Every finding on record at Conway Healthcare and Rehabilitation Center

Based on record review and interview, the facility failed to adequately monitor one (Resident #1) of one resident after an unwitnessed fall, which had resulted in a periprosthetic fracture of the right hip and a ping-pong ball sized knot to the left lateral scalp. Specifically, the nursing staff did not perform the ninth (7:15 AM) neuro check following an unwitnessed fall and did not alert the resident's provider when the resident later reported the possibility of striking their head during the fall. The findings include: Review of an admission Record revealed that the facility admitted Resident #1 on 05/28/2026 with diagnoses which included cognitive communication deficit, orthostatic hypotension, and presence of unspecified artificial hip joint. Review of Resident #1's Physician Orders (PO) revealed an order, dated 06/16/2026, for a blood thinner to be administered twice a day. The PO also revealed an order with a revision date of 06/22/2026 to transfer Resident #1 to [name of hospital] emergency room for evaluation due to an unwitnessed fall and decreased (Range of Motion) ROM in the right lower extremity. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2026, revealed Resident #1 had a Brief Interview for Mental score of 12, which indicated Resident #1 had moderate cognitive impairment. The admission MDS also revealed that Resident #1 was dependent on toileting hygiene and required substantial/maximal assistance with chair/bed-to-chair transfers and had a fracture related to a fall in the six (6) months prior to an admission/entry, reentry or prior assessment. Review of Resident #1's Care Plan with a review date of 06/18/2026, revealed Resident #1 required substantial/maximal assistance for transfers, which the helper did more than half of the effort. Review of a Facility Incident Report for Resident #1 dated 06/21/2026 at 11:30 PM revealed the following: -Incident description: This nurse heard resident hollering out help! This nurse and two CNAs (Certified Nursing Assistants) entered resident's room. Resident was sitting by bathroom door on bottom with feet in front of [them] with no socks on. W/C (wheelchair) next to resident in locked position. This nurse assessed resident, small skin tear to right forearm near elbow. Resident complained of pain to right hip. Scratch noted to area. ROM WNL (within normal limits) for this resident. -Immediate action taken: Started neuro checks, ROM WNL, ordered right hip x-ray, called mobile x-ray company at 11:57 PM. Resident taken to hospital? N (no). -Injury Type: skin tear to right elbow -Level of pain: 6 [out of 1-10 pain scale] -Notes: 06/22/2026 DON Follow Up: resident admitted to [name of hospital] due to fx (fracture) R (right) hip. POC (plan of care) to be updated upon return to facility. 06/26/26-footboard removed. Review of the Neuro Checks Recurring form for Resident #1 revealed instructions for documentation were as follows: [every] Q 15 min for first hour, Q 30 minutes X 2[hours]; Q Hour X 2 [hours]; Q 4 Hours X 2[shifts]; Q Shift for the remaining 72 hours and until stable. Review of the Neuro Checks Recurring Form with an effective date of 06/22/2026 for Resident #1 revealed that LPN #1 completed and signed the neuro checks for the following checks: initial neuro check #1, Q 15 min check #2, Q 15 min check #3, Q 15 min check #4, Q 30 min check #1, Q 30 min check #2, Q hour check #1 and Q hour check #2. There was no signature indicated for the following neuro checks: Q 4(four) hour check #1, which should have been completed at 7:15 AM on 06/22/2026. The remaining neuro checks were not completed because the resident was transferred to the hospital per review of an incident note dated 06/22/2026 at 9:53 AM, located in Resident #1's progress notes. Review of a Provider Note dated 06/22/2026 at 12:34 PM, revealed Today's visit is medically necessary because of a fall. [Resident #1] seen today lying in bed. Patient states [they] fell last night in the bathroom around midnight. Denies hitting [their] head but states the left side of [their] head is sore. C/O (complains of) significant right hip pain. Unable to straighten right leg completely 1. Right hip pain d/t [due to] hx [history] of RTHA [Right Total Hip Arthroplasty], previous dislocations, and on blood thinner. Patient sent to ER [emergency room] for further evaluation, 2. History of total right hip replacement Review of a Radiology Report dated 06/22/2026 located in Resident #1's hospital records dated 06/29/2026 revealed the following: -Procedure: CT [Computed Tomography] Pelvis -History: fall with right hip pain, multiple prior surgeries -Impression: Periprosthetic fracture of the right proximal femoral diaphysis along the posterior medical aspect cortex [fracture around or very close to an artificial hip implant], new from prior examinations. During a telephone interview on 06/29/2026 at 2:49 PM, CNA #1 stated Resident #1 could not get out of bed alone, was able to use the call light system, but did not do so. He stated Resident #1 required assistance from one staff member and used a wheelchair for mobility. He stated on the night of 06/21/2026, he was working the 11 PM to 7 AM shift and heard someone yelling for help but was unable to give an exact time. He stated that when he entered Resident #1's room, the resident had made it to the corner of the bathroom door, and the wheelchair was by Resident #1's bed. He stated Resident #1 was not able to tell him what happened at that time. He stated when he first reported to LPN #3, Resident #1 had stated they did not hit their head and was not having any pain in their head but was complaining of leg pain. CNA #1 could not recall which leg. He stated about an hour later, Resident #1 stated their head was hurting and was constantly complaining of leg pain, but he could not recall which leg. He stated that as soon as Resident #1 asked for something for their head, he immediately reported this to LPN #3. During a telephone interview on 06/29/2026 at 9:17 AM, LPN #3 stated she was working on the night of 06/21/2026. She