to become distressed.

Based on observation, interview, and record review, the facility failed to provide sufficient staffing to respond to residents needs, in a timely manner, for 8 (#s 3, 10, 14, 31, 37, 52, 56 and 64) of 31 sampled and supplemental residents. Findings include: 1. During an interview on 12/10/18 at 3:29 p.m., resident #14 stated that staff told him, they are short of staff especially on the night shift. The resident said that he was most concerned about the residents who required more care. 2. During an interview on 12/10/18 at 3:53 p.m., resident #56 stated that the facility was short of staff. Resident #56 said, It's scary, there's not enough staff. During an interview on 12/10/18 at 3:53 p.m., NF3 stated the facility does not provide ice water to resident #56 daily. NF3 stated, I always had to ask. NF3 stated the facility does not pass clean towels. He stated he is aware of his spouse's fear at night because of the shortage of staffing. 3. During a resident council meeting on 12/11/18 at 2:00 p.m., resident #64 stated, On average, we have to wait a half hour to an hour for staff to answer our call lights. As an advocate for all the people not here, I have been told they have been left on the pot for like an hour without someone coming to assist them. She stated, The more independent we are, the less they will come and care for us. During a resident council meeting on 12/11/18 at 2:00 p.m., resident #3 stated, On average, I have to wait so long, I have had to wait over an hour or an hour and a half for staff to answer my call light. He stated, Sometimes I think staff don't see the call lights. Sometimes you can't see the lights, but you can hear them. During a resident council meeting on 12/11/18 at 2:00 p.m., resident #31 stated, It takes a really long time for staff to come when I push my call light. It takes more than an hour for staff to come. 4. During an observation and interview on 12/11/18 at 7:46 p.m., a call light for resident #10 was observed ringing. The call light was not answered until 8:45 p.m. Resident #10 stated he was alright but he had to wait a long time to get his light answered. Resident #10 also stated, When I'm not feeling good, it's upsetting. It happens a lot. 5. During an observation on 12/11/18 at 8:02 p.m., a call light was observed ringing for resident #37. The call light not answered until 8:43 p.m. During an interview on 12/11/18 at 8:55 p.m., resident #37 stated, I needed my gut bag changed, and waited up to an hour. Resident #37 stated, I feel neglected, like nobody cares. He stated it could happen just about any time of day. Resident #37 said he had been at the facility for two years, and it is worse now. He said there are times when he had gone three weeks without a shower in the past eight months. He stated, After State leaves it gets better for a couple of weeks, then it's right back to the way it is now. 6. During an observation on 12/11/18 at 8:08 p.m., a call light was observed ringing for resident #52. The call light was not answered until 8:43 p.m. During an interview on 12/11/18 at 9:16 p.m., resident #52 stated her light had been on since 9:00 p.m. She stated, I have to go, what's taking them so long? Resident #52 was observed seated on a walker outside her room. During an interview on 12/11/18 at 9:25 p.m., resident #52 stated, Somebody better come pretty soon, I have had to hold myself for a long time. During an observation on 12/11/18 at 9:27 p.m., resident #52 was observed seated on her walker, in the hallway, outside of her room. Staff had not responded to her call light. 7. Review of the Resident Council Agenda and Meeting Minutes, dated 9/17/18 and 11/19/18, showed residents had concerns regarding call lights not being answered in a timely manner. Review of Grievance/Concern Report forms, dated 8/15/18, 9/17/18, 10/29/18, 11/14/18, and 11/19/18, showed residents had concerns regarding untimely answering of call lights.

