Every finding on record at Calhoun Convalescent Center

Based on review of facility policy, interviews and record review, the facility failed to protect one of four residents (Resident (R) 1) from verbal and mental abuse, which resulted in the patient's psychological harm (fear) and mental anguish at the time of the abuse. Findings include:Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment last revised 11/01/2017 revealed, Policy: 1. The facility's Leadership prohibits neglect, mental, physical, and/or verbal abuse of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injury of unknown source and misappropriation of resident property and are reported immediately.Definition as defined by CMS section 483.5: 1. Abuse. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Review of R1's Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus, epilepsy, chronic kidney disease, cachexia, absence of left leg above knee, and psychomotor deficit.Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/26 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Section GG (Functional Abilities) revealed R1 required extensive assistance with Activities of Daily Living (ADL).Review of the Facility Reported Incident dated 04/12/26 at 5:07 PM revealed on 04/12/26 at 3:15 PM, R1 reported to staff an incident of alleged verbal abuse from an agency Certified Nursing Assistant (CNA) AA.Review of an undated witness statement from CNA BB indicated, I overheard the interaction between [R1] and [CNA AA]. [CNA AA] was talking to [R1] very rudely. [CNA AA] said 'you begging me to get you up and now you want to lounge in this room. No, get out.' [R1] said he wasn't going to lounge in his room and would come out later. [CNA AA] was blocking the door at this time preventing R1 from leaving. R1 then said I will leave when you get out my way mother*cker. [CNA AA] then went behind R1's wheelchair, grabbed the handles and lifted the chair from behind, saying 'what you say? Who you calling motherf*cker?' I'll throw you out this chair.' She then let the handles go. [R1] exited the room. [CNA AA] said 'Bye, hit the road Jack.' Once he was out of the room, she closed the resident's room door and the situation was over. I later found him to see if he was okay and apologized for not speaking up then and informed him I would be going over her, he thanked me and I left. [sic]Review of R1's progress note dated 04/12/26 at 4:07 PM stated, Agency staff contacted on phone call at 1511 to report a staff to resident concern. Staff reported that assigned CNA spoke and handled res in a disrespectful and inappropriate manner. Before the agency left she made sure he was safe, okay, and addressed his needs; Noted that he was sitting on front porch. At that point his assigned CNA was no longer in his care as the shift was over. DON made aware of immediately of situation. This writer also contacted assigned nurse to make aware of situation, to assess res entirely, and monitor res emotional status. Contacted RP (wife) via phone x3 attempts to make aware of situation. No answer, was able to leave a voicemail [sic]Review of R1's progress note dated 04/12/26 at 4:32 PM stated, Unit Manager contacted nurse writing to make aware of a complaint brought to her attention regarding staff concern and asked for full body assessment be completed as well as resident's emotional status. Skin assessment obtained and there were no new skin issues noted at time. While performing skin assessment res stated 'that CNA I had came in trying to be the boss and wanted to be in charge. Nurse writing responded, What happened? Resident responded She was talking junk the whole time and she said I will dump you out of this wheelchair and tilted it up. Nurse writing, Why didn't you let me know this was going on? Resident response I didn't want to get anybody in trouble. Nurse replied, We are here to help you, when you experience something like that you need to let us know so that we can get it taken care of. Resident is currently sitting on porch, no pain, or discomfort. Nurse writing contacted unit manager to give an update of resident's status. [sic]Review of facility reported incident indicated the allegation was substantiated and CNA AA was not permitted to return to facility to work and results of investigation were forwarded to the staffing agency.During an interview on 07/07/26 at 11:45 PM with R1, he stated at the time of the incident he was afraid CNA AA would dump him out of his wheelchair when she started shaking it and tilted it forward. Stated he did not report the incident because he did not want to cause trouble, but another CNA (CNA BB) checked on him after the incident and stated she was going to notify the nurse what happened.During an interview on 07/07/26 at 12:50 PM with the Director of Nursing (DON) she stated she was notified by the on-call nurse about a situation between CNA AA and R1. She stated that CNA AA was no longer allowed to return to facility because of this incident. Further stated CNA AA would not return phone calls after the incident so the facility could obtain a statement. The DON indicated CNA BB should have intervened during the incident to prevent the situation from escalating.CNA AA and CNA BB could not be reached for interview despite numerous attempts.

Based on record review and interview, the facility failed to ensure that two of two contracted Certified Nursing Assistants (CNA) AA and BB were trained and competent in abuse prevention protocols established by the facility prior to providing direct resident care. This deficient practice was evidenced by the facility permitting a contracted CNA AA to provide direct care despite having failed the mandatory abuse training examination, resulting in the verbal and mental abuse of Resident (R)1 (who verbalized being afraid). This failure had the potential to affect all 110 residents residing in the facility.Findings include:Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment last revised 11/1/17 stated, Component II: Training 1. All new and current employees including volunteers receive continuous education, training, and reinforcement that identify all aspects of abuse prohibition, to include: A. The prompt reporting of allegations without fear of reprisal. B. The Facility Abuse Coordinator-role and responsibility of the Facility Abuse Coordinator. C. To whom the employee can report allegations of abuse including Facility Abuse Coordinator, Administrator, SS Director, Director of Nursing, Charge Nurse, and individual state agency for elder abuse prevention. 2. Education/training materials include: C. Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, and mistreatment.Review of a facility reported incident summary of findings dated 04/15/26 indicated the allegation of employee to resident abuse involving CNA AA and R1 was substantiated and CNA AA was not permitted to return to facility to work and results of investigation were forwarded to the staffing agency. CNA BB failed to intervene when she overheard CNA AA being abusive toward R1. During an interview on 07/07/26 at 11:45 PM, R1 reported that he was afraid of CNA AA during the incident on 04/12/26. Review of CNA AA's Credentials document from [contracted agency] with a print date/time of 07/08/26 at 11:11AM indicated, .REQUIRED DOCUMENTS-Identity Verification, MISSING .FACILITY ASSESSMENTS-Abuse, Neglect, and Misappropriation, FAILED TRY AGAIN, this assessment is yet to be completed. SCORE: 68% .Signed by CNA AA on 09/29/21. There was nothing in the document of the specific content of abuse or that it was specific to the facility. Review of for CNA AA's Long-Term Care Essentials Clinical Assessment (Core Test Part 1-3) provided by [contract agency name], indicated, .3. Passing grade of 70 required .4. Individuals scoring less that a 70 on assessment will be given the opportunity to retest at later time and/or date. Permission to retake assessments will be at the discretion of [contract agency name].The facility was unable to provide a completed Agency Staff Facility Orientation Checklist that included but was not limited to Abuse Probation (sic) for CNA AA and CNA BB specific to the facilities abuse protocols and practices.The Director of Nursing (DON) was interviewed on 07/08/26 at 11:15 AM and indicated the scheduler was responsible for making sure all agency staff training was up to date. The DON confirmed that the report was pulled on 07/08/26 at 11:11 AM and showed CNA AA had failed the Abuse, Neglect, and Misappropriation training. Further stated that the previous scheduler should have caught this prior to CNA AA being allowed to work at facility.

Based on review of facility policy, record reviews and interviews, the facility failed to report abuse for one resident (Resident (R)1) and injury of unknown origin for one resident (R2) in a sample of four residents sampled for abuse.Findings include:Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment last revised 11/01/2017 indicated, 'Policy: 2. The facility shall report immediately but no later than two hours after allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury.Component V: Reporting/Response 1. All alleged violations abuse, neglect, or misappropriation are reported verbally immediately to Facility Abuse Coordinator, the Administrator and to other officials in accordance with state law including State Survey and Certification Agency (nurse registry or licensing authority).'1. Review of R1's Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus, epilepsy, chronic kidney disease, cachexia, absence of left leg above knee, and psychomotor deficit. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/26 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.Review of a Patient/Resident Incident/Accident Investigation worksheet stated Agency staff contacted on call phone at 1511 to report a staff to resident concern. Staff reported that assigned CNA spoke and handled res (sic) in a disrespectful and inappropriate manner. Before agency staff left she made sure he was safe, and okay, and addressed his needs. Noted he was sitting on front porch. At that time assigned CNA was no longer in his care as the shift was over. Resident emotional status and body assessed by assigned nurse.Review of a witness statement from CNA BB with no date or time indicated, I overheard the interaction between [R1] and [CNA AA]. [CNA AA] was talking to [R1] very rudely. [CNA AA] said 'you begging me to get you up and now you want to lounge in this room. No, get out.' [R1] said he wasn't going to lounge in his room and would come out later. [CNA AA] was blocking the door at this time preventing R1 from leaving. R1 then said I will leave when you get out my way mother*cker. [CNA AA] then went behind R1's wheelchair, grabbed the handles and lifted the chair from behind, saying 'what you say? Who you calling motherf*cker?' I'll throw you out this chair.' She then let the handles go. [R1] exited the room. [CNA AA] said 'Bye, hit the road Jack.' Once he was out of the room, she closed the resident's room door and the situation was over. I later found him to see if he was okay and apologized for not speaking up then and informed him I would be going over her, he thanked me and I left. [sic]Review of the Facility Reported Incident dated 04/12/26 at 5:07 PM indicated on 04/12/26 at 3:15 PM R1 reported to staff an incident of alleged verbal abuse from an agency Certified Nursing Assistant (CNA AA).Review of the sign-out log for 04/12/26 revealed R1 signed out at 2:56 PM to sit on front porch after the incident.The facility did not provide evidence that CNA AA was reported to the Police or the State nurse aide registry for suspected and substantiated resident abuse related to R1.2. Revies of R2's EMR revealed R2 was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, dementia, type 2 diabetes mellitus, cellulitis right great toe, chronic kidney disease, vitamin D deficiency, and vitamin B-12 deficiency.Review of R2's quarterly MDS with an ARD of 03/03/26 revealed a BIMS score of three out of 15 indicating severe cognitive decline. Review of a Facility Reported Incident dated 04/08/26 at 5:07 PM revealed an injury of unknown origin was found on 04/07/26 at 5:13 PM. This was 23 hours and 54 minutes from the time of becoming aware of the injury of unknown origin after R2 returned from a Podiatrist appointment with diagnosis of closed nondisplaced fracture of left proximal phalanx.During an interview on 07/08/26 at 2:10 PM the Director of Nursing was interviewed and confirmed that the incidents were both reported outside of the two-hour time frame.

Based on review of the facility policy, record review, and interview, the facility failed to ensure that Resident (R)1 received appropriate supervision to prevent a successful elopement from the facility on 03/22/26.On 03/30/26 at 2:37 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 03/30/26 at 2:37 PM the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 03/22/26. The IJ was related to 42 CFR 483.25 - Free of Accident Hazards/Supervision/Devices. On 03/30/26 at 4:07 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth due diligence in identifying and addressing the non-compliance. The SA is considering this at Past Non-Compliance as of 03/24/26. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include:Review of the facility's policy titled, Elopement revised on 11/01/2017, revealed, To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident . Procedures: 1. Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead ______ (insert code name). 2. The DON/designee completes a missing resident profile . 4. The entire search process of the facility and grounds, from the time the patient/resident is missing, will be completed within (30) thirty minutes.Review of R1's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to, dementia, unspecified severity, muscle weakness (generalized), unsteadiness on feet, other abnormities of gait and mobility.Review R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/25, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating R1 suffered from severe cognitive impairment. Further review of the MDS, revealed R1 had no impairments of the upper or lower extremities, at risk for falls, and need partial/moderate assistance for sit to stand mobility, to walk 10 feet and walking 50 feet with two turns as not attempted due to medical condition or safety concerns.Review of R1's Progress Notes dated 03/24/2026 at 9:33 PM, revealed, Resident seen today for follow-up after recent elopement event. Since last evaluation, the patient remains ambulatory with good strength and endurance and continues to exhibit impaired judgment and poor safety awareness in the setting of vascular dementia. Nursing reports ongoing need for close supervision due to continued exit-seeking behaviors. No new elopement episodes reported since implementation of 1:1 supervision. The patient remains pleasantly confused at baseline and is unable to reliably provide history.Review of R1's Care Plan with a problem start date of 10/17/2025, under the category behavioral symptoms, revealed, R1 wanders through out the facility, is a risk for 1. Elopement and has had a recent elopement 2. Increased fall risk.Review of R1's Nursing- Elopement Risk Observation dated 03/20/26, indicated, Does the patient/resident have safe decision-making capabilities? This question is answered as No.Review of R1's PATIENT/RESIDENT INCIDENT/ACCIDENT INVESTIGATION WORKSHEET revealed under NOTIFICATIONS AND TREATMENTS: Transferred to Hospital or emergency room by police. DESCRIBE EXACTLY WHAT HAPPENED: Elopement from facility. Please see timeline/summary.Timeline/Summary of events/incident:5:30-5:40pm: Resident observed by staff in safe environment at ambulating in facility which is baseline in behavior.5:40-6:00pm: Alarm sounded at fire exit near dietary department. re-engaged alarm and returned to kitchen.5:50-6:05pm: [R1's] CNA noticed he wasn't in his room to receive his dinner tray and started to look for him. Census head count initiated.6:08-6:39pm: Employee that was leaving work in his car thought he saw the resident near the Dollar General store. The staff member called the workplace and informed staff he thought he saw [R1]. Staff in facility started a search for the resident.A nurse went to Dollar General in her car to retrieve the resident but he was not at the store when she arrived.Dollar General apparently notified police.Police called facility and validated we were missing a resident. They noted him walking on the corner of [NAME] and Mills. Police stated they would take the resident to the Emergency Department to be checked out.During this process the Administrator and DON (Director of Nursing) were informed.Census headcount completed with all residents except for [R1] account for.6:39pm: Administrator notified Clinical Services Director of incident.6:39pm: Administrator notified Clinical Services Director of incident.6:42pm: SVP notified of incident by CSD.1:1 education completed with identified dietary employee.Re-education started for staff in the facility.Review of the local police department incident report with a dispatched date of 03/22/2026, revealed the following:INCIDENT TYPE. 1. 901 - RUNAWAYDISP DATE: 03/22/2026 DISP. TIME 1821 TIME ARRIVED 1825DATE/TIME OF OFFENSE 03/22/2026. 1821Offenses: RUNAWAYON 03/22/2026, OFFICERS WERE DISPATCHED OUT IN REFERENCE TO LOCATE A SUSPICIOUS PERSON WALKING WITH A HOSPITAL BRACELET ON. OFFICERS CONDUCTED AN AREA SEARCH AND LOCATED THE SUBJECT ON FR [NAME]/ MILL ST. THE SUBJECT APPEA [sic] TO BE IN A DELIRIOUS STATE, DISORIENTED, AND UNABLE TO PROVIDE COHERENT RESPONSES. DUE TO THE SUBJECT'S CONDITIO [sic] EMS WAS REQUESTED TO THE SCENE. EMS ARRIVED AND ASSESSED THE SUBJECT. BASED ON THEIR EVALUATION, THE SUBJECT V [sic] TRANSPORTED TO MUSC ORANGEBURG HOSPITAL FOR FURTHER MEDICAL TREATMENT. DISPATCH WAS CONTACTED BY HOSPITAL PERSONNEL FOR CONFIRMATION OF RESIDENCY. OFFICERS WERE DISPATCHED TO 601 [NAME] ST ([NAME] CONVALESCENT CENTER) TO CONFIRM IF THEY HOUSED A PATIENT BY THE NAME OF [R1]. ONCE CONFIRMED THE FACILITY WAS INFORMED TO CONTACT HOSPITAL PERSONNEL. NO FURTHER INCIDENTS WERE REPORTED AT THIS TIME.During an interview on 03/30/26 at 9:25 AM, R1 revealed that he did not recall exiting the building.During an interview on 03/30/26 at 9:25 AM, Certified Nursing Assistant (CNA)1 revealed that she was assigned for 1:1 care for the resident for the day. CNA1 states that this was her first day working with the resident in this capacity, however she could not confirm how long the resident had been on 1:1 care.During a follow up interview on 03/30/26 at 10:05 AM, CNA1 explained that R1 was on 1:1 care because he had got out of the building.During an interview on 03/30/26 at 10:10 AM, CNA2 revealed that she completed her orientation with the facility on March 17, 2026. CNA2 stated that she had not received any in-service training related to elopements and today was her first time hearing about R1 exiting the building.During an interview on 03/30/26 at 11:15 AM, the [NAME] stated that on the day of the incident, between 5:00 PM and 6:00 PM, the dietary staff heard the alarm of the dining room door going off. Dietary Aide (DA)1 was sent to check the alarm and reported that he looked and did not see anyone. He then shut the alarm off and returned to the kitchen. The [NAME] stated that staff were unaware how long the alarm had been going off before they heard it, as it is difficult to hear in the kitchen.During an interview on 03/30/26 at 11:52 AM, Licensed Practical Nurse (LPN)1 stated that R1 was on thirty-minute checks due to prior wandering behaviors. She reported that R1 was in bed most of the day until about 5:00 PM, when a Certified Nursing Assistant took him to get a shower. Around 5:25 PM-5:30 PM, she last had eyes on R1 and assumed he was doing his usual laps around the facility. LPN1 further stated that around 5:45 PM, after staff noticed that R1 had not received his dinner tray and had not been seen in the halls, a search was initiated and all areas of the building were checked. Shortly after, someone called the facility to report that they thought they had seen R1 down the street at the Dollar General. She then left the facility in her car to go locate R1 but did not see him, and within 10 minutes of her arrival back at the facility, staff were notified that R1 had been picked up by the local police department near the initial sighting at Dollar General and was subsequently taken to the emergency room. LPN1 was unable to state how R1 eloped from the building but noted he was found with his wander guard still in place.During an interview on 03/30/26 at 12:09 PM, the Facility Administrator (FA) stated that on the day of the incident, the alarm to the dining room door was going off. Staff responded, did not see anyone, disarmed the alarm, and returned to work. The FA stated that between 5:50 PM and 5:55 PM, staff noticed R1 was missing and went to look for him. R1 was not located in his room or hallway. Around 6:10 PM-6:15 PM, while heading home, a staff member reported that they thought they saw R1 around Dollar General. LPN1 then left the facility in her car to go locate R1; however, when she arrived at Dollar General, R1 was not there. R1 was later located by the local police department and sent to the emergency room for evaluation. The FA reported that R1 was wearing his wander guard when he was found.During an interview on 03/30/26 at 12:29 PM, the Director of Nursing (DON) stated that she was not working the day R1 eloped. She noted that LPN1 called and informed her that she was headed to Dollar General to locate R1, after someone called to report seeing him there. While still on the phone, LPN1 stated that R1 was not there. The DON then instructed LPN1 to return to the facility. She reported that R1 may have exited through the dining room door, which alarms if pushed and opens after 15 seconds. She stated that staff were unable to tell how long the alarm was going off before hearing it. When they responded, they looked outside, did not see anything, and entered the code to shut the alarm off. The DON stated that R1 was last seen between 5:15 PM and 5:30 PM. In the weeks leading up to the incident, R1 had to be redirected and displayed wandering behaviors. She noted that all doors were checked and were working without issue. The resident was later found by the local police department.During an interview on 03/30/26 at 12:43 PM, DA1 reported that R1 was last seen around 5:25 PM - 5:30 PM. They later learned from nursing staff that R1 was missing and noted that Dollar General is about a 3.5 minute drive away from the facility.During an observation and interview on 03/30/26 at 1:23 PM, the Maintenance Director and the FA, they stated that all doors in the facility were working properly and sounded alarms. The Maintenance Director noted that when a door is opened, it sounds immediately, and a panel at each nurse station lights up showing which door is open. Then, after 15 seconds, the door will open. He demonstrated on the front door and dining room door, holding each door for 15 seconds, and the alarm sounded. The alarm was heard at the nurse stations, and the panel lit up showing the corresponding door. Multiple staff noted the alarm sounding in the halls with no response. The FA stated that staff are to respond to the alarm until the all clear is given.On 03/30/26 at 4:07 PM, the facility provided an acceptable IJ Removal Plan, which included the following:Resident #1 evaluated at emergency room on 3/22/26. No injuries indicated. Resident #1 returned on 3/22/26 and 1:1 supervision initiated and continues.Each Exit door was assessed to validate doors were working properly on 3/23/26 by the Maintenance Staff.Upon Resident return, Elopement Risk Assessment Updated to reflect current status by Licensed Nurse. Care Plan and resident profile updated on 3/22/26 by Licensed Nurse.An elopement drill was completed on 3/23/26 that included:The Administrator will notify the Charge Nurse, Director of Nursing and Social Service Designee that a resident is missing. The Director of Nursing/designee will announce Code [NAME] to signal the Elopement Drill ProcedureThe Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds. The entire search process will be completed within 30 minutesIf the search fails to locate the missing resident in the allotted time, the Administrator/designee will place a mock telephone call to the appropriate community agencies, resident's legal representative and attending physician. Staff will provide the mock police with all the physical identifying informationThe Search will continue if resident not located to include 2 staff members searching the surrounding streets by care for a 2 mile radiusWhen the volunteer resident is located the Charge Nurse will complete a head to toe assessment. The Social Services Designee will assess the resident for emotional distress.The Director of Nursing will notify the appropriate community agencies, attending physician and the resident's legal representative.The facility's Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrencesWhen the missing resident is found, an announcement will be made, Code [NAME] all clear.Residents residing in the facility had an Elopement Risk Assessments updated by 3/24/26 by Director of Nursing/Designee. Residents identified as elopement risk were placed in the elopement binder and had care plans and profiles updated by Director of Nursing/Designee on 3/24/26Facility Staff were reeducated by the Director of Nursing/Designee on Elopement Policy, including immediate staff response to the door alarm to verify if resident exited facility, and Abuse, Neglect & Misappropriation Policy by 3/24/26Any staff not receiving this education by 3/24/26 will receive prior to their next scheduled shift.New admission elopement risk assessments are being reviewed in Clinical Morning Meeting Monday - Friday by the Director of Nursing/Designee to validate accuracy and interventions validated if indicated. Quarterly Elopement risk assessments will be reviewed weekly following the MDS schedule to validate accuracy and interventions validated if indicated by the Director of Nursing/Designee.The Maintenance Director/Designee will inspect facility exit doors 3 times weekly for 4 weeks, then weekly for 2 additional months to validate doors are functioning properly.The Administrator will round weekly for 4 weeks then monthly for 2 additional months with the maintenance director validating doors are functioning properly.Ad Hoc QACPI was held on 3/25/26Medical Director was notified of the incident and plan on 3/23/26 and 3/30/26Results of these audits will be presented in the Quality Assurance and Performance Improvement Committee meeting for review and recommendations for 3 months.AOC date: 3/24/26