stated around 11:30 PM, she heard Resident #1 hollering out and when she made it to Resident #1's room, Resident #1 was sitting on the floor in the corner by the bathroom door on their bottom. She stated when she assessed Resident #1, their ROM was WNL. She stated Resident #1 had a little tear near the right elbow, and a red area on the right hip. She stated Resident #1 stated they were hurting from the fall in the right hip. She stated initially Resident #1 reported they did not hit their head. She stated later in the shift (she was not able to give an exact time), CNA #1 went back to check on Resident #1, and CNA #1 was told by Resident #1 that they believed they might have hit their head. LPN #3 stated she then started neuro checks on Resident #1. She stated after CNA #1 reported to her that Resident #1 had stated they might have hit their head, she assessed Resident #1 again but was unsure of the time. LPN #3 stated she did not see any markings, redness, or knots on Resident #1's head at that time. She stated after she was made aware that Resident #1 may have hit their head, she did not call the provider back to provide an update on Resident #1's condition. She stated that for an unwitnessed fall with a possible head injury, the facility's protocol was to notify the doctor. She stated the provider should have been notified that Resident #1 hit their head. She stated that she started the neuro checks on Resident #1 before midnight, and she administered a pain pill to Resident #1 around midnight. LPN #1 stated she did not notice or feel a knot or contusion to Resident #1's head during any of the neuro checks she performed. LPN #3 stated she reported to LPN #4, Resident #1's fall and complaints of right hip pain, an x-ray had been ordered but had not been completed yet. She stated she could not recall if she informed LPN #4 of Resident #1 hitting their head during the fall. During an interview on 06/29/2026 at 12:29 PM, LPN #4 stated she had been a nurse at this facility for about a month. She stated she came to work on the morning of 06/22/2026 around 6:45 AM. She stated she received report from LPN #3 regarding Resident #1's fall but she could not recall if LPN #3 told her that Resident #1 hit their head. She stated she did not assess Resident #1 after she received shift report and began her morning (8 AM) medication pass. She stated around 9:15 AM, she was told by the Medication Assistant Certified (MA-C) (LPN #4 could not recall the name of the MA-C) that Resident #1 requested a pain pill. LPN #4 stated by the time she went to see Resident #1, the APRN had been in to see Resident #1 and the APRN requested for her to check on the status of the radiology results. LPN #4 stated after the APRN was told that the x-ray had not been completed and would not be performed within the next 30 minutes, the APRN ordered Resident #1 to be sent to the hospital. LPN #4 stated the APRN stated upon her assessment, Resident #1 had decreased ROM in their leg. She stated she administered Resident #1 a pain pill between 9:15 AM and 9:20 AM and did not see any injuries on Resident #1 at that time. She stated someone at the facility, but she could not recall who, showed her the neuro check sheet and stated what to do with it. She stated she had not had to initiate neuro checks on a resident previously, but she was aware Resident #1 was to have neuro checks completed. During an interview on 06/29/2026 at 4:04 PM, Resident #1 was lying in bed on their right side. Resident #1 stated they had just received a pain pill due to pain. Resident #1 stated on the night of the fall, they woke up due to being cold and remembered they had a blanket in their closet. Resident #1 stated they usually got out of bed on the left side, but that night they decided to get out of bed without help on the right side of the bed and fell. Resident #1 acknowledged they were supposed to call when they needed something but did not call. During a second interview on 06/29/2026 at 4:45 PM, Resident #1 stated they did not recall hitting their head at first but started to realize the area to the left of their scalp was tender. Resident #1 stated they told LPN #3 their head was soft, and sensitive. Resident #1 stated that LPN #3 felt around on their head after being made aware they might have struck their head but indicated she did not feel anything. During an interview on 07/02/2026 at 10:20 AM, the DON stated LPN #3 had reported to her Resident #1 had an unwitnessed fall and stated they did not hit their head. She stated LPN #3 did not report that Resident #1 had hit their head during the fall. She stated if a resident complains of head discomfort or reports they did hit their head, later in the shift (after an unwitnessed fall), the nurse should assess the resident, start neuro checks, notify the provider, and document the concern. She stated the provider should be notified of the change in the resident because they need to know and may change the treatment the resident receives. She stated if a resident had neuro checks due at 7:15 AM, the 7AM to 3PM shift was responsible for completing the task. During a telephone interview on 07/07/2026 at 3:27 PM, the Medical Director stated he could not recall receiving a phone call on 06/22/2026 from a nurse regarding Resident #1 having an unwitnessed fall. He stated he knew Resident #1 had a fall because he completed a daily computer review of residents and knew when residents go out or return to the facility. He stated if he was notified that Resident #1 had hit their head, he would have asked if there were any signs/symptoms of head trauma, if there were physical evidence of trauma such as bruising or tenderness and given that information, he may or may not have given orders for a scan. He stated for any patient that had a fall and reported that they bumped their head, he would expect the nurse to take a history and perform neuro checks at appropriate intervals. He indicated it was important for him to be notified of changes in the resident's condition, and he stated the staff reported any changes to the nurse practitioner or the physician on call.