Based on record review, interview, and observation, the facility failed to adequately assess, care plan and monitor 1 (#7) of 16 sampled residents, for the risk of elopement, which resulted in two elopements out of the facility, and one elopement out of the secured unit, and failed to implement interventions to prevent an elopement for 1 (#17) of 17 sampled and supplemental residents. IMMEDIATE JEOPARDY On 9/27/17 at 12:14 p.m., the facility Administrator, Director of Nursing, and Vice President of Clinical Services were notified that an immediate jeopardy existed in the area of F323, at the severity and scope of J. PLAN TO REMOVE IMMEDIACY The facility submitted an acceptable plan to remove the immediacy on 9/28/17 at 10:19 a.m. After the plan was accepted the severity and scope was reduced to a D. A summary of the facility's plan to remove the immediacy was as follows: A wander guard was placed on resident #7's ankle. Elopement assessments were completed for all residents with a Wanderguard. Placement of the Wanderguard will be checked each shift. Education was provided to all staff regarding documenting an elopement. The elopement policy and procedure was reviewed. Findings include: 1. Resident #7 was admitted to the facility on [DATE], after a fall with a traumatic brain injury. Review of resident #7's Elopement Risk Assessment, dated 8/1/17, showed The resident is disoriented to place and time but other than that is not an elopement risk. Review of resident #7's Speech Therapy Note, dated 8/3/17, showed he was found in the facility parking lot. Review of the Physician Orders, dated 8/3/17, showed a WanderGuard was ordered for resident #7. During an interview on 9/27/16 at 9:25 a.m., staff member H stated resident #7 had been eloping on 8/3/17, so the facility placed the WanderGuard on his wheelchair. Review of resident #7's Elopement Report, dated 8/5/17, showed the Wanderguard had been placed on the resident's wheelchair instead of his body, because the facility staff could not find a band. At 8:15 resident was discovered missing with his wheelchair by front door. I called police. CNAs and I went to park, gas station, and bar, and he was not found. At 8:45 police escorted him back into building. He was found at (Facility Name) Clinic. Resident #7 crossed a busy 4-lane road. Review of resident #7's Nursing Progress Notes, dated 8/15/17, showed he was moved to the locked memory care unit. During an interview on 9/27/17 at 9:30 a.m., staff member B stated the facility did not have an evaluation for placing residents in the secured unit. It's is an IDT decision. During an interview on 9/27/17 at 2:30 p.m., staff member Q stated resident #7 packed his bag almost every day, and sat at the locked door. We were told to keep an eye on him. During an observation on 9/27/17, at 12:20 p.m., resident #7 did not have a WanderGuard on his person. During an interview on 9/27/17 at 3:40 p.m., staff member D stated resident #7 had followed a food service worker with a food cart, out of the locked unit. The food service worker had not noticed him, but staff member D stated she took him back to the locked unit. This elopement was not documented or investigated. Review of resident #17's Care Plan, dated 6/13/17, did not include a problem with exit seeking, wandering or elopement. 2. Resident #17 was admitted to the facility on [DATE], related to elopements out of another facility. Review of resdent #17's Elopement Risk Assessment, dated 5/22/17, showed the resident had a history of [REDACTED]. Review of the State Agency Event Report, dated 5/26/17, showed resident #17 got through the secured unit doors, and went out the front door, during a Fire Drill. A medication nurse was in the parking lot and immediately redirected resident back in facility. The outcome of the investigation showed All doors were tested and found operational. Staff inserviced on door monitoring during fire drills and elopement procedure. The investigation did not include interventions specific to resident #17, to keep her safe from future elopements. Review of resident #17's Care Plan, initiated 5/22/17, showed I cannot reliably recognize a dangerous situation. The intervention for safety was I live in a secured unit per my physician's orders [REDACTED]. My continued need for this unit will be evaluated quarterly. It did not include resident-focused interventions for elopements.