Based on review of facility policy and interviews, the facility failed to ensure resident's received their mail in a timely manner and unopened. This deficient practice had the potential to effect all residents in the facility that received mail. Findings include: Review of the undated facility policy titled Mail Distribution documented, To ensure that each patient's/resident's personal mail (incoming and outgoing) is handled in a private and confidential manner. It is the Facility's policy to: 1. Distribute all incoming mail to the addressed patient/resident unopened and within the same day on which it was delivered to the Activity Department. Procedures: 1. The Activity Staff or Designated Staff or Volunteer will: A. Deliver personal mail to the patient's/resident's room within 24 hours of receipt. B. Deliver all mail unopened, unless otherwise directed by the patient/resident or his/her qualified legal representative. The resident's care plan will include an approach related to staff assisting a resident to open mail if it occurs on a regular basis. C. Provide the patient/resident with privacy while opening/reviewing the mail, unless otherwise requested by the patient/resident or his/her qualified legal representative. D. Ask the patient/resident for his/her preference on where to place his/her mail. Review of the Resident Rights documented, The facility protects and promotes the rights of each resident in our care . 1. Basic Rights, each resident has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. The facility must provide equal access to quality care regardless of diagnosis, severity of condition or payment source . 14. Privacy in Communications. The resident has the right to privacy in written communications and other materials delivered to the facility for the resident through a means other than a postal service, including the right to send and promptly receive mail unopened and the right to have access to stationery, postage and writing implements at the resident's own expense. During the Resident Council meeting on 02/23/2026 at 1:40 PM, residents verbalized that their mail is opened and some times their mail is delivered late and not on the date it is delivered to the facility. During an interview with the Activity Assistant on 02/23/2026 at 2:05 PM, she stated that she was instructed by management to open all resident mail and inspect the contents before it is delivered to the residents. The Activity Assistance further stated this practice is in order keep residents safe, because sometimes residents order and receive things they should not have or have access to. The Activity Assistant stated that practice was to keep all residents safe. During an interview on 02/23/2026 at 2:15 PM, the Activity Director stated that she was instructed to open all mail belonging to residents, no matter how big or how small, prior to delivering it to the resident. She stated that letters are also opened before giving it to the residents.During an interview on 02/23/2026 at 3:18 PM, the Business Office Manager stated that she will open a resident's mail if she thinks it is something that she will need to fill out and send back for the resident, or an incoming check that is to pay for the resident's stay in the facility. She also stated that if she opens the mail and it is not pertaining to the resident payment, or a document she needs to fill out on behalf of the resident, she will ensure the resident receives it, even though it is addressed to the resident and has already been opened and reviewed.

Based on review of facility policy, observation and interview, the facility failed to ensure unlabeled, outdated and expired medications were removed from 4 of 4 medication carts, and not stored with the current medications in use for residents.Findings include: Review of the facility policy titled, General Guidelines for Storage of Medication and Biologicals, states, 1. Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. Procedures: . 5. Medications with manufacturer's expiration date expressed in month and year will expire on the last day of the month. (Unless a sooner expiration date has been placed on the package by the pharmacy). 10. Facility shall ensure that medications and biologicals are stored at the appropriate temperature, light, humidity according to manufacturer specifications and/or the United States Pharmacopeia, or WHO standards for safe storage and handling of medications, to preserve their integrity. 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed. During an observation on 02/23/2026 at 2:45 PM, of Medication Cart A on the North Hall revealed the following: A house stock bottle of the medication, Zinc 50 milligrams, with Lot# 865X02, approximately 100 tabs, were expired on 01/2026 and still stored on the medication cart. One pen of Soliqua Insulin 100/33 with Lot# 5F701A in use with no open and no expiration date, the pen had a label that stated, If no open and expiration date, discard the insulin after 10 days. At this time the medications were confirmed by Registered Nurse (RN)1 and removed from the med cart. During an observation on 02/23/2026 at 2:50 PM, of Medication Cart C on the North Hall revealed, One Kwik Pen of Humulin 70/30 Insulin with Lot# 877490C in use with no open date and no expiration date, the pen had a label that stated, Discard after 10 days if no date is noted on the pen. The medication with no dates was confirmed by Licensed Practical Nurse (LPN)1 and removed from the cart. During an observation on 02/23/2026 at 3:15 PM, of Medication Cart D revealed, Two Kwik Pens of Novolog Insulin with Lot #RZF05L6 in use with no open date and no expiration date. The insulin pens with no open date and no expiration date were confirmed by LPN3 and removed from the medication cart. During an observation on 02/23/2026 at 3:35 PM, of the Medication Cart F revealed, One bottle of B Complex with Lot #205801,100 tablets, was expired on 01/2026. The bottle of expired B Complex tablets was confirmed by LPN4 and removed from the medication cart.

Based on record review, facility policy review, and interview, the facility failed to perform Abnormal Involuntary Movement Scale (AIMS) assessments every three months as ordered by the provider for 3 out of 3 residents reviewed for psychotropic medications (Resident (R)41, R92, R97). This failure to complete AIMS assessments as ordered put residents at risk for harm due to the potential of adverse effects from psychotropic medications not being recognized in a timely manner. Findings include:Review of the facility policy titled Medication Management with a revision date of 04/17/25, revealed, . 9. The facility will monitor and document the resident's response to psychotropic medication for efficacy and adverse consequences. Monitoring will include: . F. AIMS (Abnormal Involuntary Movement Scale) testing should be completed as a baseline on admission or re-admission with an enduring antipsychotic medication, on initiation of an anti-psychotic medication, and at least every six months and with dosage changes.1. Review of R41's Face Sheet revealed he was admitted to the facility most recently on 03/31/25, with diagnoses including, but not limited to, severe bipolar disorder with psychotic features, major depressive disorder, generalized anxiety disorder, and dementia. Review of R41's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/06/26, revealed he had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he had no cognitive deficits. R41 showed no indicators of hallucinations or delusions and exhibited no behavioral symptoms towards himself or others. His medications included antipsychotic medication. Review of R41's Care Plan revealed, [R41] is currently taking an antipsychotic r/t bipolar disorder, unspecified . The goal revealed, [R41] will receive therapeutic treatment from medication with no complications through next review. Interventions directed staff to, Licensed nurse will monitor for adverse side effects and report to physician.Review of R41's Orders revealed he was prescribed Aripiprazole 30 mg every night at bedtime. On 06/20/25, R41 had an order for an AIMS assessment to be completed every three months on the 22nd of March, June, September, and December. Review of R41's Observation History from 01/24/25 - 02/23/26, revealed an AIMS assessment was completed on 03/31/25, 12/12/25, and 01/26/26. No AIMS assessment was found for the months of 06/2025 and 09/2025, as ordered. 2. Review of R92's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, borderline personality disorder, anxiety disorder, and schizoaffective disorder. Review of R92's Annual MDS with an ARD of 02/17/26, revealed she had a BIMS score of 15 out of 15, indicating she had no cognitive deficits. R92 had no indicators of hallucinations or delusions and exhibited no behavioral symptoms towards herself or others. Her medications included antipsychotic medication. Review of R92's Care Plan revealed, [R92] is at risk for adverse consequences r/t receiving psychotropic medication for treatment of anxiety/schizoaffective disorder, bipolar. This problem was identified on 02/20/26. The goal revealed, [92R] will not exhibit sign of drug related side effects or adverse drug reactions during review period. Interventions directed staff to, Assess if the resident's behavioral symptoms present a danger to the resident and/or others. and Pharmacy consultant review. The care plan also revealed, [R92] . is having mood and behavior needs as evidenced by periods of (being) physically aggressive. This problem was identified on 03/17/25. The goal revealed, [R92] will have a reduction in unwanted mood or behaviors. Interventions directed staff to, Give medications as ordered. Monitor for side effects and effectiveness. Notify physician of changes or concerns.Review of R92's Orders revealed she was prescribed Saphris (asenapine maleate) 10 mg under her tongue twice a day. On 03/20/25, she had an order to have an AIMS assessment completed every three months on the 20th day in March, June, September, and December. Review of R92's Observation History from 01/24/25 - 02/23/26, revealed an AIMS assessment was completed on 10/19/25. No other AIMS assessments were found. 3. Review of R97's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to, schizoaffective disorder, pseudobulbar affect, depressive episodes, generalized anxiety disorder, and vascular dementia. Review of R97's Annual MDS with an ARD of 11/22/25, revealed R97 had a BIMS score of 06 out of 15, indicating he had severe cognitive impairment. R97 showed no indicators of hallucinations or delusions and exhibited no behavioral symptoms towards himself or others. His medications included antipsychotic medication.Review of R97's Care Plan revealed, [R97] . is having mood and behavior needs. The goal revealed, [R97] will have a reduction in unwanted mood or behaviors, for an increased quality of life as evidenced by documentation in the medication record. Interventions directed staff to, Give medications as ordered. Monitor for side effects and effectiveness. Notify physician of changes or concerns. The Care Plan also revealed, [R97] is at risk for medication side effects r/t psychotropic drug use. The goal revealed, [R97] will not have any side effects from medication through next review. Interventions directed staff to, Monitor for side effects and report to MD.Review of R97's Orders revealed he was prescribed haloperidol 5 mg once every evening and haloperidol decanoate solution 100 mg/ml 1 ml injected into the muscle every 28 days. On 04/04/24, R97 had an order to have an AIMS assessment completed every three months on the 2nd day in January, April, June, and October. Review of R97's Observation History from 01/25/25 - 02/24/26, revealed an AIMS assessment was completed on 04/02/25, 07/02/25, 12/12/25, and 01/02/26. No AIMS assessment was found for June or October as ordered. During an interview with the Director of Nursing (DON) on 02/23/26 at 3:35 PM, she revealed while looking for the missing AIMS assessments for R92, We are looking for them. I only see the one you saw from October. I just completed the one that needed to be done in January. I'm giving you a copy of it with the October one.During a second interview with the DON on 02/24/26 at approximately 3:45 PM, she revealed, Our MDS nurse keeps the schedule of the AIMS assessments. She will notify me and the Unit Manager in our morning meetings which ones need to be completed. Either me, the Unit Manager, or the nurse taking care of the Resident will complete it. I was surprised our policy says, at least every six months. I am used to them being completed every three months. Since I am relatively new, I can only speak for what has happened since then. Since October, I have been trying to get the schedule for the AIMS assessments back on track. My expectation is they are completed as ordered.

Based on record review, facility policy review, and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) for 1 of 1 resident reviewed for Hospice care and services. Specifically, R92 began receiving Hospice care on 01/09/26, and a Significant Change MDS assessment was not completed as required. This failure had the potential for harm due to the Resident not being comprehensively assessed at the time of the significant change in her status. Findings include:Review of the facility policy titled Significant Change with a revision date of 05/05/23, revealed, Policy: 1. The nursing staff, as well as the interdisciplinary team, will evaluate the patient's/resident's change in status in accordance with the established guidelines from the Resident Assessment Instrument (RAI). Procedures: 4. All residents that are referred to Hospice need to have a Significant Change MDS completed.Review of the facility policy titled Minimum Data Set (MDS) with a revision date of 09/28/23, revealed, . 10. Each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified RAI process . A significant change is required when: A. A resident enrolls in a hospice program.Review of the facility policy title Hospice Care with a revision date of 05/05/23, revealed, . 5. The facility will complete an OBRA MDS SCSA and schedule an interdisciplinary care plan meeting for the facility team, hospice provider, and the resident and/or resident's family .Review of R92's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, chronic kidney disease, Type 2 diabetes mellitus, heart disease, congestive heart failure, chronic pain syndrome, chronic obstructive pulmonary disease, anxiety disorder, and schizoaffective disorder.Review of R92's Orders revealed R92 was admitted to Gentiva Hospice on 01/09/26.Review of R92's MDS Assessments revealed a Quarterly MDS was completed on 11/17/26, and an Annual MDS was completed on 02/17/26. No Significant Change MDS assessment was listed as having been completed in 01/2026 in response to R92's election for Hospice care and services. Review of R92's Comprehensive MDS with an Assessment Reference Date (ARD) of 02/17/26, revealed R92 was receiving Hospice care at the time of that assessment.During an interview on 02/24/26 at 10:15 AM, the Regional MDS Coordinator revealed, We usually learn about significant changes in the morning meeting. We will also pull orders in the morning to make sure we don't miss anything. A Significant Change MDS should have been done for [R92] when she was put into Hospice. There's no doubt about that. It should have been done. Usually, we have two Nurse Assessment Coordinators (NACs), but we were down to only one. Then, in early January, she just left. We just hired a new one two weeks ago.During an interview on 02/24/26 at 2:30 PM, the Social Services (SS) Director revealed, When a provider feels a Resident is appropriate for Hospice, I will call the family to discuss it with them and give them the names of the Hospice agencies we are contracted with for them to choose the Hospice provider. In [R92's] case, they chose Gentiva. I will then send the Resident's information to the Hospice provider. They will come and do an evaluation, and if the Resident is accepted, they will send me the Medicaid Election Form. I believe she was referred for Hospice because of her severe kidney disease for which she refused treatment.During an interview on 02/24/26 at approximately 3:45 PM, the Director of Nursing (DON) revealed, Our NAC nurse left in December, so we had a gap of having no NAC nurse. That is probably why the Significant Change MDS assessment wasn't done. I only started in this position officially in December.During an interview on 02/24/26 at approximately 4:15 PM, the Administrator revealed, Our NAC nurse was out the first few weeks of January. It is not normal for us to miss a Significant Change MDS. Our NAC nurse was out from 01/09/26 through 01/26/26, and she resigned on 01/27/26.

Based on record review, facility policy review, and interview, the facility failed to update the Care Plan for Resident (R)2, who changed from a Full Code status to a Do Not Resuscitate (DNR) status, for 1 of 1 resident reviewed for Hospice care and services. Specifically, R92 changed from a Full Code status to a DNR status on 11/24/25, and her Care Plan was not updated to reflect this change until 02/24/26. Findings include:Review of the facility policy titled Person-Centered Care Plan with a revision date of 06/09/23, revealed, . Procedures: . 3. The person-centered care plan is interdisciplinary and created to guide facility staff in providing treatment, care, and services necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychosocial well-being possible. The plan is also used to promote patient/resident and family involvement in planning care.Review of R92's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, chronic kidney disease, Type 2 diabetes mellitus, heart disease, congestive heart failure, chronic pain syndrome, chronic obstructive pulmonary disease, anxiety disorder, and schizoaffective disorder.Review of R92's Orders revealed an order for Code Status: Do Not Resuscitate dated 11/24/25. Review of R92's Care Plan on 02/22/26 revealed, Problem: [R92] is currently a Full Cardio-Pulmonary Resuscitation-Full Code . The Goal revealed, [R92] will be informed of her right to complete advanced directives to direct her medical care and make her values and treatment goals know. [R92] stated desires through the next review period will be honored . The Approach directed staff to, [R92] has completed the following advanced directives and copies are in the medical record: Full Code. The problem and goal start dates were 03/12/25. The problem and goal were both edited on 02/20/26 with no changes. The approach was started and last edited on 03/17/25. During an interview on 02/24/26 at 2:30 PM, the Social Services (SS) Director revealed, When someone changes their advanced directives, either me or the Nurse Assessment Coordinator (NAC) will change the Care Plan. We usually learn about it in the Clinical Meeting as a change in condition. I've already changed her Care Plan today to show she is a DNR.During an interview on 02/24/26 at approximately 3:45 PM, the Director of Nursing (DON) revealed, Our NAC nurse left in December, so we had a gap of having no NAC nurse. I only started in this position officially in December.During an interview on 02/24/26 at approximately 4:15 PM, the Administrator revealed, Our NAC nurse was out the first few weeks of January. The care plan not being changed when [R92] changed to a DNR status was probably due to this. Our NAC nurse was out from 01/09/26 through 01/26/26, and she resigned on 01/27/26.