Based on observation, record review, and interview it was determined that the facility failed to ensure proper hand hygiene during perineal care to prevent cross contamination for two (Resident #69 and Resident #74) of two sampled residents observed for bowel and bladder care. The findings include: Resident #69: During an observation on 08/18/2025 at 2:54 PM, this surveyor observed Certified Nursing Assistant (CNA) #4 and CNA #5 assist Resident #69 to bed and inform the resident that their brief would be checked, without further instruction. Then this surveyor observed CNA #5 pull down Resident #69's wet brief. CNA #4 used wipes to clean Resident #69's front perineal area and placed the wipes in a trash bag. CNA #5 rolled the resident onto their right side and CNA #4 wiped Resident #69's buttocks using one wipe in one direction. Resident #69 complained of buttocks pain. CNA #4 inspected Resident #69's buttocks, then opened the resident's bedside drawer, without changing gloves, and found a non-prescription ointment to use on Resident #69's buttocks. CNA #4 informed Resident #69 there was no skin breakdown on their buttocks. Resident #69 was rolled back onto a clean brief, and it was pulled up by both CNAs. Resident #69 was covered with a sheet, and CNA #5 returned the wipes to the bedside drawer, without changing their soiled gloves. A review of Resident #69's Medical Diagnosis revealed the facility admitted the resident with diagnoses which included stroke, type 2 diabetes mellitus, and protein malnutrition. A review of Resident #69's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/01/2025, revealed a Brief Interview for Mental Status score of 13, which indicated no cognitive impairment. Resident #69's MDS also revealed the resident required total care for toileting, personal care, and dressing the lower body, and maximum assistance for bathing. During an interview on 08/18/2025 at 2:58 PM, Resident #69 stated that for the last few days it felt like they had a sore on their buttocks, but they had not reported it. Resident #69 also said CNA #4 always did a good job with personal care, but sometimes the resident had to wait. During an interview on 08/18/2025 at 3:00 PM, CNA #4 revealed the process for perineal care was to wipe off all sides making sure you get the back side, and front side of the perineal area from left to right. CNA #5 revealed staff were trained to put on gloves before starting perineal care, and to remove gloves and wash your hands when done. CNA #5 confirmed they should have changed their gloves during Resident #69's perineal care, when going from dirty to clean to prevent cross contamination. Resident #74: During an observation on 08/18/2025 at 1:18 PM, this surveyor observed CNA #2 and CNA #3 stand Resident #74 up with the sit to stand lift for perineal care and both CNAs removed the resident's wet brief after explaining perineal care, while wearing gloves. CNA #3 removed clean wipes and proceeded to wipe Resident #74's buttocks, CNA #3 then removed three wipes and wiped down Resident #74's front skin folds left to right, then wiped the urinary meatus in a quick circular motion. CNA #2 placed a clean brief on Resident #74 and CNA #3 assisted in securing the tabs. CNA #3 stored wipes in a drawer and pulled Resident #74's clothing up, then CNA #2 and CNA #3's dirty gloves were removed. Proper hand hygiene was not performed during Resident #74's perineal care. A review of Resident #74's Medical Diagnosis revealed the facility admitted the resident with diagnoses which included dementia, overactive bladder, and ataxia (a disease characterized as poor muscle control causing clumsy movements). A review of Resident #74's quarterly MDS with an ARD of 07/16/2025, revealed a Staff Assessment for Mental Status (SAMS) score of 03, which indicated the resident was severely impaired, and rarely/never made decisions. Resident #74's MDS also revealed the resident required total care and was on scheduled pain medication. Resident #74's MDS also revealed they were always incontinent of bowel and bladder. During an interview with CNA #2 and CNA #3, CNA #3 stated staff were trained to wash their hands and put on gloves before starting perineal care. CNA #3 continued to say when perineal care was completed, CNAs were expected to remove their gloves and wash their hands. CNA #3 said, there is no time to change gloves during perineal care with the closed unit residents. CNA #2 said, you have to work fast with people that have dementia. Both CNAs agreed there was a risk of cross contamination during Resident #74's perineal care because their gloves were not changed during the care, they touched the sit to stand lift, Resident #74's clothing, the resident's wheelchair, and their drawer while wearing dirty gloves. During an interview on 08/20/2025 at 4:45 PM, the Director of Nursing (DON) confirmed that during perineal care, hand hygiene needed to be performed between clean and dirty tasks to prevent cross contamination. This surveyor asked the DON for the facilities perineal care policy/procedures, male perineal care, and signed in-services. The DON stated, We do not have a perineal care policy. During an interview on 08/21/2025 at 2:14 PM, the Administrator stated, Staff should ensure privacy and close the blinds, curtain, and door. Staff should sanitize hands and wear gloves before perineal care and then remove gloves and sanitize hands when going from dirty to clean. The Administrator revealed, the purpose of the facility having staff change gloves and sanitize hands when going from dirty to clean is about infection control. It prevents the spread of infection. Staff have annual competencies, and in-services throughout the year and as needed. A review of a facility Perineal Competency revealed for male residents, it did not address hand hygiene during perineal care, but instructs staff to remove gloves, wash and dry hands after perineal care