Based on interview and record review, the facility failed to provide interventions to prevent an 11% significant weight loss for 1 (#4) of 16 sampled residents. Findings include: 1. Review of resident #4's care plan, with a last review date of 9/5/17, showed the resident was to receive a regular diet and needed to be weighed weekly. Review of the facility's weights and vitals summary sheet, printed on 9/26/17, showed resident #4 was being weighed one time per month. The weights for the six months were as follows: - 4/4/17: 138 lbs. - 5/8/17: 137 lbs. - 6/16/17: 134 lbs. - 7/6/17: 130 lbs. - 8/18/17: 126 lbs. - 9/26/17: 123 lbs. (this weight was taken after the survey had begun and was requested by the survey team) The weights listed showed an 11% weight loss in six months. Review of resident #4's most recent Nutritional Assessment Update, dated 7/31/17, showed resident #4 was 130 lbs. There was no indication of a weight loss, but it did show a potential problem because of inadequate oral intake related to low weight for height. The nutritional intervention was that the diet and a supplement were to be followed per doctor order, and follow the appetite, weight and skin per facility routines. The nutritional note also showed that the resident could select meals and alternate choices should be provided at each meal per his desires. Review of resident #4's care plan did not show any of interventions listed on the Nutritional Assessment. The doctor order recap report was requested on 9/25/17 and was not provided. The document the facility provided was an order recap report that showed, no data found. No additional documentation was provided by the facility to show they were addressing how the weight loss was being managed. During an interview on 9/26/17 at 12:40, staff member I stated that there was not a September 2017 weight for resident #4 at the time of the interview, but that she would have one of the aides weigh him as soon as possible. During an interview on 9/26/17 at 1:45 p.m., staff member H stated resident #4 would not eat at all at some meals. She stated that he will eat cheese burgers and fries at every meal if he was able. She stated that resident #4 goes through phases with his appetite, but she struggles because she could not force him to eat. Staff member H stated that she thought that the resident had been stressed with his family situation. During an interview on 9/26/17, at 2:00 p.m., resident #4 stated he had not met with NF2 since he had started losing weight. The resident stated he was unsure of the individualized interventions on his care plan to help him maintain his weight. He stated he did not recall being asked food preferences, and did not recall anyone meeting with him to discuss the weight loss. He stated he had been stressed with his family and was unable to eat when he felt stressed or depressed. He stated he would eat burritos at meals and for snacks if he could, but that he did not like the boost that he had an order for [REDACTED].>During an interview on 9/26/17 at 2:15 p.m., staff member B stated she was unsure about the nutrition plan for resident #4. She acknowledged that there were no individualized interventions for the resident in relation to his weight loss or nutritional needs. She stated she was not aware he was feeling depressed and did acknowledge that his depression symptoms, and not eating when he was having increased depression symptoms, was not on his care plan. During an interview on 9/28/17 at 9:00 a.m., staff member G stated he was not sure resident #4 was losing weight. He stated that he did have many alternatives and individualized interventions he does with the resident. He stated he had come up with the interventions himself because he had not had a lot of support from NF2.

Based on observation, record review, and resident and staff interviews, the facility failed to prevent the development of pressure sores for 2 (#s 1 and 3) of 15 sampled residents and implement preventative interventions for 1 (#7) of 15 sampled residents who was at risk for developing pressure ulcers. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/13 at 2:10 p.m. the resident was in observed in her room lying in bed. She stated she had blisters. She was observed wearing multipodus boots and her lower legs were supported by a pillow with her heels hanging over. On 5/20/13 a review of the clinical record was conducted for resident #1. On 1/27/13, the facility first became aware of pressure ulcers to the bilateral heels of the resident. During the survey, resident #1's pressure ulcer on the left heel was 2.5 x 1.5 cm in size and was unstageable due to being covered in a black eschar scab. The facility failed to consistently and accurately assess the pressure ulcers, notify the MD or Nurse Practitioner of the status of the pressure ulcers, and obtain and implement medical and nutritional interventions to address the pressure ulcers. Supporting evidence is documented below. The Admission Resident Assessment Data Collection Form, dated 11/26/12, indicated there was no skin break down to the resident's heels. A PRN (as