Based on observation, interview, and record review, the facility failed to ensure Resident (R)7 and R37 were offered and/or assisted with hand hygiene prior to meal service for 2 of 2 residents observed during meal service. Findings include: Review of the facility's policy titled Infection Prevention and Control Policies and Procedures Subject: Hand Hygiene/Handwashing, indicated under the Procedures section that hand hygiene/handwashing is to be performed before eating and before preparing, distributing, handling, or serving food.Review of R7's electronic medical record (EMR) revealed R7 had an admission date of 08/12/25, with diagnoses including but not limited to, vascular dementia, muscle weakness, schizophrenia, bipolar disorder and dysphagia oropharyngeal phase.Review of R7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/06/26, revealed R7 had a Brief Interview for Mental Status (BIMS) score of 99 out of 15, which indicates R7 was severely cognitively impaired. Further review of the MDS revealed R7 requires setup or clean-up assistance with eating.Review of R37's EMR revealed R37 had an admission date of 01/14/28, with diagnoses including but not limited to, polyarthritis, hypertensive heart disease with heart failure and muscle weakness.Review of 37's MDS with an ARD of 01/21/26, revealed R37 had a BIMS score of 15 out of 15, which indicates R37 was cognitively intact.During a dining observation on 02/24/26 at 8:30 AM, R7 was not offered hand hygiene before their breakfast was served by Certified Nurse Aide (CNA)1. During a dining observation on 02/24/26 at 8:44AM, R37 was not offered hand hygiene before their breakfast was served by CNA1.During a dining observation on 02/24/26 at 12:26 PM, R7 was not offered hand hygiene before their lunch was served by CNA3. During a dining observation on 02/24/26 at 12:36 PM, R37 was not offered hand hygiene before their lunch was served by CNA2. During an interview on 02/24/26 at 11:00 AM, (R)7, when ask did the aide offer her to clean her hands before she ate breakfast, she shook her head yes.During an interview on 02/24/26 at approximately 12:40 PM, (R)37, when asked did the aide offer her hand hygiene before her lunch was served, she stated No, not today.During an interview on 02/24/26 at approximately 12:43 PM, (R)37's Representative, her son, started he is at the facility every day between 9:15 AM and 3:00 PM, and no one ever offers his mother hand hygiene before her meals.During an interview on 02/24/26 at 1:03 PM, CNA1 revealed she has worked at the facility for almost 2 years. She stated it's procedure and policy to clean resident hands before serving meals. She confirmed that she did not offer hand hygiene today to the residents as she forgot too.During an interview on 02/24/26 at approximately 1:10 PM, CNA2 revealed she has worked at the facility for almost 4 years. She stated it's procedure and policy to clean resident hands before serving meals. She stated R37 usually cleans her hands herself. When asked with what, she stated she has hand sanitizer. When asked did R37 clean them today, she stated No.During an interview on 02/24/26 at approximately 1:42 PM, CNA3 revealed she is unsure of the procedure and policy regarding hand hygiene before serving meals. When asked how she knows any procedures and policy when working at the facility, she revealed that staff will tell her. CNA3 confirmed that she did not offer hand hygiene to any of the residents that she served meals to today.During interview on 02/24/26 at 1:48 PM, the Administratar revealed that she would love staff to offer hand hygiene to each resident before meals. She would like them to have warm clean cloth, and at the very least hand sanitizer. She stated it is her expectation to offer hand hygiene to residents before serving meals.

Based on review of the facility policy, record review and interview, the facility failed to report allegations of sexual abuse, to the State Agency (SA), involving Resident (R)1, R2 and R3, for 3 of 3 residents reviewed for allegations of sexual abuse.Findings include:Review of the facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment states under, Component V. Reporting Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally, immediately to the Facility Abuse Coordinator, the Administrator and to other officials in accordance with state law including the State Survey and Certification Agency. 2. An analysis is completed to determine what changes are needed, if appropriate, to prevent further occurrences. 3. Complete the Investigation Summary Log, maintained by the Administrator or his/her designee. 4. Employees always have the right to report allegations directly to the state agency for elder abuse prevention.Review of R1's Face Sheet revealed the facility admitted R1 with diagnoses including, but not limited to, cognitive communication deficit and dementia. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated severe cognitive deficits.Review of R2's Face Sheet revealed the facility admitted R2 with diagnoses including, but not limited to, alcohol dependence with alcohol-induced persisting dementia, post traumatic stress disorder, anxiety disorder, major depressive disorder and schizophrenia. Review of a Quarterly MDS dated [DATE] revealed a BIMS was not conducted due to R2 not able to understand and is not understood. Review of R3's Face Sheet revealed the facility admitted R3 with diagnoses including, but not limited to, dementia, transient ischemic attack (TIA) and cerebral infarction, convulsions, adult failure to thrive and cocaine use. Review of a Quarterly MDS with an ARD of 01/15/2026 revealed a BIMS of 6 out of 15 indicating severe cognitive deficits. Review of the progress notes for R1, R2 and R3 did not include any documentation of alleged abuse. The abuse allegations were mentioned in a morning meeting with staff on 02/06/2026, but according to staff some were informed on 02/04/2026 and some on 02/05/2026. The abuse allegations were not reported to the SA within the required 2 hour timeframe. R1 was observed by a Certified Nursing Assistant (CNA) to have her hands in the brief of R2. And it was also alleged that R2 and R3 had sexual intercourse, when R2 was found in the bed of R3. During interviews on 02/11/2026 with the Nutrition Director, the Staff Development Coordinator, Activity Director, the Admissions Director, the Assistant Director of Nursing, Licensed Practical Nurse (LPN)1 and LPN3, all knew of the allegations of abuse. The allegation of sexual abuse was reported to the nurse when it happened but the staff failed to report the allegation to the Abuse Coordinator and the Abuse Coordinator failed to report the allegation of sexual abuse to the SA.

Based on observation, interview, record review, and facility policy review, the facility failed to implement Care Plan interventions related to fall prevention for Resident (R)4, for 1 of 2 residents reviewed for falls.Findings include:Review of the facility policy titled, Fall Management with a revision date of 05/05/23 indicated, The facility will identify each patient/resident who is at risk of falls and will plan care and implement interventions to manage falls . (1) The Fall Risk Evaluation assists in identifying the appropriate preventative interventions that will be recorded on the patient/resident's care plan . (5) The care plan reflects individualized interventions that are reassessed and revised as needed. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE], with diagnoses including but not limited to dementia, history of falling, diabetes mellitus, hypokalemia, chronic kidney disease, and urinary tract infection.Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/25 revealed R4 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R4 was severely cognitively impaired. Further review of the MDS revealed R4 needed maximum assistance for bed mobility and was dependent on toilet transfers. The MDS also revealed R4 had no falls since admission or prior assessment.Review of R4's Care Plan dated 05/29/2024 with a target completion date of 02/28/2026 revealed the following, Impaired cognitive function related to dx (diagnosis) of dementia, at risk for falls related to my impaired, decreased mobility, History of falls, impaired vision, impaired cognition. Interventions directed staff to, I need a safe environment with: (SPECIFY: even floors free of clutter); Nursing to monitor resident when ambulating in the hall. Encourage the resident to wait for assistance before ambulating. Fall mat at bedside. Please remind me to call for assistance with the call bell prior to transfers and ambulating. Staff education.Review of R4's Fall Incident Report dated 10/19/2025 revealed R4 has a history of falling. The report stated, In October/November 2024, resident had no acute fracture or dislocation. Resident was noted as having femoral hardware. Also noted as osteopenia with moderate tricompartmental osteoarthritic changes and degenerative changes. [R4] is bed bound and requires a Hoyer-Lift and 2- person assist when transferring from bed to wheelchair. [R4's] last fall was October 24, 2024. During an observation on 02/11/2026 at 9:45 AM, R4 was in bed asleep. No fall mats in place per care plan. Residents bed was in the lowest position to the floor. During a 2nd observation on 02/11/2026 at 11:40 AM, R4 was in bed asleep, periodically pulling herself up in the bed using top bedrails. No fall mats in place per care plan. Residents bed was in the lowest position to the floor. During an interview with the Director of Nursing (DON) on 02/11/2026 at 2:32 PM, the DON stated, I just came into this position and all I know is that the care plan and the MDS wasn't updated. We only had one MDS nurse on staff at the time of the incident and she was behind when she started the position. We currently do not have an MDS nurse on staff. The Unit Managers are trying to get all MDS and care plans updated every day. The fall wasn't documented in the care plan. Interventions should have been put in place based on the submitted statements.

Based on observation, interview, and record review the facility failed to follow manufacturer's guidelines to ensure that blood glucose glucometers were sanitized/cleaned properly. On 03/25/25 at 12:10 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 03/25/25 at 12:15 PM, the Administrator was notified that the facility's failure to have systems in place to monitor for blood glucose glucometers constituted Immediate Jeopardy (IJ) at F880. On 03/26/25 at 3:00 PM, the facility provided an acceptable IJ Removal Plan. On 03/26/25 at 4:10 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F880 at a lower scope and severity of D. Findings include: Record review of facility policy titled Staff Education/Orientation Policies and Procedures Blood Glucose Monitoring last revised 01/12/24 revealed reference facility specific Blood Glucose Monitoring Device manufacturer's recommendations. Clean Glucometers utilizing two-step process with an approved Environmental Protective Agency (EPA) disinfectant wipe which is labeled effective against Tuberculosis (TB), or Hepatitis B Virus (HBV), Hepatitis C (HCV), or Human Immunodeficiency Virus (HIV) to remove any visible contaminants, soil, or other debris. Use a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time. Record review of facility policy Infection Prevention and Control Policies and Procedures Transmission Based/Standard Precautions, and Enhanced Barrier Precautions (EBP), last revised 05/15/23 revealed EBP will be implemented for all residents with the following: infection or colonization with a Multidrug-resistant Organisms (MDRO) when contact precautions due not otherwise apply; wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Record review of the Manufacturer's recommendation for the Evencare G2 Meter revealed Cleaning and disinfecting the meter is very important in the prevention of infectious disease. The following products are validated for disinfecting the EVENCARE G2 Meter ., .Medline Micro-Kill Bleach Germicidal Bleach Wipes. During a medication administration observation on 03/24/2025 at 5:20 PM with Registered Nurse (RN)1. She stated each resident has an individual glucometer. She pulled R86's pouch from the medication cart. The glucometer was not located in the pouch. She checked some of the other pouches and said R168's glucometer was not in his pouch either. She then looked in the drawers of the medication cart and found a glucometer and said this was R86's blood sugar check machine (finger stick blood sugar). She found an Even Care G2 glucometer. It did not have R86's name on it. RN1 said she checked her blood sugar this am. It was 153 at lunch. She wiped the machine with an alcohol prep pad and entered R86's room to perform the blood sugar checks check. She then returned to the medication cart afterward. She cleaned the glucometer with an alcohol prep pad. She returned the pouch back into the medication cart. Observation on 3/24/25 at 5:50 PM, Licensed Practical Nurse (LPN) 1 was observed placing an Evencare G2 glucometer into a pouch. LPN1 stated she had just finished checking a resident's blood sugar and had cleaned it with an alcohol wipe since all residents have their own glucometer. During an interview on 3/24/25 at 5:54 PM, LPN2 described how she cleans the Evencare G2 glucometers stating that she uses MicroKill Bleach Wipes even though each resident has their own glucometer. On 03/24/2025 at 5:55 PM RN1 opened the medication cart. She opened each pouch and pulled the machine from the pouch to verify who had a glucometer. R168 and R67 did not have a glucometer in their pouches. When asked if she performed a blood sugar check on either of these residents, she stated, I had to do a blood sugar checks check earlier on R168, around noon. I used R86's blood sugar checks machine for him. I always clean with an alcohol pad, with each person. His blood sugar was 279. Record review of R86's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes mellitus, binge eating disorder, and morbid obesity. Record review of R86's quarterly Minimum Data set (MDS) with an Assessment Reference Date (ARD) of 02/19/25 revealed a Brief Interview Mental Status (BIMS) score of 15, of 15, indicating she was cognitively intact. Record review of R168's Face Sheet revealed he was admitted on [DATE] with diagnoses including but not limited to: orthopedic aftercare following surgical amputation. Record review of R168's MDS admission MDS with an ARD date of 03/18/25 revealed a BIMS score of 15, of 15, indicating he was cognitively intact. Record review of R168's MAR dated 03/24/25 at 12:30 PM indicated that a blood sugar check was performed, with a result of 279 mg/dL. Record review of R67's Face Sheet revealed R67 was admitted to the facility on [DATE] with the diagnoses including but not limited to: type 2 diabetes mellitus with hyperglycemia, hypertension, pain, and schizophrenia. Record review of R67's quarterly MDS with an ARD of 03/14/25 revealed a BIMS score of 12 of 15 which indicates he is moderately impaired. Record review of R67's Medication Administration Record (MAR) dated 03/24/25 at 12:00 PM, indicated that a blood sugar check was performed, with a result of 106 mg/dL. During an interview 03/25/25 at 08:23 AM, the Director of Nursing (DON) said, for glucometer cleaning, wash hands, don gloves. Inspect the glucometer to see it is visibly soiled, wipe with an alcohol pad, then use Environment Protection Agency (EPA) approved germicidal wipes, wash hands, don gloves, place barrier down and place glucometer on it, wet it down, with blue top for 3 minutes. Each patient has their own glucometers, we have extras in the supply room. If they don't have one, we have replacements. She said it is not ok for a nurse to use another resident's glucometer; each resident has their own. In the room, they should transport the glucometer in a cup and or place a barrier down at bedside. Each resident has their own clear pouch. The Unit Manager audits the carts every Monday, making sure each resident has their own glucometer. I made sure we had at least 5 extras in the supply room. During an interview on 03/25/25 at 10:48 AM RN2 stated, R188 has a wound vac and is not on EBP. During an interview on 03/25/25 at 11:05 AM, LPN4 stated R86 should be on EBP and should have an order for it. She also confirmed R168 should have EBP signage on his door and an order for it as well. The facility's removal plan dated 03/26/25 noted the following: Residents who require blood glucose moitoring will be assessed for signs and symptoms of infection by the licensed nurses on 02/25/2025. R#188 without negative effects. Resident #168 had EBP implemented on 03/25/2025. EPA disinfectant wipes were placed in medication carts that store glucometers. An audit of glucometers was completed by the DON/Designees on 03/25/2025 to validate each resident that requiring blood glucose monitoring has a glucometer available. A review of current in house residents will be completed by the DON/Designee on 03/25/2025 to identify residents who require EBP which include; Resident with an infection or colonization with a multi-drug resistant organism not on transmission based precautions. Resident with wounds, including pressure, diabetic foot, unhealed surgical and venous wounds. Residents with an indwelling medical device such as a central line, urinary catheter, feeding tube, tracheostomy, and peripherally inserted central catheters. Residents identified as meeting the criteria for EBP will have a signage placed at the door, provider notified and order written, responsible party notified and care plan updated on 03/25/2025. Licensed nurses will be reeducated with competency validation by the DON on 03/25/2025 on blood glucose monitoring including; Validating the residents assigned glucometer is used. Location and availability of additional glucometers. Using a barrier to place the glucometer on if needed in residents room. Using a 2 step process with an approved EPA disinfectant wipe to remove any visible contaminants, soil or other debris and using a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time. Validating EPA disinfectant is available on their medication cart at the beginning of their shift. Licensed nurses will be reeducated by the DON on 03/25/2025 on EBP including criteria that required EBP: Resident with an infection or colonization with a multi-drug resistant organism not on transmission based precautions. Resident with wounds, including pressure, diabetic foot, unhealed surgical and venous wounds. Residents with an indwelling medical device such as a central line, urinary catheter, feeding tube, tracheostomy, and peripherally inserted central catheters. Any licensed nurse not receiving this reeducation validation by 03/25/2025 will receive prior to their next scheduled shift. This will be presented in new hire orientation and in Agency orientation. The DON will randomly observe 2 licensed nurses for 5 days performing blood glucose monitoring to validate proper procedure including infection control technique and correct glucometer is being utilized. The DON/Designee will validate each morning for 5 days EPA disinfectant wipes and available on each med cart that stores glucometers. The DON/Designee will review the facility activity report and 24-hour report in the clinical morning meeting Monday-Friday to identify any resident who require EBP and validate orders are written, provider and responsible party are notified, signage on residents door, PPE is available and care plan updated. On 03/26/2025 at 4:00 PM the removal plan was accepted.

Based on review of the facility policy, observations and interviews, the facility failed to ensure medications and biological were not expired for 2 of 2 units reviewed. Findings include: Review of the facility policy titled Medication Storage last revised [DATE] revealed, Policy: Medications and biologicals are stored safely, securely and properly following manufacturers recommendations or those of the supplier. Once any medication or biological package is opened, the facility should follow manufacturers guidelines with respect to expiration date of opened medications. An observation and interview on [DATE] at 9:25 AM of the medication room East Wing with Licensed Practical Nurse (LPN) 4 revealed the following: One unopened bottle of Pink Bismuth Regular Strength 8 fluid ounces with an expiration date of ,d+[DATE], one Laboratory Vacutainer blue top with an expiration date of [DATE], two insulin Novolog pens with an expiration date of [DATE] and Lot number MZF3X25 and two boxes of Blood Culture Collection Kits with an expiration date of [DATE] all confirmed by LPN 4. An observation on [DATE] at 9:40 AM in the Central Supply Room, revealed the following: One box of 12 Tegaderm Dressings with an expiration date of [DATE] lot number (#) 33C893, confirmed by LPN 5 as expired. During an interview on [DATE] at 9:43 AM, the Central Supply personnel stated, There should not be any expired items in here, I should be checking them, and I try to but don't have the time. An observation and interview on [DATE] at 9:45 AM of the North Unit Treatment Cart revealed, one unopened Blood Culture Kit with an expiration date of [DATE], LPN 5 confirmed it was expired and said she was going to throw it away. During an interview on [DATE] at 10:52 AM, the Director of Nursing (DON) stated, Insulin pens are stored in the fridge until open. The wound supplies should be current, not expired. There should not be expired meds in the med room or med room refrigerator.