before repositioning with bed covers, touching the call light, cleaning the basin and bed stand then washing and drying hands thoroughly. The call light should be in easy reach of the resident. On exit, the survey team was given Competency Assessment Perineal Care revised October 2010. CNA #2 completed on 02/27/2025, CNA #5 completed on 02/26/2025. A review of a facility lecture dated 04/04/2025, revealed staff were expected to tell the resident what care was being done before starting. It was the residents' right and ensured their dignity. Based on the sign-in sheet, CNA #2, CNA #3, CNA #4, and CNA #5 were not included in this lecture. A review of in-service dated 06/27/2025, revealed perineal care was a fundamental skill for CNA's and was crucial for hygiene and preventing skin breakdown, odors, and infection. Proper perineal care improved comfort and dignity. CNAs should use gentle cleaning agents and work from the back to the front to avoid contamination. Based on the sign-in sheet, CNA #2, CNA #3, CNA #4, and CNA #5 were not included in this in-service. A review of an in-service on Perineal Care, Peg tube use and Care, Call light use, dated 08/20/2025, revealed staff were educated using the Competency Assessment Perineal Care. Based on the sign-in sheet, CNA #2 attended this in-service, but CNA #3, CNA #4, and CNA #5 were not in attendance. A review of an in-service titled Handwashing dated 08/20/2025, revealed handwashing protected residents from getting sick. Wash hands often, especially during times that will spread germs: after changing briefs or cleaning up a resident who has used the toilet. Based on the sign-in sheet, CNA #2 and CNA #3 were not included in this in-service. New in-service has not been seen by all staff at this time.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure resident centered care was provided to two of two (Resident #8 and Resident #69) sampled residents dependent on staff for care based on one of one observation to ensure residents physical and psychosocial needs were met. Specifically, staff did not respond to a feeding tube alarm in a timely manner, a call light was placed out of the reach of a resident, and pain was not addressed in a timely manner. The findings include: Resident #8: During an observation on 08/18/2025 at 2:13 PM, this surveyor observed Resident #8 resting with their eyes closed, their tube feed was beeping, and the pump was not running. The resident's feeding pump said, tube slip detected, remove and reload cassette. This surveyor observed the resident's feeding supplement of 1.5 calories was hanging on a pump, and 60 milliliters (mL) an hour was written on the bottle. Resident #8 was not responding verbally and was not able to demonstrate use of the call light to report continuous beeping. The resident's bed was at 45 degrees, and an enhanced barrier precaution sign was posted outside of the room. This surveyor also observed CNA #6 and therapy staff pass by Resident #8's room, and there was no response to the alarming feeding tube. During an observation on 08/18/2025 at 2:54 PM, Certified Nursing Assistant (CNA) #5 was overheard in the hall saying the nurse needed to be told about Resident #8's feeding pump beeping. During an observation on 08/18/2025 at 3:03 PM, Licensed Practical Nurse (LPN) #7 entered Resident #8's room and said, [CNA #5] just told me Resident #8's tube feeding was beeping. LPN #7 fixed the feeding pump, stopped the beeping, and revealed they last rounded on Resident #8 at 12:30 PM, and confirmed that staff were expected to round every two hours. A review of Resident #8's Medical Diagnosis revealed the facility admitted the resident with diagnoses which included stroke, failure to thrive, and dementia. A review of Resident #8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/21/2025 revealed a Staff Assessment for Mental Status (SAMS) score of 03, which indicated the resident was severely impaired and never/rarely made decisions. Resident #8's MDS also revealed the resident had a feeding tube while a resident, required total care, was unable to respond, and was dependent on staff for bathing, eating, toileting, dressing and personal care. A review of Resident #8's Care Plan, revised 06/04/2025, revealed the resident was at risk for fluid volume deficit related to tube feeding. Resident #8's Care Plan specified interventions that directed staff to monitor input and output, and report signs of dehydration. A review of Resident #8's Medication Administration Record (MAR), dated 06/14/2024, revealed the resident received a feeding supplement at 60 mL/hour and water flushes at 30 mL/hour for enteral feedings every shift. Further review of Resident #8's MAR revealed on 11/11/2024, staff were to make sure the resident's feeding tube was running each shift, and during medication pass. During an interview with Resident #8's Caregiver on 08/19/2025 at 9:34 AM, the Caregiver revealed being at the resident's bedside daily until 1:30 PM, then came back late in the evenings. The Caregiver said, sometimes the call light beeps over 30 minutes. Resident #69: During an observation on 08/18/2025 at 2:14 PM, this surveyor observed Resident #69 sitting in a wheelchair raising their right leg and arm up and down and said, my butt hurts from sitting here. Resident #69 revealed Resident #8's feeding pump had been beeping since their Caregiver left around 1:30 PM. Resident #69's call light was resting on the bed, out of the resident's reach. Resident #69 pointed out a CNA and physical therapist walking past the open door. During an observation on 08/18/2025 at 2:20 PM, this surveyor observed Resident #69 was handed their call light and demonstrated how to call for assistance, and surveyor observed for response for assistance. During an observation on 08/18/2025 at 2:29 PM, this surveyor observed CNA #6 walk into Resident #69's room to turn off the call light and asked the resident, Who