needed) nursing order was entered into the Treatment Administration Record on 12/7/12 to "elevate heels..keep heels off bed" as a preventative measure. A nursing note dated 1/27/13 at 4:17 p.m. read, "resident in shower today when cna discovered a blister on left heel that has popped- skin underneath is intact - no s/s (signs and symptoms) of infection, skin is completely closed- blister on right heel is still fluid filled- does hurt her to touch- will continue to use slipper socks and no shoes until it resolves - will continue to monitor." The medical record did not include evidence that the Physician was notified of the break in skin integrity. A facility form called Body Check, dated 2/9/13, included the following documentation, " 'blisters' on the left and right, heel protectors & floating heels." No measurements were taken of the wounds and no further description of the wounds was documented. The medical record did not contain evidence of any assessments, wound staging measurements, or physician notification from 1/27/13 through 2/9/13. The Braden Scale for predicting pressure ulcer risk was completed on 2/9/13; the resident #1 scored a 16 which indicated she was at risk for skin breakdown. On 2/13/13 resident #1 visited the Physician and the Physician documented a 2 x 3 cm blister to the left heel and a 2 x 3 cm blister to the right heel. The physician documented, "Nursing has noted skin break down to the patient's heels bilaterally. They have been elevating her heels with pillows. They have noted improvement. When I visit with the patient, she states that she is doing well. Does complain of blisters to both of her heels." The facility medical record did not contain evidence of treatment orders from the Physician. A dietary note dated 2/25/13 incorrectly documented the resident's skin as being intact, "Nutrition Q review: Regular diet provided. Appetite > 75%. Weight 135#, BMI 21.5 stable x 90 days. No labs. Meds list includes MVI. Skin intact. Follow appetite, weight, skin per facility routine." Based on the assessment the Registered Dietitian was unaware of the pressure ulcers to resident #1's heels. Nutritional interventions were not implemented. The Weekly Pressure Ulcer Healing assessment dated [DATE] revealed the resident's left heel was unstageable and had increased in size to 3.0 x 4.0 cm and the depth of the wound as noted as being unbroken. The right heel had also increased in size to 4.5 x 3.0 cm and the depth of the wound was noted as being unbroken. This was the only descriptive assessment of the pressure ulcers up to this date. The facility medical record did not contain evidence that the Physician was contacted in response to the pressure ulcers becoming larger and the left heel becoming unstageable. A nursing order was entered into the Treatment Administration Record on 3/1/13 for "wound assessment" to be completed three times daily. In addition, multi-podus boots were to be applied to both feet while the resident was in bed. Although the order for wound assessment had been checked off on the computerized treatment sheets consistently as having been completed, there was only one descriptive assessment completed for the wound dated 3/4/13. A nursing note dated 3/4/13 read, "Wounds to bilateral heels assessed, rt (right) heel scab is gone, skin looks pink and new, no drainage or depth to wound. It is resolved to rt. heel, continued monitoring daily. Scab intact to left heel, boots on in bed to bilateral feet. The medical record did not include evidence or documentation that the left heel wound was measured and there was no indication the Physician was notified. The progress note by the NP (Nurse Practitioner) dated 4/24/13 read, "Skin Break Down to heels bilaterally. Continue with elevation with pillows. Also ordered heel protectors. Notify if symptoms worsen or don't improve." Between the dates of 3/4/13 and the date of this note from the NP on 4/24/13, there had been no assessment of the pressure ulcers to the heels. A review of the Care Center Daily Bath Report dated 5/8/13 read, "lotioned back-black blister on L heel". There was no evidence in the medical record that the wound was further assessed by nursing staff or that the Physician was notified. This was the only bath assessment that relayed information regarding the wound for the months of April and May 2013. Skin assessments were to be completed with every bath per the "PARKVIEW CARE CENTER DAILY BATH REPORT." The care plan written to address the problem of "skin at risk" directed staff to "Use pillows, pads, or edges to reduce pressure on heels and pressure points. Turn/reposition. STATUS: Active (current) heel protectors while in bed". The care plan did not include information about the size, number, location of the pressure ulcers, assessing the pressure ulcers, collaboration with other professionals such as the Wound Care Nurse, the Doctor, or the Registered Dietitian, and did not include any medical treatment for [REDACTED]. On 5/21/13 at 1:45 p.m., the surveyor observed resident #1's heels with staff member O, an RN. Staff member O measured the wound on the left heel as