Based on review of the facility policy, observation, record review and interviews, the facility failed to ensure a room was clean and sanitary for 1 of 1 Residents (R) 80 reviewed for environment. Findings include: Review of the facility policy titled Patient/Resident Room Cleaning/Bathroom Cleaning dated 03/06, revealed, This routine procedure will clean and disinfect patient/resident rooms and bathrooms thereby providing a clean, safe decontaminated environment for our patients/residents. Expected results, patient/resident rooms and bathrooms that are clean, sanitary odor free and safe. Record review of R80's facesheet revealed R80 was admitted to the facility on [DATE] with diagnosis that include but are not limited to: vascular dementia with anxiety, diabetes mellitus, hypertension and benign prostatic hyperplasia. Record review of R80's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/25 revealed a Brief Interview of Mental Status (BIMS) of 00, indicating he was non interviewable. Record review of R80's care plan revealed he has behavioral symptoms of rejection of care, defecating in the room, placing feces in his clothes and placing clothes into the drawers, smearing feces on the wall. Record review of R80's psychiatry note dated 01/06/25 documented staff have difficulty getting him to shower. Staff denied physical or verbal aggression. Observation on 03/23/25 at 11:55 AM, revealed a very offensive odor on the unit hall where R80's resides. Upon entering R80's room, observation revealed debris all over the room, along the base board and a strong foul odor. Deep yellow stains were noted on the floor that appear wet and some dry. There was wet toilet tissue throughout the room on the right side of the bed with feces. A yellow wet sign was observed by the door in the hallway. Observation of R80's room on 03/23/24 at 12:30 PM, revealed, plastic food containers. The room had a very strong offensive odor. Urine all over the right side of the room and up in the corners as well. R80 was observed with gray jogging pants, not pulled up all the way, with holes and one shoe on his left foot. Wet toilet tissue with feces was noted to the right side of the head of the bed. There was debris all along the walls of the room. There was smeared feces on the walls in 2 areas. Gnats were observed flying near his bed and near where the feces were on the floor. The odor permeated out into and down the hallway. Observation of R80's room on 03/23/24 at 2:00 PM, R80 is noted sitting on his bed with a soiled sheet on his bed with yellow stains. No change noted from previous observation at 12:30 PM. Interview on 03/23/25 at 2:12 PM, Housekeeper (HK)1 stated, this room is not acceptable. I wouldn't have my family in a room like this. It's terrible. HK1 confirmed the feces and urine throughout the room on the floors. HK1 observed the walls and base boards with debris and said this could not be from 1 day. HK1 said he will clean it. Interview on 03/23/24 at 2:14 PM, the Director of Housekeeping (DOH), said R80 did this on another hall in another private room. The tiles need to be replaced. He cannot have a roommate because he also had another room with a roommate and this was the problem. She confirmed R80 urinates in the trash and has bowel movements on the floor. He's been this way since he came in. She confirmed the room was very offensive with terrible odor and gnats throughout. She also confirmed he cannot have regular meal trays in his room, he uses disposables. Interview on 03/23/25 at 2:14 PM, Certified Nursing Assistant (CNA)1 confirmed R80 was her resident and said she'd been in the room. She said she did not walk over to where the feces and urine were all over the right side of the room. She confirmed he always get disposable trays because he will not return the regular dishes and silverware. She said he will try to hit you if you try to help him with getting cleaned up. She confirmed his room had a terrible odor and the odor could be smelled from down the hall. Interview on 03/24/25 at 10:30 AM the DOH stated, we will do a deep clean of everything in E-2 [R80's room] since he is in the hospital. Interview on 03/25/25 at 10:07 AM, the Administrator stated, housekeeping should go in, wipe down bedside drawers and table, and we have a deep cleaning schedule. We try to hit all the rooms in that quarter. She tries to get 8-10 rooms some weeks. They sweep, mop, empty the trash, sweep/mop in the bathrooms. R80 goes through these cycles, where he is fixated that someone is going to pick him up to take him home. He will not let anyone near him. He will barricade himself in his room. They ask every day if they can clean his room, give him a shower, dress him. Residents have a right to refuse services. He won't let us clean, defecate and urinate on the floor. When he is escalated, they will serve him his meals in Styrofoam disposable. He is very territorial. He needs a Dementia Unit. We send email referrals out to try to find placement for him. He urinates in the fan. He won't use the bathroom when he's in that cycle. She agreed the room still needed to be cleaned every day.

Based on review of the facility policy, record review, observation and interviews, the facility failed to ensure residents right to be free from neglect by failing to provide Resident (R)107 Activities of Daily Living (ADL) care in a timely manner. 1 of 3 reviewed for abuse/neglect. Findings include: Review of the facility policy titled Leadership Policies and Procedures: Abuse, Neglect, Exploitation, Mistreatment last revised 10/23/19 revealed, The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. Neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors such as ignoring the patient/resident's needs requests etc. Record review of R107's Face Sheet revealed was admitted to the facility on [DATE] with the diagnosis including but not limited to: sepsis, pressure ulcer of sacral region stage 4, muscle weakness, and unsteadiness on feet. Record review of R107's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/10/25 revealed that R107 has a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicates that he is cognitively intact. Further review of the Admission MDS revealed that R107 is dependent on staff for toileting hygiene, requires substantial/maximal assistance with showers/bathing and upper and lower body dressing. Record review of R107 Care Plan last revised 01/13/25 revealed, R107 requires up to max/dependent assist with most ADLs at this time with interventions that included mechanical lift with two person staff assistance. Further review revealed, R107 experiences bladder incontinence related to right sided hemiplegia, post status stroke, decreased mobility, need for assistance. Interventions include report signs of Urinary Tract Infection (UTI), keep call light in reach, provide assistance for toileting, provide incontinence care after each incontinent episode. An observation and interview on 03/24/25 at 12:47 PM with R107 and his Resident Representative (RR) revealed, R107 in bedtime wear and eating his lunch meal. R107 and their RR stated the resident often has to wait until the afternoon before someone assists them with getting dressed due to short staffing. During an interview on 03/24/25 at 3:42 PM R107 revealed, staff often comes into his room and turns off his call light without providing assistance. R107 continued to state that at times he has waited thirty minutes to an hour for help at times because staff ignore his call light or don't provide him care when he first calls for assistance. An observation and interview on 03/25/25 at 7:40 AM with R107 revealed him in bed and in need of ADL care. R107 stated I am wet and I waiting for someone to change me, I have been waiting for about 20 - 30 minutes, a staff member came into the room earlier and said that they would help me or get someone to help me and turned my call light off without helping me. An observation and interview on 03/25/25 at 7:45 AM revealed Certified Nursing Assistant (CNA)5 entering R107's room turning off the resident's call light and exiting shortly after without providing R107 assistance. CNA5 stated they were not assigned to the resident and was going to find the resident's CNA. An observation on 03/25/25 at 7:55 AM revealed Licensed Practical Nurse (LPN)1 along with CNA4 explaining to CNA5 that they should not turn off the resident's call light without providing assistance. During the observation that staff were having there were no observations of staff attempting to determine which resident needed care. A follow up observation and interview on 03/25/25 at 8:15 AM with R107 revealed that two staff members had refused him care. R017 put his call light back on at this time and CNA4 entered the resident's room. R107 became frustrated with CNA4 and began yelling that's what the last lady said, and I still haven't been changed. CNA4 explained to R107 that they would be right back to provide him ADL care and turned off the resident's call light. An observation on 03/25/25 at 8:17 AM CNA4 entered back into R107's room and provided him with ADL care, CNA4 exited the room on 03/25/25 at 8:22 AM. A follow up interview on 03/25/25 at approximately 8:30 AM revealed that the resident's assigned CNA did not show up to work or called out. LPN1 further stated that all staff are responsible for responding to resident's call lights or requests. An third observation on 03/25/25 at 12:00 PM revealed R107 in bed in nighttime wear, R107 stated, after they provided him ADL care earlier (8:22 AM), no one had come back to get him dressed in appropriate wear for the day. Resident continued to state that he turned on his call light but was ignored by staff. Record review of R107 Point of Care History ADLs How did the resident maintain personal hygiene? section revealed the following documentation: -03/23/25 at 1:49 AM - activity did not occur -03/24/25 at 1:58 AM and 10:38 PM - total dependence -03/25/25 at 10:24 PM - total dependence -03/26/25 at 1:18 AM, 2:55 PM total dependence on 03/26/25 at 7:56 PM -extensive assistance Record review of R107 Point of Care History ADLs Staff support provided for personal hygiene? section revealed the following documentation: -03/23/25 - no documentation charted for this date -03/24/25 at 1:58 AM and 10:30 PM - one-person physical assist -03/25/25 at 10:24 PM - one-person physical assist -03/26/25 at 1:18 AM, 2:55 PM, and 7:56 PM - one-person physical assist Record review of R107's Point of Care History ADLs Type of Bath? section revealed the following documentation: -03/23/25 - no documentation charted for this date -03/24/25 - no documentation charted for this date -03/25/25 - no documentation charted for this date -03/26/25 at 2:55 PM -partial bed bath Record review of R107 Point of Care History ADLs What is the resident's level of bladder function? section revealed the following documentation: -03/23/25 at 1:51 AM - incontinent -03/24/25 at 1:52 AM and 10:30 PM - incontinent -03/25/25 at 10:25 PM -incontinent -03/26/25 at 1:18 AM, 2:55 PM - incontinent; at 7:57 PM - continent Record review of R107 Point of Care History ADLs What is the resident's level of control with bowel function? revealed the following documentation: -03/23/25 at 1:51 AM - incontinent -03/24/25 at 1:52 AM and 10:30 PM - incontinent -03/25/25 10:25 PM - incontinent -03/26/25 at 1:18 AM, 2:55 PM, and 7:57 PM - incontinent An interview on 03/25/25 at 1:25 PM with the Administrator and Director of Nursing (DON) revealed, their expectation is that when a staff member see's a resident call light is on is to answer the call light and complete the resident's request prior to turning off the call light. The Administrator further stated that if the staff member that first see the resident call light is not able to answer the resident's request (CNA answer's call light but the resident requested medication) then the call light should remain on until the appropriate staff person can assist the resident. An interview on 03/26/25 at 2:16 PM with LPN5 revealed, they were informed of the situation that occurred on 03/25/25 with R107. LPN5 further revealed that staff ignoring the resident's request to be provided with ADL care in a timely manner is considered neglect. LPN5 finally stated, CNA4 was the resident's assigned CNA for 03/25/25 and is now placed on the Do Not Return list for the facility.

Based on review of the facility policy, record review, observation and interview, the facility failed to revise/implement Care Plan interventions for Resident (R)41 to reflect his need for assistance with dining/feeding after an injury to the residents' dominant hand for 1 of 3 residents reviewed for nutritional care plans. Findings include: Review of facility policy titled Social Services Policies and Procedures Person-Centered Care Plan last revised 06/09/23 revealed, The resident has the right to be informed of and participate in the development of a baseline and or comprehensive care plan for each patient/resident. Care plans include baseline care plan developed and initiated within 48 hours of admission; comprehensive care plan developed after completion of the discipline-specific assessment and within (1) week after completion of the Minimum Data Set (MDS); will be reviewed and updated as needs are identified and after each MDS assessment (excluding discharge). The person-centered care plan is interdisciplinary and created to guide facility staff in providing the treatment, care, and services necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychosocial well-being possible. The plan is also used to promote patient/resident and family involvement in planning care. Record review of R41's Face Sheet revealed he was admitted to the facility on [DATE] with the diagnosis including but not limited to nontraumatic ischemic infarction of muscle left hand, legal blindness, end stage renal disease, and mild cognitive impairment of uncertain or unknown etiology. Record review of R41's Annual MDS with and an Assessment Reference Date (ARD) of 02/16/25 revealed that R41 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicates that he is cognitively intact. Further review of the Annual MDS revealed that during this period R41 required set up or clean up assistance with meals. Record review of a Nurses Note dated 01/03/25 at 9:26 AM revealed Noted swelling to left and band-aid on left middle finger. R107 states had a hangnail that he bit off, and it's been hurting ever since. Band-aid removed, noted swelling to left middle finger, nailbed pale bluish white with small amount of dried blood present. Complaints of discomfort while making a fist, Medical Director present and check R41 hand, new order received for Bactrim two times a day after meals for seven days. Resident Representative contacted and informed of findings and new order, voice understanding. Record review of a Nurses Note dated 01/06/25 at 6:26 AM revealed Unit manager noted resident in continuous pain despite pain medication, antibiotics, and application of topical antibiotic ointment. Called Nurse Practitioner and notified him of warmth, swelling, tender to touch of left upper digits. Per patient he would like to be sent out, per provider, sent patient to emergency department for further evaluation and treatment. Record review of a Nurses Note dated 01/10/25 at 6:21 AM revealed Resident returned to facility via stretcher transport from local hospital transferred to his wheelchair per request. Alert and responds appropriately, continue to have swelling to left hand. Left middle finger dark with pale, bluish nailbed, complaints of tenderness to finger. Lateral distal aspect of middle finger slightly red with small blister noted, requests dinner at this time. Record review of R41's Care Plan with a last Care Plan Conference date of 02/25/25 revealed no Care Plan interventions related to the resident's injured hand or his need for assistance with meals. An observation and interview on 03/23/25 at 10:53 AM with R41 revealed him in his room sitting in his wheelchair with gauze and medical tape on the resident's left hand, index finger and middle finger. R41's right hand was noted with long and dirty fingernails. R41 revealed he injured his hand by biting off a hangnail, but it later got infected. R41 further stated that he is legally blind, and his left hand is his dominant hand and that he has had a difficult time feeding himself since he injured his hand. R41 finally stated that some days staff assist him with meals, but it is not consistent so most days he has to feed himself. An observation and interview on 03/24/25 at 6:28 PM revealed the Administrator setting up and providing a clothing protector to R41 for his dinner meal. Licensed Practical Nurse (LPN)5 then assisted the resident with his dinner meal. LPN5 stated, residents who need assistance with meals have a red napkin for staff to identify those specific residents. R41 did not have red napkin on his tray. An observation and interview on 03/25/25 at 7:35 AM revealed R41 eating his breakfast meal without staff assistance. During observation resident had a difficult time determining how much grits and eggs were on his tray. Grits were observed on the side of the resident's face and on his clothing protector and his tray. R41 stated that he asked staff for assistance, but staff became argumentative with him and told him that he could feed himself. An observation and interview on 03/25/25 at 7:37 AM with Certified Nursing Assistant (CNA)4 and LPN1 revealed them at the nursing station and having a personal conversation. During interview with CNA4 and LPN1 both stated that the R41 could feed himself. CNA4 stated they were not the resident's assigned CNA for the day but volunteered to assist the resident. Further interview with LPN1 revealed that the resident can feed himself but does require staff assistance. LPN1 finally stated that R41 does not have care plan interventions related to his hand injury or assistance with meals due to his injury. An observation on 03/26/25 at 9:04 AM revealed R41 feeding himself his breakfast meal tray with difficulty. An interview on 03/26/25 at 12:47 PM with the Dietary Manager (DM) and Registered Dietitian (RD) revealed R41 should be assisted with meals. Therapy attempted to work with the resident after R41 injured his hand but was unsuccessful. Further interview revealed R41's care plan had not been revised to reflect a change of condition with the resident's ability to feed himself. An interview on 03/26/25 at 1:05 PM with the Director of Rehabilitation (DOR) revealed R41 received Occupational Therapy (OT) shortly after he injured his dominant hand. During OT there were attempts to have the resident use his right hand for meals, but it was unsuccessful. The DOR finally stated that the resident does require assistance with meals and was unable to locate care plan interventions related to this change of condition. An interview on 03/26/25 at 4:01 PM with the Director of Nursing (DON) revealed they would have expected the resident's care plan to have been revised to reflect his change of condition.

Based on observations, record reviews and interviews the facility failed to ensure that a medication was administered according to physician orders for 1 of 2 residents reviewed for tube feeding. Resident (R) 85 was admitted to the facility on [DATE] with diagnoses including, but not limited to severe intellectual disabilities, gastrostomy, schizophrenia and anxiety, The facility policy on Physician Orders, revised May 5, 2023, states The qualified nurse will obtain and transcribe orders according to Facility Practice Guidelines, .PRN (as needed) medications: Transcribe or electronically enter all PRN Medication/Treatment Orders to properly identified area of MAR (medication administration record). Findings: On 3/24/25 at approximately 3:30 PM, a review of R 85's medical record revealed the following, dated 3/21/25, in the progress notes Res (resident) could be heard yelling out/screaming in the hallway and at the nursing station several times thus far in shift. Several interventions attempted; None effective. Res calms down when nurse consoles at bedside but soon as this nurse walks out room patient behaviors starts back. Res tells his roommate to shut up even though roommate doesn't say anything. Denies any pain or discomfort. NP 1 (Nurse Practitioner) Aware via telephone; Verbal order given for Benadryl 50 mg (milligram) by peg (percutaneous endoscopic gastrostomy tube) every 8 hours prn for 14 days. Med (medication) administered via peg without difficulty flowing. Will re-assess behavior LPN (Licensed Practical Nurse) 3 On 3/24/25 at approximately 4:19 PM, R 85 was yelling and the DON (Director of Nursing) stated that had R 85 had an order for Benadryl 50 mg for agitation. On 3/24/25 at approximately 5:28 PM, during an interview RN (Registered Nurse) 1 confirmed that R 85 had been yelling, that she had tried to calm him down but had administered no medications for yelling. After reviewing the progress notes, RN 1 confirmed that on 3/21/25 Benadryl 50 mg PRN x 14 days by way of peg tube, a verbal physicians order, taken by LPN 3 did not appear in the EMR (electronic medical record) MAR and that none had been administered. On 3/24/25 at approximately 5:07 PM, during an interview the DON confirmed her previous statement that there had been a verbal order on 3/21/25 for Benadryl 50 mg PRN. She reviewed the EMR physician orders and MAR and stated that the order had not been entered or administered, then called NP 1 on 03/24/25 at approximately 5:09 PM. NP 1 confirmed over the telephone that she had ordered Benadryl 50 mg PRN x 14 days on 3/21/25 and still wanted the order to be in place. The DON stated this physicians order should have been entered as a medication order in the EMR and administered as prescribed.