is your aid, sweetie? Resident #69 said, CNA #4 I think, and I need to get off my butt I am hurting. CNA #6 turned and left the room. Resident #69's roommate [Resident #8's] feeding tube continued to beep. During an observation on 08/18/2025 at 2:50 PM, this surveyor observed CNA #4 and CNA #5 enter Resident #69's room and place the resident back in bed 30 minutes after Resident #69 used the call light. CNA #5 revealed she knew Resident #69 used the call light, because it lit up above the door and at the nurse's desk. A review of Resident #69's Medical Diagnosis revealed the facility admitted the resident with diagnoses which included stroke affecting the left side, type 2 diabetes mellitus, and cervical radiculopathy (a condition of the cervical spine leading to pain with tingling weakness in the arms and hands). A review of Resident #69's admission MDS with an ARD 06/01/2025, revealed a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. Resident #69's MDS also revealed the resident was dependent for toileting and personal care, required maximum to total dependence for dressing and received scheduled pain medication. A review of Resident #69's MAR, dated 07/19/2025, revealed the resident received a pain patch every morning for pain and a narcotic tablet, twice a day for pain. A review of Resident #69's Care Plan, with a revision date of 06/04/2025, revealed the resident was weight bearing/non weight bearing with ADLs related to a stroke with left side weakness. Resident #69's Care Plan also revealed the resident required total two-person assistance for bed mobility and dressing, with an intervention that directed staff to encourage the resident to use their call light. A review of Care Plan for Resident #69, revised 06/04/2025, Resident #69 is at risk for altered skin integrity related to immobility and incontinence. Assist and encourage repositioning as needed, Resident #69 needs a pressure relieving device for bed and wheelchair, perineal care as needed. A review of Resident #69's Medication Administration Record (MAR) showed on 08/03/2025 an order was discontinued to turn Resident #69's feeding pump off at 7:00 AM, for breakfast and at lunch for caregiver to feed the resident a supplement. During an interview on 08/20/2025 at 4:30 PM, CNA #6 stated the process for answering call lights on another hall was to find the residents CNA and let them know the resident needed assistance. CNA #5 was found in the dining room and I let him know [Resident #69] wanted back in bed. CNA #6 confirmed call lights could be seen above the resident doors and at the nurse's station, and that staff were expected to answer call lights within five minutes. During an interview on 08/20/2025 at 4:35 PM, the Director of Nursing (DON) revealed all staff were expected to respond to call lights within 10-15 minutes. The DON then stated, Ideally the CNA will assist the resident, but in the real world, they will find the assigned CNA. The DON then confirmed the facility was unable to run a call light report, because the call light system is old. CNA are to tell nursing when a resident complains of pain or ask for the nurse. During an interview on 08/21/2025 at 2:25 PM, the Administrator revealed the expectation was that call lights would not beep for more than 15 minutes. The Administrator then stated, If it is something small that resident wants any CNA can handle it, and if they need a lift or something then staff would tell that CNA caring for the resident, because it will take two staff members. The Administrator revealed complaints of pain should be taken to the resident's nurse. If a call light was going off and staff were walking up and down the hall, the Administrator revealed any staff could answer the call light, and it did not have to specifically be a CNA. The Administrator said he was not aware of any call light problems and did not know if Percutaneous Endoscopic Gastrostomy (PEG) tube [tube that provides nutrition and medication directly to the stomach] alarms could be heard at the nurses station, but 50 minutes would be too long for a feeding tube to beep, because it could affect the residents nutrition. The Administrator then said, If a resident such as [Resident #8] cannot use a call light, and their PEG tube is beeping, the standard is to check on residents every two hours. During an interview on 08/21/2025 at 5:30 PM, the Administrator stated he could check into it, but Resident #8's feeding tube could be turned off during ADLs. During the 50 minutes, this surveyor observed Resident #8, and no activities or services were provided. A review of an in-service/lecture on PEG tubes, dated 04/04/2025, revealed nurses were to ensure PEG tube feedings and flushes were changed as soon as possible when empty or near empty, and CNAs were to alert nursing if PEG tubes were beeping or bags appeared low or empty. Based on the sign-in sheet, CNA #4, CNA #5, CNA #6, and LPN #7 were not part of this in-service. A review of an untitled in-service, dated 07/29/2025, was done on call response time and two-hour checks. Based on the sign-in sheet, CNA #4, CNA #5, CNA #6, and LPN #7 were not part of this in-service. A review of an in-service on Perineal Care, PEG tube use and care, Call light use, dated 08/20/2025, revealed call lights should be in easy reach of the resident. Based on the sign-in sheet, CNA #5 participated in this in-service, but CNA #4, CNA #6, and LPN #7 were not in attendance. A review of an in-service on Reasonable Accommodation of Needs, dated 03/26/2025, addressed staff were to make sure call lights were in reach of residents at all times in the room. Based on the sign-in sheet, CNA #4, CNA #5, CNA #6, and LPN #7 were not part of this in-service. A review of a policy titled Pain Management revealed the facility had to ensure residents who required pain management services received those services in a manner consistent with professional standards.