being 2.5 x 1.5 cm and being unstageable due to it being covered in a black eschar scab (an area of dead tissue). This was the first assessment including descriptive wound information completed since 3/4/13. On 5/22/13 at 9:35 a.m., the surveyor requested information from staff member C, the DON, regarding wound assessments and physician notification, and any other supporting documentation regarding the wounds to resident #1 heels. Staff member C did not provide any further documentation. Staff member C indicated the facility Wound Care Nurse had not been notified of resident #1's skin issues. There was no indication in the clinical record of when information was relayed to the doctor or Nurse Practitioner. Staff member C also stated, "I know certain nurses are not documenting the assessments of the wounds. I plan to start monitoring this." The wounds to resident #1's heels were not consistently measured and assessed. The facility staff, such as the Dietitian and Wound Care Nurse were not aware of the pressure ulcers. The Doctor and Nurse Practitioner were not kept informed of the status of the pressure ulcers. The Resident Assessment Instrument and Care Plan was not changed to reflect the wounds until the quarterly review of 2/26/13. The pressure ulcer to resident #1's left heel was not healed as of 5/23/13 and was unstageable on that date due to the large black eschar that covered the wound area. 2. Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/13 the surveyor reviewed resident # 3's medical record. A physician's orders [REDACTED]."Upon further review, the medical record did not include evidence of any other documentation describing the skin breakdown to the left buttock for resident #3. On 5/20/13 at 2 :10 p.m., the surveyor interviewed staff member J, an LPN, and asked about treatment to the left buttock; there was a lack of documentation in resident # 3's medical record. Staff member J reported resident # 3's left buttock was reddened and they were applying the [MEDICATION NAME] paste to protect the area from breakdown. On 5/22/13 at 1:20 p.m. the surveyor interviewed staff member L, the MDS Coordinator and the ADON, regarding wound and skin assessments for resident #3. Staff member L reported she would be completing the resident # 3's MDS and care plan and would provide a copy to the surveyor. On 5/22/13 at 2:20 p.m. the surveyor observed the dressing changes for resident #3 to his left leg surgical sites and his left buttock. Staff member V applied sterile dry dressings to the surgical sites on the left knee and left inner ankle. Staff member V rolled resident # 3 over to apply the [MEDICATION NAME] to his left buttock. Staff member V pulled resident #3's sweat pants down. Staff member V lifted resident # 3's right buttock at which time the surveyor observed an open area approximately the size of a quarter to the left buttock. Staff member V stated, "Do you see that open area?" The surveyor went back to the resident's medical record after the observation and found no documentation in the medical record describing a stage II pressure ulcer. On 5/22/13 at 2:45 p.m. the surveyor interviewed staff member V, an LPN, regarding the process for admission orders [REDACTED]. The surveyor reviewed resident #3's admission form mentioned above. There were no entries indicating any skin concerns for the buttocks area of the diagram. On 5/22/13 at 3:30 p.m. the surveyor interviewed staff member C, the DON, who reported she was not aware of the resident's stage II pressure ulcer and would look into it and give the surveyor a copy of any documentation addressing assessment and staging of the pressure ulcer. On 5/23/13 staff member L, the ADON, provided the surveyor the admit MDS and comprehensive care plan to the surveyor. The MDS and the care plan did not include evidence of the resident's stage II pressure ulcer. There were no care planned interventions to address the pressure ulcer. No other documentation was submitted to the surveyor regarding the assessment of the stage II pressure ulcer to the left buttocks. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7's care plan revealed he was at risk for skin breakdown. The care plan directed staff to ensure the resident had "a pressure relieving wheel chair pad, a pressure relieving mattress and pressure relieving pillows and pressure relieving wedge for behind knees to reduce pressure to heels and pressure points, for use at bedtime to prevent skin breakdown." The resident was interviewed on 5/21/13 at 11:30 a.m. and stated he did not use pillows or wedges when he was in bed. Observations at this time revealed no wedges or additional pillows were located in the resident's room for pressure reduction as identified in the care plan. Staff member P, a CNA, was interviewed on 5/21/13 at 11:45 a.m. and stated she had not seen pillows or wedges used in bed for resident #7 when she had gotten him up in the mornings. The surveyor asked about the pressure relieving cushion that was supposed to be in resident #7's wheel chair. Staff Member P told the surveyor that "(Resident's name) doesn't use a wheel chair."