Based on interviews, record review, and review of facility policy, the facility failed to provide appropriate supervision to prevent Resident (R)1's elopement from the facility. On 06/14/24 at 1:28 PM, the Administrator was notified that the failure to properly supervise a resident, resulting in a successful elopement from the facility, constituted Immediate Jeopardy (IJ) at F689. On 06/14/24 at 1:28 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 06/11/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 06/14/24 at approximately 2:18 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The survey team considers the IJ at Past Non-Compliance as of 06/12/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility's policy titled Elopement last revised 11/01/17, stated, To safely and timely redirect patients/residents to a safe environment. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: vascular dementia, abnormalities of gait and mobility, lack of coordination, difficulty in walking, unsteadiness on feet, reduced mobility, altered mental status, fall from bed, neurocognitive disorder with Lewy bodies, and depression. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/08/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating R1 was severely cognitively impaired. Further review of the MDS revealed that wandering behaviors occurred 1 to 3 days. Review of R1's Elopement Risk Tool dated 05/02/24, revealed R1 is not alert and oriented. R1 is confused and does not have safe decision-making capabilities. R1 has a history of wandering and has previously attempted to leave the health care center. Further review revealed, R1 has diagnoses that requires supervision. Review of R1's Physician Orders dated 08/01/23, revealed the following order, Wander guard to right ankle; check placement and function Q shift. Review of R1's Progress Note dated 06/11/24 at 7:21 PM, revealed, At 6:30 resident attempt to go out of building doors was opened, but I the nurse and staff re-direct her back into the building. Review of R1's Progress Note dated 06/11/24 at 9:32 PM revealed, At 7.18pm this nurse was in the med room. when i got out of the med room I saw other nurses running towards the back door. This nurse left the stuff she was carrying in the cart and rushed to where the other nurses where running to. Upon going out, this nurse saw that it was her resident who was on the ground. Assessment done on resident she reported she hit her head . During an interview on 06/14/24 at 11:59 AM, Licensed Practical Nurse (LPN)1 stated that on the night of 06/11/24 at approximately 7:15 PM, the door alarm/wander guard system alarm went off, LPN1 then went to check the panel to see which door it was, it was 2B, LPN1 then went down the hall, however it was the wrong hall. LPN1 then went down E hall and out the door and found R1 lying on the ground in the parking lot next to a light pole. LPN1 states that R1 reported to her that she fell and hit her head. 911 was then called for R1. During an interview on 06/14/24 at 12:09 PM, R1 stated that she wanted to go to the white house across the street, so just got up and walked out the door. R1 further stated that she fell in the parking lot on a curb and hit her head and was sent to the emergency room . During an interview on 06/14/24 at 12:45 PM, LPN2 stated that R1 was wearing a white top, pink pants and non-slip socks, when she was found in the parking lot. According to the Weather Channel, on 06/11/24, the high was 89 degrees Fahrenheit with a low of 63 degrees Fahrenheit. On 06/14/24 at approximately 2:18 PM, the facility provided a removal plan, which included the following: Resident R1 had fall, possibly hitting head. Sent to ED for evaluation as precaution. Elopement risk evaluation repeated. Resident had Wandergard in place and properly functioning at time of incident. MD/RP notified. Administrator and CSD notified of incident. Residents at risk of elopement have the potential to be affected. Elopement risk evaluations done in the past 90 days on current residents in facility reviewed by nursing managers for accuracy. Residents identified at risk will be reviewed for appropriate interventions. All doors check for auditory alarm; found to be in working order. Educate facility staff the expectation that if a door is noticed to be alarming, immediately report to door to verify no resident has eloped then do a facility wide head count of residents. If door is found to be malfunctioning, administrator to be notified immediately and an employee posted at the door until otherwise indicated and redirected by a member of management. Licensed nurses will be re-educated on the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. Staff will be reeducated on appropriate response to alarms. This re-education will be initiated on 06/11/2024 and completed by 06/12/2024. Any member of target audience not receiving this by this date will receive prior to next scheduled shift. New admissions will be reviewed in morning meeting daily Monday thru Friday as part of the clinical morning meeting process. Elopement risks assessments will be reviewed for accuracy and interventions validated if indicated. Quarterly assessments will be reviewed as part of the MDS/Care planning process. The Director of Nursing or designee will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy. The maintenance director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. The Administrator or designee will make rounds weekly for 4 weeks then monthly for 2 additional months to validate that doors are functioning properly. The maintenance director or designee will activate a door alarm once a month on each shift to validate appropriate response for 3 months or until compliance. Ad hoc QAPI held on 06/12/2024. Medical Director was notified of the incident and plan for improvement on 06/12/2024. This process will be reviewed in QAPI for a minimum of 3 months.

Based on review of the facility policy titled, Catheter- Urinary Catheter, Cleaning and Maintenance, observations, and interviews, the facility failed to follow a procedure during catheter care for Resident (R)1 to prevent the likelihood of infection for 1 of 1 residents observed for Foley catheter care. Findings include: Review of the facility policy titled, Catheter- Urinary Catheter, Cleaning and Maintenance last revised May 2023 states under Catheter care: Gather and prepare the necessary equipment and supplies, perform hand hygiene, confirm the patient's identity using at least two patient identifiers, provide privacy, raise the patient's bed to waist level before performing patient care, perform hand hygiene, put on gloves and other personal protective equipment, as needed, to comply with standard precautions, provide routine hygiene for meatal care. Further review stated, Keep the catheter and drainage tubing free from kinks and avoid dependent loops to allow the free flow of urine. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to cystitis with hematuria, sepsis, urinary tract infection, diffuse traumatic brain injury and a need for assistance with personal care. Observation on 02/22/24 at 10:35 AM of catheter care for R1 went as follows: Certified Nursing Assistant (CNA)1 along with CNA2, explained the procedure and provided privacy. CNA1 proceeded to wash her hands and donned (put on) gloves. She then touched the over-bed table to move it closer to the bed, touched the curtain to pull it open and then close, then set up the supplies on the over-bed table, which consisted of wipes that she had placed on the over-bed table. CNA1 then took the bed control in hand and raised the bed. She then removed the bed cover and pulled R1's gown up, folding it above her waist. She then unfastened her brief. Observation revealed CNA1 did not remove her gloves, cleanse her hands or apply clean gloves, prior to taking a wipe in hand and wiping down the left- side of R1's groin. She then discarded the wipe and wiped down the right side of the groin area, and then wiped down the tubing, fastened the brief, pulled the gown down, and lowered the bed. She then removed her gloves and washed her hands. During an interview on 02/22/24 at 10:41 AM with CNA1 and CNA2, CNA2 confirmed the observation. CNA1 then stated that she typically provided catheter care for R1 daily and as needed when working and that the CNAs are responsible for catheter care, but Nurses provide the care as well. CNA1 acknowledged that R1 did not have a securement device in place and did not place one during the observation nor did she adjust R1's foley to unkink the line. During an interview on 02/22/24 at 11:05 AM with the Director of Nursing (DON), the DON stated that it is her expectations that the CNAs follow policy when providing catheter care and that it should be daily and as needed.

Based on a review of the facility policy, record reviews, and interviews, the facility failed to protect 1 of 1 residents from sexual abuse. Resident (R)1 inappropriately touched R2 on 08/28/2023 at approximately 5:20 p.m. This was observed by staff members. On 09/01/2023 at 05:30 pm, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 09/01/2023 at 05:30 pm, the survey team presented the Administrator with the Immediate Jeopardy (IJ) template, notifying her that the failure to protect R2 from sexual abuse by R1 constituted IJ at F600 with the start date of 08/28/2023. The facility presented an acceptable removal plan for F600 on 09/01/2023 via email. The SA returned to the facility on [DATE] to verify the removal of the IJ. Following a review of the facility's implementation plan, along with a review of audits, education, and interviews, the IJ was verified as removed as of 09/01/2023 and the facility remained out of compliance at a scope and severity level at D. An extended survey was conducted in conjunction with the complaint survey constituting substandard quality of care. Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revised 10/01/2020, states Sexual abuse is non-consensual sexual contact of any type with a resident. C- Rape, Molestation, or other inappropriate sexual behavior against a resident such as Sexual harassment, Sexual assault, Sexual Coercion, or Inappropriate sexual behaviors displayed by and/or toward incapable resident. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia with other behavioral disturbances and cognitive communication deficit. R1 scored a Brief Interview of Mental Status (BIMS) of 07 out of 15, indicating severe cognitive impairment, as of 07/26/2023 on quarterly Minimum Data Set (MDS). Review of R1's Physician orders revealed R1 had an order for 1:1 supervision with a start date of 07/13/2023. A policy was requested for 1:1 supervision, however, the facility Administrator stated there was no policy related to 1:1 supervision. R1 had been care-planned since 07/31/2023 for Unwanted touching of female and entering other resident's rooms without permission. Interventions included redirection, visits with psychiatric services, and Gradual Dose Reduction (GDR) attempts. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, cognitive communication deficit and major depressive disorder. R2 scored a BIMS of 11 out of 15 indicating she was moderately, cognitively impaired as of 08/02/2023 on a quarterly MDS. An interview with the Facility Administrator and DON (Director of Nursing) on 09/01/2023 at 12:40 PM revealed that they were informed by the agency nurse who worked the floor that she had witnessed R1 in R2's room with his hand on her breast, outside of clothing, while R2 was resting, and was not aroused. There was no evidence of the resident making inappropriate comments. The DON stated that R1 did not attempt to remove any of her clothing and that R1 has a history of using physical touch to communicate. The DON stated that two (2) staff members were suspended for failure to provide R1 with 1:1 supervision. The scheduler pulled the 2nd shift sitter to work a group setting because R1 was going to have a decrease on 1:1 due to behaviors improving. The 7-3 sitter clocked out early due to her relief showing up. The DON also stated that a review of the Resident's Psych notes confirms that the resident is being seen for impulse control. The DON also stated that clarification of staff interviews related to inappropriate touching reveals resident will use terms such as dear, baby, honey when addressing staff and places his hand on the female hip and/or lower back. The DON stated that R1 has a tendency to become irate and agitated when questioned because he believes that his behaviors are appropriate, and gestures are his normal way of communicating. The DON stated that psych services continue to reinforce accountability and work on impulsive behaviors. The DON stated that R2, who was the victim has a BIMS of 9 and was startled upon the male resident being in the room. R2 was easily calmed down by staff when staff saw and immediately removed R1 from the room. DON stated that Social Services Director did refer R2 to psych services due to initial trauma from waking up and being startled. DON stated that R1 was discharged home the next day, 08/29/2023 into the custody of his brother and R2 remains at baseline and followed by psych services as a preventative measure. In an interview with R2 on 09/01/2023 at 1:55 PM she revealed, I was sleeping, and he was kissing me in my mouth, he touched me (pointing at both breasts), I woke up scared and said, You got to go, and he did not leave. R2 stated that two staff members saw R1 and pulled R1 out of the room and started checking me. R2 stated that she fears for her life, she can't sleep, and every time she closes her eyes, she sees him. R2 stated that staff comes in to visit and try to cheer her up, however, she just wants to go home. The Social Services Director was unavailable for interview. A phone interview with Licensed Practical Nurse (LPN)1 on 09/01/2023 at 02:38 PM revealed that R1 was on 1:1 supervision when the incident occurred. LPN1 stated that she was walking with R1 at the nurse's station and turned around to talk to another staff member for less than 30 seconds and when she (LPN1) turned around to check on R1, he was gone. LPN1 stated that she started searching for him due to wandering behaviors and she (LPN1) located R1 in R2's room in his wheelchair, on the right side of R2's bed, with his hand on R2's right breast, over her clothing. LPN1 stated that R2 stated Get off of me, and immediately removed R1 from the room and notified another nurse to report it to the DON. The facility's removal plan included: Staff and resident interviews did not reveal any other concerns, completed on 08/28/2023. Re-Education on Abuse, Neglect, and Misappropriation and Abuse policy to staff. This re-education will be completed by 09/01/2023. Any staff member not receiving this education by this date will receive it prior to the next scheduled shift. DON or Social Services will review the resident's reported inappropriate behaviors in the clinical morning meeting Monday-Friday to validate that safety interventions are appropriate and in place to maintain a safe environment. The administrator will review monitored information and the clinical morning meeting agenda with identified changes of condition/signs and symptoms of trauma, including grief weekly for 4 weeks then monthly for two months. Ad-hoc QAPI held on 08/29/2023. The Medical Director was notified of the incident and plan for improvement on 08/29/2023 (via phone call). The results of the monitoring will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations for a period of 3 months. Concerns identified will be addressed at the time of discovery.

Based on interviews, record review, and review of facility policy, the facility failed to provide and document sufficient preparation and orientation to a resident to ensure safe and orderly discharge from the facility for 1 of 1 residents reviewed for discharge. Specifically, Resident (R)1, nor his representative was adequately prepared or informed of R1's discharge from the facility. On 09/01/23 at 5:30 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 09/01/23 at 5:30 PM, the survey team presented the Administrator with the Immediate Jeopardy (IJ) template, notifying her that the failure to ensure a proper and safe discharge for R1 constituted IJ at F624 with a start date of 08/29/23. The facility presented an acceptable removal plan for F624 on 09/01/23 via email. The survey team returned to the facility on [DATE] to verify the removal of the IJ. Following a review of the facility's implementation plan, along with a review of audits, education, and interviews, the IJ was verified as removed as of 09/01/23 and the facility remained out of compliance at a lower scope and severity level of D. Finding Include: Review of the facility policy titled Discharge Notification, with a complete revision date of 10/01/20, documented, All patients/residents will be discharged /transferred from the Facility by order of his/her attending physician, in a safe, secure and correct manner. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia with other behavioral disturbances, morbid obesity, diabetes mellitus, and cognitive communication deficit. Review of R1's Physician Orders revealed R1 received, Levemir FlexTouch U-100 Insulin (insulin determir u-100) 100 unit/mL (3 m/L) insulin pen twice a day 45 units, subcutaneous, twice a day, Depokote (divalproex) 250 mg tablet, delayed release (DR/EC), Enema (sodium phosphates) 19-7 gram/118 mL enema once a day - PRN (as needed), 19-7 gram/118ml, rectal, once a day - PRN, may have enema if no bowel movement x7 days, and nitroglycerin 0.4 mg tablet, sublingual, 1 tablet, sublingual, every shift - PRN, place 1 tablet under the tongue every 5 minutes as needed for chest pain. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/23 revealed R1's Brief Interview of Mental Status (BIMS) score of 7 out of 15, indicating R1 was severely cognitively impaired. Review of R1's functional status revealed R1 required limited assistance with one person physical assist with Activities of Daily Living (ADL). Further review of the MDS revealed R1 utilizes an indwelling catheter and is occasionally incontinent of bowel. Documented under Medications revealed R1 received insulin injections during the last 7 days. The MDS also indicated that R1 has no guardian or legally authorized representative. Review of R1's discharge MDS with an ARD of 08/29/23 revealed R1 was discharged on [DATE] and indicated the type of discharge was Planned. The MDS indicated R1 was discharged to the community. Further review of the MDS revealed R1 required physical help in part of bathing activity. R1 was not rated for urinary continence due to R1 having a catheter, urinary ostomy, or no urine output. The MDS documented that R1 was occasionally incontinent of bowel. Review of R1's Care Plan dated problem start date 07/31/23, revealed the following, [R1] has not had a fall but he is at risk due to psychoactive medication use and unsteadiness in transitions. He has dx [diagnosis] of dementia. ADL/Dental/Vision; [R1] has teeth with some in poor appearance. He has not c/o [complaints of] mouth or teeth pain. He has impaired hearing and vision. [R1] scored 7 on his BIMS, has impaired cognitive skills with impaired memory recall and he requires supervision. He has unclear speech but is able to make concrete requests and he responds adequately to simple direct communication and he has dx of Dementia AND bilateral conductive hearing loss. [R1] is at risk for infection r/t [related to] use of foley catheter. He has dx of urinary retention/obstructive uropathy. [R1] is at risk for medication side effects r/t psychotropic drug use. he has dx of dementia and depression. [R1] has potential for fluctuating of blood pressure, headaches, lightheadedness/dizziness r/t dx of hypertension/hypotention. Review of R1's Social Service Review dated 07/27/23 revealed R1 has severe impairment with behaviors of wandering and removing catheter from privacy bag. The Social Service Review also indicated under Discharge Planning, Remain in facility. Review of R1's Discharge Summary dated 08/29/23 revealed R1 is Discharge per facility. He is being discharged per facility order due to behavioral issues, he is to be picked up by his son today. The Discharge Summary further documented, Follow up with PCP in 30 day. and Needs to follow up with urology regarding long term foley catheter or alternatives for treatment of urinary retention. Review of R1's Progress Note dated 08/29/23 at 11:21 AM documented, Resident discharged and left facility via transport to brothers house. Transport driver called and notified facility that resident was dropped off at brothers home. In an interview on 09/01/23 at 12:11 PM, R1's representative (RR1) revealed the facility called him the day of and stated that the resident went into another resident's room and touched her inappropriately. RR1 stated that the resident likes to talk with his hands. The facility told him They needed to pick the resident up right now or they are kicking him out. RR1 stated he couldn't pick him up, which he was not in agreement with because the resident was supposed to stay long-term. RR1 stated, The only thing the facility was concerned about was where to send him because they were kicking him out. RR1 further stated that he is active in his brother's care and participated in his care plan meeting and a discharge was not discussed. An attempted interview with the Social Services Director was unsuccessful. An attempted interview with R1's Physician was unsuccessful. In a follow up interview on 09/01/23 at 4:08 PM, RR1 stated, That night they called me and told me I needed to come get him right now. I told them I have no means to take care of him or pick him up. They said they could put him in an Uber the next day. I called them back the next morning and they said they sent him about 15 mins ago. He arrived in a transport van, he had a Walmart bag full of medicine. He can't take his own medication. They (the facility) didn't provide me with any education or anything. He arrived in a broken wheelchair, and I called 911 to pick him up. Because I couldn't take care of him. He is currently in room L502 at the local hospital. I had a couple phone meetings with the facility about updates, we never discussed any discharge plans for him. They literally kicked him out and I didn't know he left until I called and they said he was 15 minutes out. In an interview on 09/01/23 at 5:00 PM, R1's Nurse Practitioner (NP) stated, I was told by the facility that they were getting him out of the facility. I was told that he was going home with his son. I was not informed that the resident was not able to be cared for upon discharge. This is the first time I have dealt with a situation like this. Normally people are set up with home health and physical therapy and have a plan for discharge. I was not aware of the full situation, I was told that they were going home and it was a quick discharge given the situation. I was under the impression that family was going to be caring for him. On 09/01/23 the facility provided a removal plan which included the following: Notification to resident responsible party on 08/28/2023 RP agreed to accept custody of resident and requested facility arrange transportation. Primary Care Physician notified of event on 08/28/2023 and order received to discharge resident to RP brothers care On 8/28/23 via phone with RP DON offered to set up home health care and RP declined, stated he would use family PCP. Transportation arranged on 8/29/23 [R1] discharged on [DATE] to care of POA with additional catheter kit, medications, personal belongs. Social services attempted to set up additional home health services with RP on 8/31/23 via phone, no answer- message left. Residents who have been discharged in past 48 hours have been reviewed to validate safe, orderly transfer/discharge. 1 resident identified and has transferred back to facility no concerns. Re-education facility staff responsible for discharge planning (Administrator, Social Services, DON, Therapy Director, Medical Supply) will be completed by 9/1/23. Any staff member not receiving this education by this date will receive prior to next scheduled shift. DON, Social Services and Administrator will review anticipated discharges in morning meeting Monday-Friday times 3 months to identify preparation for safe, orderly transfer/discharge. The Administrator will review monitored information with identified changes of for 4 weeks then monthly for 2 months. Ad-hoc QAPI held on 09/01/23. Medical Director was notified of the incident and plan for improvement on 9/1/23 (via phone call). Results of the monitoring will be presented to the Quality Assurance Performance Improvement committee for review and recommendations for a period of 3 months. Concerns identified will be addressed at time of discovery.