Based on interview, record review, and facility document review the facility failed to ensure one (Resident #52) of one sampled resident was free of a significant medication error, which caused Resident #52 to be hospitalized for acute toxic encephalopathy. The findings include: During an interview on [DATE] at 3:23 PM, Resident #52 revealed they went to the hospital around [DATE], due to being given the wrong medications. Resident #52 said they spent the night at the hospital and almost died, because the medicine they were given was not theirs, but belonged to a resident who lived down the hall. A review of Resident #52's Medical Diagnosis revealed the facility admitted the resident with diagnoses which included high blood pressure, reflux, diabetes mellitus, hyperlipidemia, Alzheimer's disease, anxiety disorder, post-traumatic stress disorder (PTSD), chronic obstructive pulmonary disease, constipation, history of falling, sleep apnea, and insomnia. A review of Resident #52's annual Minimum Data Set (MDS) with an Assessment Reference Date of [DATE], revealed a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. Resident #52's MDS also revealed the resident was to be independent for most Activities of Daily Living. A review of Resident #52's Progress Note dated [DATE] at 9:25 AM, revealed Registered Nurse (RN) #1 had stepped outside to give medication to a different resident when she noticed Resident #52 with their head down. When RN #1 returned to the medication cart, she noticed Resident #52's medications were still in the cart. RN #1 then requested help from a Certified Nursing Assistant (CNA) to return Resident #52 to their room and get a set of vital signs. RN #1 immediately notified the Director of Nursing (DON) and the Advanced Practical Registered Nurse (APRN). A review of a Change in Condition Evaluation listed in Resident #52's Progress Notes on [DATE] at 9:44 AM, documented the resident had an altered mental status. The resident's vital signs were documented as follows: Blood Pressure (BP) - 108/78, Pulse - 77; Respiratory Rate - 18; Temperature - 98; weight 188.9, taken [DATE] at 9:00 AM; Pulse Oximetry (O2) 88% - room air; Blood Glucose was 123. The Physical Assessment revealed Resident #52 had an altered level of consciousness. RN #1 took the resident's vitals and called the APRN and the DON. Oxygen was recommended and was started with a nasal cannula at two liters a minute; normal saline was started and two doses of a medication used to reverse the effect of opioids, were administered. A review of Resident #52's Progress Note dated [DATE] at 2:59 PM, revealed the residents' vitals were taken at 10:45 AM, and were documented as follows: BP of 104/69, Heart Rate (HR) of 68, and O2 of 94%. Resident #52's family member was then called, and a voicemail was left. At 10:53 AM, Resident #52's Blood Glucose was 136, BP was 108/69, HR was 72, and O2 was 96%. At 11:00 AM, the resident's BP was 105/64, HR was 67, O2 was 93%. It was then documented at 11:05 AM, the facility contacted ambulance services for transport to the local hospital. A review of Resident #52's Progress Note dated [DATE] at 1:35 AM, revealed a facility nurse (unnamed) called the local hospital Intensive Care Unit (ICU) for an update. The nurse was told Resident #52 was doing better, vitals were staying within normal limits, and that the resident had eaten applesauce and had been awake throughout the day. The nurse was told the resident would start speech therapy the following day and that the resident's short-term memory had not yet returned. A review of Resident #52's Progress Note dated [DATE] at 1:34 PM, revealed Resident #52 returned to the nursing home, via family vehicle. The resident was oriented to person, place, time, and event, with no changes in medication. The local hospital stated they did not give Resident #52 any medications, except for a medication used to reverse the effect of opioids in the emergency room (ER). A review of the facility Medication Error report filed for Resident #52 on [DATE] at 4:37 PM, was dated [DATE] at 8:30 AM, with RN #1 identified as the nurse who made the error. The Medication Error Report revealed Resident #52 was given the wrong medications inadvertently, with a Physician Order for an opioid antagonist to counteract the error. Resident #52's condition before the incident was documented as alert and oriented and the resident's condition after the incident was documented as drowsy.RN #1 provided a handwritten statement and documentation in the residents' Progress Notes. Resident #52's Medication Administration Record (MAR) was included, and the DON signed the Medication Error report on [DATE]. A review of Resident #52's Hospital Records revealed the reason for hospitalization was due to the administration of sedative mediations, which caused Resident #52 to have with an official diagnosis of acute toxic encephalopathy: secondary to accidental administration of multiple medications capable of altering mentation. Resident #52 was drowsy and kept eyes closed most of the interview but was easily wakened. Resident #52 was able to recall their birthday and knew where they were. Resident #52's family was at their bedside and reported to the hospital the resident had mistakenly been administered another resident's medications. Resident #52's family reported the resident had a history of Alzheimer's dementia, was wheelchair-bound, but otherwise usually alert and oriented times three. Per the ER Physician, the medications Resident #52 had accidentally been given were Seroquel, paroxetine, meclizine, gabapentin, aspirin, cyclobenzaprine, alprazolam, ciprofloxacin, methylphenidate, and hydrocodone. The record revealed that Resident #52 was not on any sedating medications at the nursing home and had received two doses of an opioid antagonist, prior to arrival at the ER. It was noted that it was unclear if the medications made a difference to residents' mentation. At the ER, the resident's vital signs and labs were noted to be normal and the resident was resting comfortably on room air. Resident #52's initial electrocardiogram was done in the ER which showed a QTc interval of 464 milliseconds, this was considered borderline prolonged, which indicated the heart ventricles were taking longer than normal to recharge between beats. Resident #52 was monitored in the ICU with no complications reported, and was discharged on [DATE], back to the nursing home. A review of Resident #52's Medication and Diagnosis contraindications utilizing the Mayo Clinic contraindicators for methylphenidate hydrochloride documented appropriated studies on the relationship of age to the effects of methylphenidate have not been performed in the geriatric population. Resident #52 had a diagnosis of high blood pressure which was contraindicated for use of methylphenidate hydrochloride. Resident #52 was prescribed a medication used to treat excess stomach acid on [DATE], which was contraindicated for methylphenidate hydrochloride. Symptoms of an overdose of methylphenidate hydrochloride were noted to be a change in consciousness, irregular heartbeat or pulse, loss of consciousness, and unusual tiredness. A review of Resident #52's Medication and Diagnosis contraindications utilizing the Mayo Clinic contraindicators for hydrocodone, documented hydrocodone was contraindicated for use with Ketoconazole and Tiotropium. Resident #52's MAR revealed the resident had been prescribed to ketoconazole external shampoo, on [DATE]. The MAR also documented Resident #52 had been prescribed Tiotropium monohydrate inhalation aerosol solution related to COPD, on [DATE]. The Mayo clinic information stated using Hydrocodone may cause an overdose, with signs of change in consciousness, sleepiness, or unusual drowsiness. A review of Resident #52's Medication and Diagnosis contraindications utilizing the Mayo Clinic contraindicators for alprazolam. Elderly patients were more likely to have unwanted effects of severe drowsiness, dizziness, confusion, clumsiness, or unsteadiness and kidney, liver or lung problems. Symptoms of overdose included change in consciousness, confusion, dizziness, faintness, lightheadedness, drowsiness, and sleepiness. A review of the Medication Guide, provided by the facility on [DATE] at 1:16 PM, revealed a compound opioid pain medication was defined as a strong prescription pain medicine that contained an opioid used to manage severe pain. An opioid pain medicine could put you at risk for overdose and death. Important information listed in the guide about this medication was to get emergency help right away, if you take too much or overdose, serious or life-threatening breathing problems that could lead to death may occur. Taking this medication with other opioid medicines, benzodiazepines, or other central nervous system depressants could cause severe drowsiness, decreased awareness, breathing problems, coma, and death. Never give anyone else your medication, they could die from taking it. Do not take this medication if you have severe asthma, trouble breathing, or other lung problems. Possible side effects are constipation, tiredness, dizziness. Get emergency medical help if trouble breathing, shortness of breath, fast heartbeat, chest pain, swelling of face, tongue, or throat, extreme drowsiness, feeling faint, and mental changes such as confusion. A review of the Medication Guide provided by the facility on [DATE] at 1:16 PM, revealed methylphenidate hydrochloride was a federally controlled substance. The following issues had been reported: Heart-related problems and Mental Psychiatric problems. This drug was a central nervous system stimulant prescription medicine. The side effects of this medication could be painful, including prolonged erections, circulation problems in fingers and toes, fast heartbeat, abnormal heartbeat, headache, trouble sleeping, nervousness, sweating, decreased appetite, dry mouth, nausea, and stomach pain. A review of the Medication Guide, provided by the facility on [DATE] at 1:16 PM, revealed alprazolam is a benzodiazepine medicine. Taking benzodiazepines with other opioid medicines, or other central nervous system depressants could cause severe drowsiness, breathing problems (respiratory depression), coma, and death. This medication could make you sleepy or dizzy and can slow your thinking and motor skills. This is a federal controlled substance. Elderly patients are especially susceptible to dose related adverse effects when taking this medication. During an interview on [DATE] at 11:10 AM, RN #1 revealed they had been working at the facility since March of 2025 and have been a nurse for 15 years. RN #1 stated they were the Treatment Nurse and worked the floor at times. RN #1 stated they had started their med-pass on the 200-hall and had prepared a resident's medication, who resided on the same hall as Resident #52, but was interrupted by two to three other residents asking for things. One of the residents, who can have behavior issues, wanted their meds right then and the other resident wanted their hair done. So, to prevent the one resident from having a behavior, RN #1 put the medication they had prepared belonging to a resident who lived down the hall from Resident #52 in the top drawer of the cart and then pulled the medication for the resident who had behaviors. RN #1 stated, when I went back to the cart, Resident #52 was sitting at the cart, and I was flustered. I inadvertently gave Resident #52 the medication I had previously prepared for the other resident. RN #1 said it was between 8:00 AM – 8:30 AM, Resident #52 kept driving their wheelchair toward the dining room, but they guessed Resident #52 decided to go outside because Resident #52 was later seen outside. RN #1 said they did not look at the MAR before handing the cup of medications to Resident #52. RN #1 said they then moved to 300-hall and the resident RN #1 was looking for had gone outside. RN #1 said it was about 9:30 AM and I went outside. RN #1 stated, that is when I noticed [Resident #52] sitting there and they appeared drowsy. I went back to the Medication Cart, and I noticed [Resident #52] medications were still in the cart. RN #1 then said, I immediately realized what medications I had given [Resident #52] and that is why I was so concerned. [Resident #52] was not prescribed any of those medications. RN #1 said they immediately went to the DON, and they called the APRN. We took [Resident #52's] vitals, got an order for oxygen, an order for an opioid antagonist, intravenous fluids-normal saline, then we gave [Resident #52] a second opioid antagonist. The DON immediately took me off the medication cart and suspended me for two days. RN #1 said they were concerned Resident #52 was over sedated and expressed further concern for the resident, their family, and other residents not trusting RN #1 as a nurse. RN #1 stated they felt they might have lost the resident's trust. During an interview on [DATE] at 11:10 AM, RN #1 said they had never made a medication error before and revealed they had been a med-pass nurse since [DATE]. RN #1 stated she was in-serviced/trained and the Pharmacy Consultant and the DON observed her four times, after returning to work. During an interview on [DATE] at 3:56 PM, the DON said they had started working at this facility on [DATE]. The DON said they were notified of the medication error around 9:30 AM the morning of [DATE]. The DON said prior to going into the facility morning meeting they had noticed RN #1's med-cart was parked at the beginning of the 200-hall. The DON revealed there was another resident at the