Based on observations, record review, interviews, and the review of the facility's policy titled Abuse, Neglect, Exploitation and Mistreatment, the facility failed to prevent a successful elopement for 1 of 3 residents reviewed for Neglect. Resident (R)1 had a successful elopement from the facility on 05/09/23 at an unspecified time and was without supervision for an extended period of time. R1 was found by the police at the baseball field, across the street from the facility on 05/09/23 around 08:50 PM and at 9:00 PM Licensed Practical Nurse (LPN)2 went to the baseball field and returned R1 back to the facility. On 5/16/23 at approximately 10:00 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 5/16/23 at 10:50 AM, the Administrator was notified that the allegation of elopement for R1 constituted Immediate Jeopardy (IJ) at F600 and the IJ template was presented. On 5/16/23 at 3:31 PM, the facility provided an acceptable plan of removal for the IJ. The IJ was lowered to a scope and severity of D for no actual harm with potential for more than minimal harm, that is not immediate jeopardy. An extended survey was conducted on 5/16/23 due to the failure constituting substandard quality of care. The facility's implemented removal plan included required facility wide training, along with in-services to be conducted, beginning 5/16/23 related to elopement/neglect. Findings include: Review of the facility's policy Abuse, Neglect,, Exploitation, or Mistreatment, with a revision date of 11/1/17 revealed The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. R1 was admitted to the facility on [DATE] from an acute care hospital. Review of R1's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he is cognitively intact. R1 has diagnoses including but not limited to; age-related physical debility, acquired absence of left leg, and muscle weakness. R1 requires assistance with activities of daily living (ADL)s. Review of R1's care plan revealed no evidence related to R1's ability to sign himself out of the facility, unsupervised. Review of R1's Physician Orders did not indicate an order allowing R1 to sign himself out. An observation of R1 on 5/15/23 at 06:42 PM revealed R1 was appropriately dressed without odors noted. Review of R1's elopement assessment dated [DATE] revealed R1 was not at risk for elopement/wandering at this time. There was no other elopement assessment made available at the time of the survey. During an interview on 5/15/23 at 6:15 PM, LPN1 reported that R1 did not elope from the facility. She stated he is alert and oriented and is capable of signing himself in and out of the facility. On this day, he signed himself out and went to the ball game. LPN1 reported that R1 is not an elopement risk. During an interview on 5/15/23 at 6:42 PM, R1 revealed he left the facility and failed to sign himself out when he left. He stated he wanted to watch the baseball game and the police was called and this was the first time something like this has occurred. R1 reported he was fussed at by staff for not signing himself out to attend the ball game. During an interview on 5/15/23 at 6:50 PM, the Administrator stated that R1 did not elope from the facility. She stated, R1 signed himself out of the facility and has a BIMS of 13 or 15. She reported that she received a phone call from the on-call nurse reporting that R1 was across the street at the ball game and saw a former nurse of the facility, who called the police and R1 did not understand why this occurred since he had previously watched the games. During an interview on 5/15/23 at 8:43 PM, LPN2 reported to be R1's nurse on the night of the elopement and she was not aware that R1 was not in the facility. She reported passing medications on D hall and was going to pass some of the meds on C hall, as she and another nurse split that hall and she reported hearing staff say R1 was at the baseball game on 5/9/23. She reported working the 7:00 PM -7:00 AM shift and learned at 8:50 PM that R1 was not in the facility and walked over to the ball game get him at 9:00 PM. She reported she pushed him back in his wheelchair. During an interview on 5/16/23 at 09:45 AM the DON reported R1 had 2 elopement assessments in the system. The DON reported getting a call at 9:30 PM on 5/9/23 from the Administrator informing her that a resident had left the facility. She was unsure at this time what resident had left the facility. The DON reported she called the facility and asked who was out of the building and a nurse reported that R1 was not in facility and had signed himself out and at this time this was all over Facebook. The DON stated, The receptionist at the front desk put the code in to allow R1 to leave and this would have occurred before 8:00 PM. The DON reported that when residents leave the facility, they ring the doorbell to come back into the facility. The DON said the facility interprets R1's leaving the facility as a leave of absences and not an elopement. During an interview on 5/16/23 at 11:15 AM, the Receptionist revealed that R1 went to the front door and told her he had signed himself out of the facility at the nurse' station. The Receptionist could not confirm the time R1 left and estimated it to be between 6:00 and 6:30 PM on 5/9/23. The Receptionist was asked what time R1 returned to the facility, and she reported prior to her leaving for the day, which is between 8:00 PM and 8:05 PM. The Receptionist confirmed she does not verify with the nurses' station if a resident signs out, she takes their word. She also confirmed she did not notify anyone of R1 being out of the building. Review of the Leave of Absence (LOA) sign in/out log revealed a signature, however, it indicated a time of 8:02, with no indication of AM/PM. The Receptionist confirmed R1 was supposed to be back in the facility prior to her leaving, so she was unsure how he got back out of the facility. During an interview on 5/16/23 at 1:06 PM, the Social Worker (SW) reported being advised about R1 leaving the facility on 5/10/23 when she reported to work. She said R1 went to a baseball game. She said I do not get any information about him signing himself out, just that he was found at the baseball field and no time given. The SW reported not being aware of R1 going to the games. The facility's removal plan included: 1. R1 has a BIMS level 15 reviewed on 05/09/23 and was reviewed by Nurse Practitioner on 05/16/23, no concerns with LOA privileges. 2. Review of Sign in/Sign out LOA log revealed R1 signed out 8:02 on 05/09/23. 3. Facility staff completed an audit of all the remaining residents. All residents were accounted for on 05/09/23. 4. Phone interview completed with evening receptionist. Statement obtained. Resident did not elope independently, signed LOA. Receptionist allowed him to leave. 5. Exit doors locked and secure. Audit revealed exits secure, environment safe. 6. Residents at risk for elopement accounted for with wanderguard in place. 7. R1 re-educated on LOA process, verbalized understanding. 8. Staff re-educated on LOA process with focus on checking sign in/out binder to validate in house census. 9. Re-education on F600/F689. Staff not present will received prior to next scheduled shift after 05/16/23. -Residents at risk for elopement have the potential to be affected. Residents at risk for elopement accounted for with wanderguard in place. -Capable residents with a BIMS of 15 or higher with privileges will be re-educated on LOA process. -The DON will randomly interview a minimum of 2 staff and 2 capable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with LOA sign in/out process. -The Maintenance Director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. -The Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with Maintenance Director to validate that doors are functioning properly. -Adhoc QAPI held on 05/16/23. This process will be reviewed in QAPI for a minimum of 3 months.

Based on observations, record review, interviews, and the review of the facility's policy, the facility failed to provide adequate supervision to prevent a successful elopement for 1 of 3 residents reviewed for accidents. Resident (R)1 had a successful elopement from the facility on 05/09/23 at an unspecified time and was without supervision for an extended period of time. R1 was found by the police at the baseball field, across the street from the facility on 05/09/23 around 08:50 PM and at 9:00 PM Licensed Practical Nurse (LPN)2 went to the baseball field and returned R1 back to the facility. On 5/16/23 at approximately 10:00 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 5/16/23 at 10:50 AM, the Administrator was notified that the allegation of elopement for R1 constituted Immediate Jeopardy (IJ) at F689 and the IJ template was presented. On 5/16/23 at 3:31 PM, the facility provided an acceptable plan of removal for the IJ. The IJ was lowered to a scope and severity of D for no actual harm with potential for more than minimal harm, that is not immediate jeopardy. An extended survey was conducted on 5/16/23 due to the failure constituting substandard quality of care. Findings include: Review of the facility's policy titled, Leadership Policies and Procedure subject Elopement, last revised November 1, 2017, revealed, To safely and timely redirect patients/residents to a safe enviroment. R1 was admitted to the facility on [DATE] from an acute care hospital. Review of R1's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he is cognitively intact. R1 has diagnoses including but not limited to; age-related physical debility, acquired absence of left leg, and muscle weakness. R1 requires assistance with activities of daily living (ADL)s. Review of R1's care plan revealed no evidence related to R1's ability to sign himself out of the facility, unsupervised. Review of R1's Physician Orders did not indicate an order allowing R1 to sign himself out. An observation of R1 on 5/15/23 at 06:42 PM revealed R1 was appropriately dressed without odors noted. During an interview on 5/15/23 at 6:15 PM, LPN1 reported that R1 did not elope from the facility. She stated he is alert and oriented and is capable of signing himself in and out of the facility. On this day, he signed himself out and went to the ball game. LPN1 reported that R1 is not an elopement risk. During an interview on 5/15/23 at 6:42 PM, R1 revealed he left the facility and failed to sign himself out when he left. He stated he wanted to watch the baseball game and the police was called and this was the first time something like this has occurred. R1 reported he was fussed at by staff for not signing himself out to attend the ball game. During an interview on 5/15/23 at 6:50 PM, the Administrator stated that R1 did not elope from the facility. She stated, R1 signed himself out of the facility and has a BIMS of 13 or 15. She reported that she received a phone call from the on-call nurse reporting that R1 was across the street at the ball game and saw a former nurse of the facility, who called the police and R1 did not understand why this occurred since he had previously watched the games. During an interview on 5/15/23 at 8:43 PM, LPN2 reported to be R1's nurse on the night of the elopement and she was not aware that R1 was not in the facility. She reported passing medications on D hall and was going to pass some of the meds on C hall, as she and another nurse split that hall and she reported hearing staff say R1 was at the baseball game on 5/9/23. She reported working the 7:00 PM -7:00 AM shift and learned at 8:50 PM that R1 was not in the facility and walked over to the ball game get him at 9:00 PM. She reported she pushed him back in his wheelchair. During an interview on 5/16/23 at 09:45 AM the DON reported R1 had 2 elopement assessments in the system. The DON reported getting a call at 9:30 PM on 5/9/23 from the Administrator informing her that a resident had left the facility. She was unsure at this time what resident had left the facility. The DON reported she called the facility and asked who was out of the building and a nurse reported that R1 was not in facility and had signed himself out and at this time this was all over Facebook. The DON stated, The receptionist at the front desk put the code in to allow R1 to leave and this would have occurred before 8:00 PM. The DON reported that when residents leave the facility, they ring the doorbell to come back into the facility. The DON said the facility interprets R1's leaving the facility as a leave of absences and not an elopement. During an interview on 5/16/23 at 11:15 AM, the Receptionist revealed that R1 went to the front door and told her he had signed himself out of the facility at the nurse' station. The Receptionist could not confirm the time R1 left and estimated it to be between 6:00 and 6:30 PM on 5/9/23. The Receptionist was asked what time R1 returned to the facility, and she reported prior to her leaving for the day, which is between 8:00 PM and 8:05 PM. The Receptionist confirmed she does not verify with the nurses' station if a resident signs out, she takes their word. She also confirmed she did not notify anyone of R1 being out of the building. Review of the Leave of Absence (LOA) sign in/out log revealed a signature, however, it indicated a time of 8:02, with no indication of AM/PM. The Receptionist confirmed R1 was supposed to be back in the facility prior to her leaving, so she was unsure how he got back out of the facility. During an interview on 5/16/23 at 1:06 PM, the Social Worker (SW) reported being advised about R1 leaving the facility on 5/10/23 when she reported to work. She said R1 went to a baseball game. She said I do not get any information about him signing himself out, just that he was found at the baseball field and no time given. The SW reported not being aware of R1 going to the games. The facility's removal plan included: 1. R1 has a BIMS level 15 reviewed on 05/09/23 and was reviewed by Nurse Practitioner on 05/16/23, no concerns with LOA privileges. 2. Review of Sign in/Sign out LOA log revealed R1 signed out 8:02 on 05/09/23. 3. Facility staff completed an audit of all the remaining residents. All residents were accounted for on 05/09/23. 4. Phone interview completed with evening receptionist. Statement obtained. Resident did not elope independently, signed LOA. Receptionist allowed him to leave. 5. Exit doors locked and secure. Audit revealed exits secure, environment safe. 6. Residents at risk for elopement accounted for with wanderguard in place. 7. R1 re-educated on LOA process, verbalized understanding. 8. Staff re-educated on LOA process with focus on checking sign in/out binder to validate in house census. 9. Re-education on F600/F689. Staff not present will received prior to next scheduled shift after 05/16/23. -Residents at risk for elopement have the potential to be affected. Residents at risk for elopement accounted for with wanderguard in place. -Capable residents with a BIMS of 15 or higher with privileges will be re-educated on LOA process. -The DON will randomly interview a minimum of 2 staff and 2 capable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with LOA sign in/out process. -The Maintenance Director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. -The Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with Maintenance Director to validate that doors are functioning properly. -Adhoc QAPI held on 05/16/23. This process will be reviewed in QAPI for a minimum of 3 months.

Based on review of the facility's policy titled, Abuse, Neglect and Exploitation, record review, and interviews, the facility failed to ensure Resident (R)1 was free from neglect related to elopement. R1 had a successful elopement from the facility on 04/07/23 at 7:15 AM. On 04/07/23 at 7:15 AM R1 was found by Certified Nursing Assistant (CNA)1, walking on a local street, near a local BBQ restaurant and Hardees. R1 was found approximately 0.7 miles from the facility, which was a 7 minute brisk walk according to Apple Maps. R1 was observed wearing a white t-shirt, pajama bottoms, and construction like boots. R1 was not wearing a jacket or hat. The temperature outside on 04/07/23 at 6:53 AM was 66 degrees Fahrenheit and a 3 mile per hour wind speed. CNA1 stated, It was chilly that morning and I had a coat on when I was on the way to work that morning. On 04/10/23 at 4:23 PM, an Immediate Jeopardy (IJ) template was presented to the Administrator and Director of Nursing (DON), notifying them that an IJ existed at F600 with an effective date of 04/07/23. On 04/11/23 at 4:00 PM , the facility presented an acceptable IJ Removal Plan. The immediacy of the IJ was removed on 04/11/23. The IJ was lowered to a scope and severity of D (no actual harm with potential for more than minimal harm). The facility's failure constituted substandard quality of care at F600 and an extended survey was conducted on 04/11/23. Findings include: Review of the undated facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed The facilities leadership prohibits neglect, mental, physical, and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds ensure and all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately. R1 was admitted to the facility on [DATE] with the diagnosis including but not limited to; type 2 diabetes, acute osteomyelitis (right ankle and foot), anxiety disorder, dementia with behavioral disturbances, and chronic kidney disease. According to the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/23, R1 has a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicates R1 has severe cognitive impairment. Review of R1's Care Plan dated 01/24/23 revealed, history of wandering through out the facility. Resident is a risk for elopement; entering into others private space; increased fall risk; rejection of care; and moving furniture in the hallway related to diagnosis of dementia and stroke. Review of R1's Progress Note dated 04/07/23 at 7:45 AM revealed, resident sitting on bed in his room, resident alert and confused. No acute distress noted, resident does not recall leaving the facility nor returning with staff member. When asked where his electronic monitoring system was at, resident lifted his right leg and said 'I don't know'. Electronic monitoring system already replaced on left ankle. Review of R1's Progress Note dated 04/07/23 at 5:45 PM revealed This writer was receiving report from oncoming nurse when C.N.A. brought resident to desk and stated he was off premises, and she brought the resident back to the facility. Resident has asked staff in the past to remove the electronic monitoring device from ankle and has history of exit seeking. This writer assessed resident and he was not in any distress, no visible signs of injury but the electronic monitoring device was not in place. This writer replaced the electronic monitoring system to left ankle and order was updated in electronic medical record. Resident stated 'I was going to work', this writer made sure his Resident Representative was aware of the elopement and Nurse Practitioner. An interview on 04/10/23 at 11:07 AM with the Director of Nursing (DON) revealed, the resident was found by CNA1 on 04/07/23 around 7:15 AM, away from the premises of the facility. CNA1 was on the way to work and recognized the resident and brought him back to the facility. R1 was accounted for at approximately 7:00 AM by Licensed Practical Nurse (LPN)2 and other staff. LPN2 and the Wound Nurse assessed the resident, and he had no signs of distress or injury. R1 had an electronic monitoring system due to his high risk of elopement however, during the time of elopement the device was not on the resident. R1 must have taken it off but unsure of when or how long it's been off. An interview on 04/10/23 at 11:18 AM with the Wound Nurse/ Licensed Practical Nurse (LPN)1 revealed, they received a call on the way to work that R1 had eloped from the facility. When they arrived to work the resident was back at the facility in his room agitated and looking for his work boots (believing that he had to go to work). They were able to redirect the resident and did a body audit, the resident had no injuries and showed no sign of distress. LPN1 stated, I work with the resident several times a week (Monday - Thursday) because he has a surgical wound on his right great toe, I think I saw his electronic monitoring system on his left leg on Monday and Tuesday, but I can't remember if I saw it during the later days of the week. An interview on 04/10/23 at 11:32 AM with CNA1 revealed, CNA1 observed R1 attempting go across a very busy street in town. R1 had recognized CNA1 and was willing to return to the facility with CNA1. R1 has issues with his feet and has difficulty walking, R1 walks slow but can ambulate without assistance. A phone Interview on 04/10/23 at 1:05 PM with LPN2 revealed, I was receiving a report from another (LPN3) when CNA1 had come into work with R1 and said that she found him close to Hardees and brought him back to the facility. The LPN that was giving me the report about the night before (LPN3) was unaware that R1 was outside and not at the facility. I assessed R1 and noticed that he no longer had an electronic monitoring system on. I put it on him in December of 2022. I put another electronic monitoring system on the resident and did a body audit and the resident had no signs of injury or distress. I spoke with the resident's niece and made her aware of the situation. A phone interview with R1's Resident Representative (RR) on 04/10/23 at 2:02 PM revealed, LPN2 had notified them that the resident had eloped from the facility on 04/07/23 around 11:00 AM. Staff told her that a CNA had saw the resident walking nearby on a side street and brought him back to the facility. The LPN explained to her that R1 was able to exit the building because it was in the middle of a shift change with night shift and day shift leaving the facility. R1 must have walked out of the front door because at that time the front door is unlocked for staff and visitors. The LPN also explained that R1 was supposed to have on an electronic monitoring system but must have taken it off. R1's RR stated, I've been at the facility and have noticed R1 wearing an electronic monitoring system but can't remember if I saw it during my last visit about a month ago, but I also wasn't looking of it specifically. I have seen him have one in previous visits. A phone interview on 04/10/23 at an unspecified time, with CNA2 revealed, CNA2 worked the night into the day shift of 04/7/23. R1 was one of my residents and when the other CNA and I were completing our last set of rounds around 4:30 or 4:45 AM that morning, R1 was in his bed. R1's room is located on the C unit and we started our rounds on that side of the building with his room first and finished on the A unit. It is possible that he was able to leave while we were rounding on other residents because I think the front doors unlock at 5:30 AM. I never heard an alarm go off that night so he must have not had on his electronic monitoring system. I got a call when I was off and already left the facility that R1 was found walking down a side-street near the facility. Multiple attempts were made to contact LPN 3 on 04/10/23 and 04/11/23 with no success. The facility's removal plan for F600 included the following: 1. R1 has a Brief Interview of Mental Status (BIMS) score of 3 and was assessed upon arrival at the facility with no injuries noted. A complete body audit was done by the Wound Care Nurse and R1 with no abnormalities noted. 2. Facility staff completed an audit of all the remaining residents; all residents were accounted for. 3. Maintenance checked all exit doors to ensure they were secure. The windows in residents' rooms were checked to ensure that they would not open fully. Nurses performed checks on all residents with an electronic monitoring device to ensure proper functioning. 4. Residents at risk for elopement had an elopement evaluation repeated, clinical manager evaluated all residents for elopement risk. 5. R1's electronic monitoring device had been removed, the new device was placed, and the order was updated to reflect the new placement of the device. 6. Staff re-educated on monitoring the electronic monitoring device for R #1 and all residents who are at elopement risk. 7. The Medical Director (MD) and Resident Representative were notified of R #1 elopement and the ongoing need for an electronic monitoring device. 8. R1 was evaluated, no emotional distress was noted. 9. R1 Care Plan was reviewed for accuracy and updated as appropriate. 10. Elopement risk evaluations done in the past 60 days on current residents in the facility were reviewed by nursing managers for accuracy. Residents identified as at risk will be reviewed for appropriate interventions. 11. New admissions will be reviewed in the morning meeting daily Monday - Friday as part of the clinical morning meeting process. Elopement risk assessments will be reviewed for accuracy and interventions validated if indicated. Quarterly assessments will be reviewed as part of the Minimum Data Set/ Care planning process. 12. The DON will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy. 13. The Maintenance Director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. 14. The Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with the Maintenance Director to validate that doors are functioning properly.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure adequate supervision was provided to prevent accidents/hazards for 1 of 3 Residents (R)1, reviewed. On 04/07/23, R1 had a successful elopement from the facility. On 04/07/23 at 7:15 AM R1 was found by Certified Nursing Assistant (CNA)1, walking on a local street, near a local BBQ restaurant and Hardees. R1 was found approximately 0.7 miles from the facility, which was a 7 minute brisk walk according to Apple Maps. R1 was observed wearing a white t-shirt, pajama bottoms, and construction like boots. R1 was not wearing a jacket or hat. The temperature outside on 04/07/23 at 6:53 AM was 66 degrees Fahrenheit and a 3 mile per hour wind speed. CNA1 stated, It was chilly that morning and I had a coat on when I was on the way to work that morning. On 04/10/23 at 4:23 PM, an Immediate Jeopardy (IJ) template was presented to the Administrator and Director of Nursing (DON), notifying them that an IJ existed at F689 with an effective date of 04/07/23. On 04/11/23 at 4:00 PM , the facility presented an acceptable IJ Removal Plan. The immediacy of the IJ was removed on 04/11/23. The IJ was lowered to a scope and severity of D (no actual harm with potential for more than minimal harm). The facility's failure constituted substandard quality of care at F689 and an extended survey was conducted on 04/11/23. Findings include: Record review of facility policy titled Leadership Policies and Procedures: Elopement last revised 11/01/17 revealed, To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code 'Code White' to designate a missing patient/resident. R1 was admitted to the facility on [DATE] with the diagnosis including but not limited to; type 2 diabetes, acute osteomyelitis (right ankle and foot), anxiety disorder, dementia with behavioral disturbances, and chronic kidney disease. According to the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/23, R1 has a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicates R1 has severe cognitive impairment. Review of R1's Care Plan dated 01/24/23 revealed, history of wandering through out the facility. Resident is a risk for elopement; entering into others private space; increased fall risk; rejection of care; and moving furniture in the hallway related to diagnosis of dementia and stroke. Review of R1's Progress Note dated 04/07/23 at 7:45 AM revealed, resident sitting on bed in his room, resident alert and confused. No acute distress noted, resident does not recall leaving the facility nor returning with staff member. When asked where his electronic monitoring system was at, resident lifted his right leg and said 'I don't know'. Electronic monitoring system already replaced on left ankle. Review of R1's Progress Note dated 04/07/23 at 5:45 PM revealed This writer was receiving report from oncoming nurse when C.N.A. brought resident to desk and stated he was off premises, and she brought the resident back to the facility. Resident has asked staff in the past to remove the electronic monitoring device from ankle and has history of exit seeking. This writer assessed resident and he was not in any distress, no visible signs of injury but the electronic monitoring device was not in place. This writer replaced the electronic monitoring system to left ankle and order was updated in electronic medical record. Resident stated 'I was going to work', this writer made sure his Resident Representative was aware of the elopement and Nurse Practitioner. An interview on 04/10/23 at 11:07 AM with the Director of Nursing (DON) revealed, the resident was found by CNA1 on 04/07/23 around 7:15 AM, away from the premises of the facility. CNA1 was on the way to work and recognized the resident and brought him back to the facility. R1 was accounted for at approximately 7:00 AM by Licensed Practical Nurse (LPN)2 and other staff. LPN2 and the Wound Nurse assessed the resident, and he had no signs of distress or injury. R1 had an electronic monitoring system due to his high risk of elopement however, during the time of elopement the device was not on the resident. R1 must have taken it off but unsure of when or how long it's been off. An interview on 04/10/23 at 11:18 AM with the Wound Nurse/ Licensed Practical Nurse (LPN)1 revealed, they received a call on the way to work that R1 had eloped from the facility. When they arrived to work the resident was back at the facility in his room agitated and looking for his work boots (believing that he had to go to work). They were able to redirect the resident and did a body audit, the resident had no injuries and showed no sign of distress. LPN1 stated, I work with the resident several times a week (Monday - Thursday) because he has a surgical wound on his right great toe, I think I saw his electronic monitoring system on his left leg on Monday and Tuesday, but I can't remember if I saw it during the later days of the week. An interview on 04/10/23 at 11:32 AM with CNA1 revealed, CNA1 observed R1 attempting go across a very busy street in town. R1 had recognized CNA1 and was willing to return to the facility with CNA1. R1 has issues with his feet and has difficulty walking, R1 walks slow but can ambulate without assistance. A phone Interview on 04/10/23 at 1:05 PM with LPN2 revealed, I was receiving a report from another (LPN3) when CNA1 had come into work with R1 and said that she found him close to Hardees and brought him back to the facility. The LPN that was giving me the report about the night before (LPN3) was unaware that R1 was outside and not at the facility. I assessed R1 and noticed that he no longer had an electronic monitoring system on. I put it on him in December of 2022. I put another electronic monitoring system on the resident and did a body audit and the resident had no signs of injury or distress. I spoke with the resident's niece and made her aware of the situation. A phone interview with R1's Resident Representative (RR) on 04/10/23 at 2:02 PM revealed, LPN2 had notified them that the resident had eloped from the facility on 04/07/23 around 11:00 AM. Staff told her that a CNA had saw the resident walking nearby on a side street and brought him back to the facility. The LPN explained to her that R1 was able to exit the building because it was in the middle of a shift change with night shift and day shift leaving the facility. R1 must have walked out of the front door because at that time the front door is unlocked for staff and visitors. The LPN also explained that R1 was supposed to have on an electronic monitoring system but must have taken it off. R1's RR stated, I've been at the facility and have noticed R1 wearing an electronic monitoring system but can't remember if I saw it during my last visit about a month ago, but I also wasn't looking of it specifically. I have seen him have one in previous visits. A phone interview on 04/10/23 at an unspecified time, with CNA2 revealed, CNA2 worked the night into the day shift of 04/7/23. R1 was one of my residents and when the other CNA and I were completing our last set of rounds around 4:30 or 4:45 AM that morning, R1 was in his bed. R1's room is located on the C unit and we started our rounds on that side of the building with his room first and finished on the A unit. It is possible that he was able to leave while we were rounding on other residents because I think the front doors unlock at 5:30 AM. I never heard an alarm go off that night so he must have not had on his electronic monitoring system. I got a call when I was off and already left the facility that R1 was found walking down a side-street near the facility. Multiple attempts were made to contact LPN 3 on 04/10/23 and 04/11/23 with no success. The facility's removal plan for F689 included the following: 1. R1 has a Brief Interview of Mental Status (BIMS) score of 3 and was assessed upon arrival at the facility with no injuries noted. A complete body audit was done by the Wound Care Nurse and R1 with no abnormalities noted. 2. Facility staff completed an audit of all the remaining residents; all residents were accounted for. 3. Maintenance checked all exit doors to ensure they were secure. The windows in residents' rooms were checked to ensure that they would not open fully. Nurses performed checks on all residents with an electronic monitoring device to ensure proper functioning. 4. Residents at risk for elopement had an elopement evaluation repeated, clinical manager evaluated all residents for elopement risk. 5. R1's electronic monitoring device had been removed, the new device was placed, and the order was updated to reflect the new placement of the device. 6. Staff re-educated on monitoring the electronic monitoring device for R #1 and all residents who are at elopement risk. 7. The Medical Director (MD) and Resident Representative were notified of R #1 elopement and the ongoing need for an electronic monitoring device. 8. R1 was evaluated, no emotional distress was noted. 9. R1's Care Plan was reviewed for accuracy and updated as appropriate. 10. Elopement risk evaluations done in the past 60 days on current residents in the facility were reviewed by nursing managers for accuracy. Residents identified as at risk will be reviewed for appropriate interventions. 11. New admissions will be reviewed in the morning meeting daily Monday - Friday as part of the clinical morning meeting process. Elopement risk assessments will be reviewed for accuracy and interventions validated if indicated. Quarterly assessments will be reviewed as part of the Minimum Data Set/ Care planning process. 12. The DON will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy. 13. The Maintenance Director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. 14. The Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with the Maintenance Director to validate that doors are functioning properly.

Based on observations, record review, interviews, and review of the facility's policy titled, Abuse, Neglect, Exploitation and Mistreatment, the facility failed to protect 1 Resident (R) of 3 residents reviewed for sexual abuse. R2 was observed sitting next to R1 with his hands on R1's breast. On 2/22/23 at approximately 4:02 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 2/22/23 at 4:15 PM, the Administrator and the Director of Nursing (DON) were notified that the allegation of sexual abuse for R1 by R2 constituted Immediate Jeopardy (IJ) at F600. The facility presented an acceptable plan of removal of the IJ on 2/22/23 at 6:20 PM. The survey team validated that the IJ was removed on 2/22/23 at 6:20 PM following the facility's implementation of the plan of removal of the immediate jeopardy. An extended survey was conducted on 2/22/23 due to the failure constituting substandard quality of care. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Mistreatment, last revised 11/1/17, revealed: Sexual abuse is non-consensual sexual contact of any type with a resident. Review of the electronic medical record (EMR) revealed R1 has diagnoses including but not limited to; cardiovascular disease, hypertension, type 2 diabetes, hyperlipidemia, chronic kidney disease and muscle weakness. Review of R1's Minimum Data Set (MDS) with an unspecified date revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating R1 is not cognitively intact. Review of R1's care plan revealed R1 had an incident with another resident with inappropriate sexual behavior. Listed goals were for staff to provide emotional support to minimize mood, behavior, or ADL (activities of daily living) care. Approaches were to ensure R1 has no contact with male residents, observe for signs and symptoms of decline in mood, behavior or ADLs, observe for changes in sleep patterns, mood, affect, eating or vital signs and provide 1:1 interaction PRN (as needed). Staff will utilize non-pharmacological interventions i.e., redirect, offer comfort and reassurance to R1. Review of R1's progress notes revealed a note timed and dated 2/19/23 at 5:59 PM, which read, At 3:20 pm staff stated they saw R1 being touched inappropriately. Body assessment done by Nurse. Nothing observed. Administrator and DON and Unit Manager aware. Responsible party is aware and in route to facility. Dr. is aware and no new orders. R2 was admitted to the facility with diagnoses including but not limited to; end stage renal disease, muscle weakness, type 2 diabetes, vascular dementia with behavioral disturbance, age-related nuclear cataract, right eye, and hypotension. Review of R2's care plan revealed a problem: Resident allegedly had an incident of inappropriate sexual behavior. The listed goal is R2 will not touch any resident inappropriately and will be monitored by staff thru next review date. Listed approaches were R2 will have 1:1 staff member, continue Psychotherapist services with Life Source Behavioral Health, encourage and praise appropriate behavior and acceptable comments and will have no contact with R1. Additional approaches are to observe for episodes of inappropriate behavior and redirect, provide for safety of resident involved and other female residents at facility and seek alternative placement for R2. Review of R2's MDS with an unspecified date revealed a BIMS score of 15, indicating R2 is cognitively intact. Review of R2's Progress Notes revealed a note dated 02/20/2023 03:32 AM, which read, R2 returned to CCC via ambulance x2 attendants. R2 is A&Ox4 and able to make needs known. R2 has been moved from D-8-2 to A-8-1. Since R2 returned to the facility, he has been disturbing other residents, yelling out in the hallways, and demanding for his needs to be met. I've explained to R2 that this move is temporary till the morning. R2 insists he goes back to his room d/t his dialysis in the morning. R2 is on a 1:1 supervision. R2 returned with no new orders at this time, VS WNL. Will continue current plan of care. On 02/22/23 at 11:42 AM, during an interview with the Administrator, she reported the facility has conducted an in-service about abuse to the nurses and others and the incident was reported to the state and the facility is currently working on completing the investigation. She reported, A staff member, identified as Certified Nursing Assistant (CNA)1 went to staff at 3:20 PM and advised she saw R1 and R2 sitting next to each other in the day room with R2's hands on R1's breast. The Administrator stated review of the incident revealed R1 with a BIMS of 99 and R2 with a BIMS of 15, whom have been separated and R1 remains in her room on the East wing and R2 was moved to the North wing. MD and family were notified of the incident and R2 was placed on 1:1 observation until he was sent to the ER and will remain on 1:1 until he leaves the facility. The Administrator also revealed, According to R2, the incident was consensual and R1 placed R2's hand on her breast. R1 can understand some English and is able to communicate in broken English. R1 does not recall the incident. The facility has had two (2) interpreters in on yesterday (2/21/23) and another one this morning (2/22/23) and R1 is responding no to all questions regarding being hurt and reported nothing happened and reported she feels safe in the facility. During an interview on 2/22/23 at 12:08 PM, CNA1 reported she was walking down the hall just past the day room and observed R1 and R2 sitting next to each other. R2 was sitting very close to R1. CNA1 stated she then asked him why he was bothering R2 and at this time, CNA1 observed R2 remove his hands from inside her (R1)'s blouse and said, I am not doing anything. R1 had tears in her eyes. R2 was sitting on R1's right side and R1 was sitting in her Geri chair with a blouse with no bra on. R1 was immediately taken to her room. R1 was saying Man, Man, and she held her shirt up and stroked her breast. She looked like she was about to cry. CNA1 stated she reported the incident to the Nurse. R2 was placed on 1:1 and currently remains on 1:1. During an interview on 2/22/23 at 12:20 PM, R1 reported she did not want R2 to touch her. She reported this was the first time he touched her, and it is ok to be his friend, but not to touch her. During an interview on 2/22/23 at 12:52 PM with R1's son, he revealed, I got a call from the facility on Sunday 2/19/23, about my mother being touched. R1's son stated, I know my mother did not consent, she has Dementia and the entire time I was talking with her about the other resident touching her, she kept on asking me to go to the temple to ask for forgiveness for her. R1's son reported staff was trying to get her calm and it was hard. After speaking with facility staff on yesterday, I am a bit better, but I feel this whole thing could have been handled better. I wanted management here to tell me what occurred in person, not over the phone. After a meeting with the Social Worker (SW) and the current DON, I feel better, and the SW is keeping me updated daily with calls on how mom is doing. I would prefer if R2 was no longer here, but I know this takes time and with him being on 1:1 observation, I can handle this. During an interview on 2/22/23 at 1:29 PM, the SW revealed she was not present during the incident but was informed that R1 and R2 were in the day room and staff saw R2's hands on R1's breast. Per her knowledge, these two residents are not friends and are not involved in an ongoing relationship. The SW stated, R2 is currently on 1:1 observation and waiting on placement to another facility. During an interview on 2/22/23 at 1:41 PM, R2 reported that he attended dialysis today. R2 stated this was not the first time R1 had put his hands on her breast as she always does this, and this has been going on for weeks. R2 reported he told R1 to stop and R1 told him, This is my body, I can do what I want. R2 was asked if he had his hands inside R1's blouse and he responded, I have cataracts, I cannot see, so I do not know. R2 stated he is in an ongoing relationship with R1. During an interview on 2/22/23 at 2:55 PM, Registered Nurse (RN)1 revealed CNA1 alerted her to the situation, and she took steps to prevent R2 to getting near R1. R1 was wearing a v neck shirt and R2 had his hands inside R1's shirt. R1 looked distraught and she called the Administrator to report the incident. The residents were immediately separated and R1 looked very upset and had tears in her eyes. RN1 reported this was the first occurrence for something like this for R1 and R2 and R2 had been placed on 1 to 1 observation. During an interview on 2/22/23 at 3:22 PM, the Unit Manager revealed, R2 was sent out and was not sure of the time the incident took place, as she was not here. However, she was present when R2 returned to the facility at 1:15 AM, Monday morning. He was placed on 1:1 observation. R1 did not have any visits from R2 and to her knowledge, R2 did not have his hands on R1 in the past and R1 would not have given R2 consent to touch her. Implementation of the removal plan for F600 includes required facility wide re-education on Abuse, facility to review residents that trigger on behavioral monitoring forms, review 1:1 documentation for change in behavior for alleged perpetrator, transfer to alternative care setting as available for alleged perpetrator, and ongoing psyc consults for residents.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from neglect. Resident #1 was noted to have a fall with injury. CNA (Certified Nursing Aide) #1 failed to provide the resident's lap tray as ordered by the physician for safety. One of three residents reviewed for neglect. The findings included: The facility reported a fall with injury for Resident #1 on 6/10/18. Review of the facility's Five-Day Follow-Up Report dated 6/14/18 revealed after full investigation it was determined CNA #1 removed Resident #1's lap tray during meals per the resident's care plan. The CNA delivered incontinent care and forgot to reapply the lap tray as s/he continued rounding on other assigned residents. Another resident was heard calling for help from the dayroom to alert staff that Resident #1 had fallen. The incident occurred at approximately 3:40 PM. The nurse found Resident #1 lying on the floor between a table and permanent column in the dayroom. Blood was noted and the resident was found to have a laceration (11 x 12 centimeters) to the back of his/her head with swelling. A skin tear (2 centimeters) was noted to the right lateral hand, and a bruise noted to the right middle finger knuckle area. It was noted that the resident's lap tray was not in place. Investigation revealed at lunch time the residents lap tray was removed per the care plan of being restraint free during meals, the lap tray was set to the side in the dayroom. Review of the Incident Report for 6/10/18 at 3:40 PM revealed the nurse heard another resident calling for help in the dayroom and found Resident #1 on the floor between the table and column. Blood was noted on the floor. Resident #1 had a laceration with swelling to the right back of head. Also had a skin tear to the right lateral hand. A bruise was noted to the right middle finger knuckle. The resident's lap tray was not on wheelchair. Findings and analysis indicated the lap tray was not in place. Explained to staff the importance of lap tray being in place at all times. Resident sent out to emergency room for evaluation. Upon return to facility the resident was noted with 6 sutures to laceration. Review of Resident #1's care plan revealed physical restraint, resident has lap tray to wheelchair related to history of multiple falls/poor safety awareness, to prevent injury and provide safe place for self. Interventions and approaches were listed on the care plan and included release during meals and ADL (Activities of Daily Living) care. review of the resident's medical record revealed [REDACTED]. Checked and released per policy ordered 4/18/18. CNA #1's facility-obtained statement dated 6/11/18 revealed s/he removed Resident #1's restraint for lunch, rolled the resident in place at the table, and locked the wheel chair. The restraint was left in the dayroom. The resident's meal was served and CNA #1 was down the hall assisting other residents. Another CNA removed Resident #1's meal tray from the table after s/he completed his/her meal. CNA #1 did not see Resident #1 again until 2:00 PM rounds. At approximately 2:00 PM, CNA #1 removed the resident from the dayroom, did incontinent care in the resident's room, and returned the resident to the dayroom when completed. The CNA did not put the restraint on the chair and exited the dayroom to do care on other residents. CNA #1 clocked out prior to the resident's fall. Reviewed facility policy provided for Restraints and there was no information related to when to check and release restraints. The policy indicated under the procedure section that orders for restraint should include type of restraint, duration to be utilized, medical [DIAGNOSES REDACTED]. Review of the facility's policy on Abuse, Neglect and Misappropriation of Property revealed neglect was defined as 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. In an interview with the surveyor on 6/10/18, the facility administrator confirmed that CNA #1 admitted to not applying the resident's lap tray as ordered prior to the incident.

Based on review of facility files and interview, the facility failed to implement policies and procedures that prohibit and prevent neglect. Resident #1 was noted to have a fall with injury. The resident's lap tray was not in place per physician order [REDACTED]. The findings included: The facility reported a fall with injury for Resident #1 on 6/10/18. Review of the facility's Five-Day Follow-Up Report dated 6/14/18 revealed after full investigation it was determined CNA (Certified Nursing Aide) #1 removed Resident #1's lap tray during meals per the resident's care plan. The CNA delivered incontinent care and forgot to reapply the lap tray as s/he continued rounding on other assigned residents. Another resident was heard calling for help from the dayroom to alert staff that Resident #1 had fallen. The incident occurred at approximately 3:40 PM. The nurse found Resident #1 lying on the floor between a table and permanent column in the dayroom. Blood was noted and the resident was found to have a laceration (11 x 12 centimeters) to the back of his/her head with swelling. A skin tear (2 centimeters) was noted to the right lateral hand, and a bruise noted to the right middle finger knuckle area. It was noted that the resident's lap tray was not in place. Investigation revealed at lunch time the residents lap tray was removed per the care plan of being restraint free during meals, the lap tray was set to the side in the dayroom. Review of the Incident Report for 6/10/18 at 3:40 PM revealed the nurse heard another resident calling for help in the dayroom and found Resident #1 on the floor between the table and column. Blood was noted on the floor. Resident #1 had a laceration with swelling to the right back of head. Also had a skin tear to the right lateral hand. A bruise was noted to the right middle finger knuckle. The resident's lap tray was not on wheelchair. Findings and analysis indicated the lap tray was not in place. Explained to staff the importance of lap tray being in place at all times. Resident sent out to emergency room for evaluation. Upon return to facility the resident was noted with 6 sutures to laceration. Review of Resident #1's care plan revealed physical restraint, resident has lap tray to wheelchair related to history of multiple falls/poor safety awareness, to prevent injury and provide safe place for self. Interventions and approaches were listed on the care plan and included release during meals and ADL (Activities of Daily Living) care. review of the resident's medical record revealed [REDACTED]. Checked and released per policy ordered 4/18/18. CNA #1's facility-obtained statement dated 6/11/18 revealed s/he removed Resident #1's restraint for lunch, rolled the resident in place at the table, and locked the wheel chair. The restraint was left in the dayroom. The resident's meal was served and CNA #1 was down the hall assisting other residents. Another CNA removed Resident #1's meal tray from the table after s/he completed his/her meal. CNA #1 did not see Resident #1 again until 2:00 PM rounds. At approximately 2:00 PM, CNA #1 removed the resident from the dayroom, did incontinent care in the resident's room, and returned the resident to the dayroom when completed. The CNA did not put the restraint on the chair and exited the dayroom to do care on other residents. CNA #1 clocked out prior to the resident's fall. Reviewed facility policy provided for Restraints and there was no information related to when to check and release restraints. The policy indicated under the procedure section that orders for restraint should include type of restraint, duration to be utilized, medical [DIAGNOSES REDACTED]. Review of the facility's policy on Abuse, Neglect and Misappropriation of Property revealed neglect was defined as 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. In an interview with the surveyor on 6/10/18, the facility administrator confirmed that CNA #1 admitted to not applying the resident's lap tray as ordered prior to the incident.

Based on review of facility files and interview, the facility failed to ensure that each resident's care plan was implemented consistent with the resident's rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Resident #1 was noted to have a fall with injury when his/her restraint was not in place per the care plan. One of three residents reviewed for care plans. The findings included: The facility reported a fall with injury for Resident #1 on 6/10/18. Review of the facility's Five-Day Follow-Up Report dated 6/14/18 revealed after full investigation it was determined CNA (Certified Nursing Aide) #1 removed Resident #1's lap tray during meals per the resident's care plan. The CNA delivered incontinent care and forgot to reapply the lap tray as s/he continued rounding on other assigned residents. Another resident was heard calling for help from the dayroom to alert staff that Resident #1 had fallen. The incident occurred at approximately 3:40 PM. The nurse found Resident #1 lying on the floor between a table and permanent column in the dayroom. Blood was noted and the resident was found to have a laceration (11 x 12 centimeters) to the back of his/her head with swelling. A skin tear (2 centimeters) was noted to the right lateral hand, and a bruise noted to the right middle finger knuckle area. It was noted that the resident's lap tray was not in place. Investigation revealed at lunch time the residents lap tray was removed per the care plan of being restraint free during meals, the lap tray was set to the side in the dayroom. Review of the Incident Report for 6/10/18 at 3:40 PM revealed the nurse heard another resident calling for help in the dayroom and found Resident #1 on the floor between the table and column. Blood was noted on the floor. Resident #1 had a laceration with swelling to the right back of head. Also had a skin tear to the right lateral hand. A bruise was noted to the right middle finger knuckle. The resident's lap tray was not on wheelchair. Findings and analysis indicated the lap tray was not in place. Explained to staff the importance of lap tray being in place at all times. Resident sent out to emergency room for evaluation. Upon return to facility the resident was noted with 6 sutures to laceration. Review of Resident #1's care plan revealed physical restraint, resident has lap tray to wheelchair related to history of multiple falls/poor safety awareness, to prevent injury and provide safe place for self. Interventions and approaches were listed on the care plan and included release during meals and ADL (Activities of Daily Living) care. review of the resident's medical record revealed [REDACTED]. Checked and released per policy ordered 4/18/18. CNA #1's facility-obtained statement dated 6/11/18 revealed s/he removed Resident #1's restraint for lunch, rolled the resident in place at the table, and locked the wheel chair. The restraint was left in the dayroom. The resident's meal was served and CNA #1 was down the hall assisting other residents. Another CNA removed Resident #1's meal tray from the table after s/he completed his/her meal. CNA #1 did not see Resident #1 again until 2:00 PM rounds. At approximately 2:00 PM, CNA #1 removed the resident from the dayroom, did incontinent care in the resident's room, and returned the resident to the dayroom when completed. The CNA did not put the restraint on the chair and exited the dayroom to do care on other residents. CNA #1 clocked out prior to the resident's fall. Reviewed facility policy provided for Restraints and there was no information related to when to check and release restraints. The policy indicated under the procedure section that orders for restraint should include type of restraint, duration to be utilized, medical [DIAGNOSES REDACTED]. Review of the facility's policy on Abuse, Neglect and Misappropriation of Property revealed neglect was defined as 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. In an interview with the surveyor on 6/10/18, the facility administrator confirmed that CNA #1 admitted to not applying the resident's lap tray as ordered prior to the incident.

Based on review of facility files and interview, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was noted have a fall with injury on 6/10/18. The resident's lap tray was not in place per physician's orders [REDACTED]. The findings included: The facility reported a fall with injury for Resident #1 on 6/10/18. Review of the facility's Five-Day Follow-Up Report dated 6/14/18 revealed after full investigation it was determined CNA (Certified Nursing Aide) #1 removed Resident #1's lap tray during meals per the resident's care plan. The CNA delivered incontinent care and forgot to reapply the lap tray as s/he continued rounding on other assigned residents. Another resident was heard calling for help from the dayroom to alert staff that Resident #1 had fallen. The incident occurred at approximately 3:40 PM. The nurse found Resident #1 lying on the floor between a table and permanent column in the dayroom. Blood was noted and the resident was found to have a laceration (11 x 12 centimeters) to the back of his/her head with swelling. A skin tear (2 centimeters) was noted to the right lateral hand, and a bruise noted to the right middle finger knuckle area. It was noted that the resident's lap tray was not in place. Investigation revealed at lunch time the residents lap tray was removed per the care plan of being restraint free during meals, the lap tray was set to the side in the dayroom. Review of the Incident Report for 6/10/18 at 3:40 PM revealed the nurse heard another resident calling for help in the dayroom and found Resident #1 on the floor between the table and column. Blood was noted on the floor. Resident #1 had a laceration with swelling to the right back of head. Also had a skin tear to the right lateral hand. A bruise was noted to the right middle finger knuckle. The resident's lap tray was not on wheelchair. Findings and analysis indicated the lap tray was not in place. Explained to staff the importance of lap tray being in place at all times. Resident sent out to emergency room for evaluation. Upon return to facility the resident was noted with 6 sutures to laceration. Review of Resident #1's care plan revealed physical restraint, resident has lap tray to wheelchair related to history of multiple falls/poor safety awareness, to prevent injury and provide safe place for self. Interventions and approaches were listed on the care plan and included release during meals and ADL (Activities of Daily Living) care. review of the resident's medical record revealed [REDACTED]. Checked and released per policy ordered 4/18/18. CNA #1's facility-obtained statement dated 6/11/18 revealed s/he removed Resident #1's restraint for lunch, rolled the resident in place at the table, and locked the wheel chair. The restraint was left in the dayroom. The resident's meal was served and CNA #1 was down the hall assisting other residents. Another CNA removed Resident #1's meal tray from the table after s/he completed his/her meal. CNA #1 did not see Resident #1 again until 2:00 PM rounds. At approximately 2:00 PM, CNA #1 removed the resident from the dayroom, did incontinent care in the resident's room, and returned the resident to the dayroom when completed. The CNA did not put the restraint on the chair and exited the dayroom to do care on other residents. CNA #1 clocked out prior to the resident's fall. Reviewed facility policy provided for Restraints and there was no information related to when to check and release restraints. The policy indicated under the procedure section that orders for restraint should include type of restraint, duration to be utilized, medical [DIAGNOSES REDACTED]. Review of the facility's policy on Abuse, Neglect and Misappropriation of Property revealed neglect was defined as 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. In an interview with the surveyor on 6/10/18, the facility administrator confirmed that CNA #1 admitted to not applying the resident's lap tray as ordered prior to the incident.

On the days of the survey, based on interviews and record review, the facility failed to thoroughly investigate or report 1 of 1 allegations of abuse. Resident #20 reported to the facility an allegation of verbal abuse that was not thoroughly investigated, nor reported to state agencies. The findings included: The facility admitted Resident #20 on 1/18/1999 with [DIAGNOSES REDACTED]. On 2/23/2011 during an interview at 12:30 PM, the resident stated: "About 4 weeks ago I asked for a ham sandwich. I was told that the ham was frozen. I asked one of the CNAs (Certified Nursing Assistants) to get me a hamburger from .... The CNA brought me a hamburger. I was sitting in my room and the young man from the kitchen came down from the kitchen and said to me, 'Here, Here is your damn sandwich. Quit telling lies on the kitchen. All you do is sit on your ass and tell lies.' " The resident stated that she had reported the incident to the DON (Director of Nurses). "She (DON)went and talked to the people in the dining room. The people in the dining room didn't know what happened. He came to my room, not in the dining room. My children told me to stay out of the dining room. I don't go to the dining room anymore, only to activities there, Bingo." During the days of the survey the resident was not observed in the dining room during meals The resident's medical record was reviewed on 2/23/11 at 1:00 PM. A Social Services note was written on 2/4/2011, stating, "An incident was reported to me this morning..... This resident reported to the .......RN (Registered Nurse) that yesterday (2/3/11)....went to the kitchen to get a ham sandwich. Resident states that she was told that the ham was frozen, and that she could not get a ham sandwich. Resident then sent someone out to....to get her something to eat. Resident stated that after she had gotten her food .... (name of dietary employee) from the kitchen came in her room with a sandwich and cursed at her. Resident states ... told her that she needed to stop telling those damn lies about the kitchen....I also attempted to contact resident's daughter who is her RP (Responsible Party)... and was unable to reach her." On 2/23/2011 at 1:30 PM, the Social Services Director (SSD) was interviewed regarding the alleged incident. The SSD stated that the incident had been reported to her the next morning (2/4/2011). She then reported it to the DON (Director of Nurses) and the Dietary Manager. The SSD stated that she had tried to reach the resident's family several times but was never able to reach them, she therefore left messages on a cell phone voice mail. On 2/23/2011 at 1:40 PM, the DON was interviewed regarding the alleged incident. The DON stated that she had investigated the incident with the Dietary Manager. A nurse had witnessed the dietary employee take the tray into the resident's room. The employee told the resident that she should have checked the tray. The employee did not cuss at the resident, he did cuss in the hallway. "We didn't substantiate the complaint. There was a witness and I did not report it." The investigation of the incident was requested. The investigation included an Employee Disciplinary Report, a statement of the nurse that witnessed the incident, and a typed and handwritten statement from the alleged perpetrator. There was no statement from the resident. There were no statements from other staff that were working on the unit or any other alert or oriented residents that may have witnessed the alleged event. There were no other residents statements regarding any concerns they may have had with the employee. Under employee remarks on the Employee Disciplinary Report, there was a handwritten statement that included: ".... pointed out all 4 (four) sandwiches to the nurse and commented the tray had not been touched and that res. (resident) shouldn't be telling those damn lies about dietary." The nurses statement stated that the resident wanted 2 ham sandwiches because she did not want the supper they had. He (dietary employee) said she had 2 ham sandwiches and 2 peanut butter and jelly sandwiches on the tray and, "she must not even looked at the tray. ...She must not looked at the Dam (sic) tray. ...then went into residents room to speak with her but I did not here (sic) any ang (sic) appropriate language used at that time." The typed statement from the dietary employee stated, "Prior to entering (resident) room I told the nurse ... that she (resident) must not have even checked the damn tray....I stood in the doorway of (resident) room and asked why she lied to the nurse." The handwritten statement from the dietary employee stated that he went to resident room and asked why the resident was telling that dietary didn't give what the resident had asked for. The Administrator was interviewed on 2/23/11 at 4:00 PM and reviewed the investigation. The Administrator stated that she was aware of the incident. The reason that a full investigation was not done was because a nurse had witnessed the incident and stated that it did not happen. The Administrator also stated that the resident has a history of telling untruths. Review of the resident's MDS (Minimum Data Set) of 11/30/10, had the resident coded as being alert and oriented and making her own decisions. Review of the resident care plan dated 12/7/10 under problem #6, Social, listed the problem of behaviors with [DIAGNOSES REDACTED]. Under the approaches it is listed that the resident has tendency to tell untruths concerning not being offered ADL (Activities of Daily Living) assistance or receiving medications as ordered. Another approach listed was "Do not argue with resident". Another approach listed was, "Resident deemed competent". The Abuse Policy provided by the facility on 2/22/2011, was reviewed. "Upon report of any allegations or violations the Administrator or his/her designated representative will thoroughly investigate the situation......" "The investigation will include but not limited to the following facts: 3. The resident's statement concerning the incident. Allegations of abuse are reported within 24 hours to the Nursing Home Ombudsman and SCDHEC. (South Carolina Department of Health and Environmental Control) There was no evidence provided that the facility conducted a thorough investigation of the alleged incident. The allegation was not reported to state agencies. On 2/23/2011 the resident involved in the allegation continued to report the incident.