med-cart. The DON confirmed RN #1 was getting the residents their medications. The DON said RN #1 had gone outside to give a resident their medication when RN #1 noticed Resident #52 was drowsy and difficult to arouse, and RN #1 tried to figure out what was going on. The DON said then they understood RN #1 went back to the med-cart and realized they had given Resident #52 another resident's medications. The DON said they then called the APRN and took Resident #52 to their room, took the resident's vitals, gave a dose of an opioid antagonist, and started intravenous fluids. The APRN wanted a second dose of an opioid antagonist to be given, and then the resident was to be sent to the ER. The DON said Resident #52 knew where they were, they could open their eyes, and they knew who the staff were, they were just really drowsy. The DON confirmed RN #1 should have had Resident #52's MAR pulled up on the screen and matched the medications given to the card to the MAR. The DON said, my concerns with the medications was Resident #52 respiratory status, I looked up the meds Resident #52 had been given, which was quite concerning, the combination and the strengths. The DON stated, I did not run a contraindicator report, but we did contact the APRN. During an interview on [DATE] at 3:30 PM, the Medical Director (MD) said they were familiar with Resident #52, because they and the APRN were Resident #52's primary care givers. The MD said they were aware Resident #52 was inadvertently given the wrong medications and was then sent to the hospital. The MD said the Nurse Practitioner had ordered an opioid antagonist be given while the resident was still at the nursing home. The MD said their concern was that medications be given as ordered. The MD said, mistakes happened and I had to accept that fact. The MD stated they and the facility kept a close eye on the residents and the medications. The MD said the negative outcome of receiving the wrong medication was it affected Resident #52's respirations and blood pressure, and that was likely the immediate side effects. The MD stated they did not expect Resident #52 to have any long-term negative outcomes. The MD revealed the process that a nurse should use when giving medications was, the nurse should have checked the resident's orders and the MAR, and dispense the medications as they were written on the MAR. During an interview on [DATE] at 2:18 PM, the Administrator stated a nurse should check the resident name, the resident's MAR and check the medication card three times before administering their medications. The Administrator then said, I was made aware immediately after the nurse told the DON about the medication error. At that point we got [Resident #52] assisted to their room and assisted to bed, and an IV was started. The Administrator said they looked to see what medications were missing for the other resident and they called and got a one-time order for that resident. The Administrator said they monitored and assessed Resident #52's BP, HR, O2 and any interventions that were requested by the APRN were followed. The Administrator stated, we notified the family, and the nurse [RN #1] was immediately taken off the floor. RN #1 did assist with the interventions and notifications. RN #1 counted out with a different nurse to take over the med cart. The Administrator said their understanding of how this happened was that the nurse was doing a med-pass as normal and there were some distractions that occurred away from that resident, so the nurse went to deal with the distraction and when the nurse got back, the nurse administered the wrong meds to Resident #52. Resident #52 was transported to the hospital for observations, but there were no other medications or fluids given at the hospital. The Administrator stated Resident #52 had drowsiness and slurred speech. The Administrator reviewed the hospital paperwork and stated Resident #52 did not receive any opioid antagonist at the hospital but had received two doses prior to arrival at the ER. The Administrator said the risk concerns they had related to a resident receiving medications not prescribed for them was the change in condition varying from this incident to a worse outcome. The Administrator said it was important for a nurse to follow the appropriate procedures when passing medications to ensure the health and safety of the resident. The Administrator said their expectations for the nurses was to follow the policy and procedures of medication administration. A review of an in-service Education Report provided by the Administrator on [DATE], documented RN #1 had been trained on the 6-Rights of Medication Administration on [DATE]. A review of the facility Policy Medication Preparation – General Guidelines provided to the survey team documented, Five Rights include Right resident, right drug, right dose, right route and right time are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication administration: when the medication is selected, when the dose is removed from the container, and finally, just after the dose is prepared and the medication put away. The policy also revealed, when medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Residents are identified before medication is administered using two methods of identification: checking photograph attached to medical record, calling resident by name, having the resident verify his/her last name, or verifying resident identification with other facility personnel. Finally, the policy revealed, Medications supplied for one resident are never administered to another resident. A review of the facility policy Medication Administration revealed the six rights of medication administration are as follows: Right patient – identify residents before giving a medication, Right Medication – compare the order with the label three times- when getting medication; before removing from the container; and before giving to the resident; Right Dosage – Check the label three times, Right Route, Right Time, Right Documentation – record on the MAR immediately.

Based on record review, observation, interview, and facility policy review, the facility failed to ensure the medication error rate was less than 5%, to prevent potential complications for two (Residents #35 and #76) of two sampled residents observed during the medication pass. The medication error rate was 6.67%, based on observations of 30 medications administered. The findings include: A review of Resident #35's Order Summary Report revealed an order for [Brand Name] eye drops for dry eyes, with the order to instill two drops in both eyes twice a day for dry eyes. The eye drops started on 11/18/2024. A review of Resident #76's Order Summary Report indicated an order for 80 milligrams (mg) of an anti-flatulent medication twice a day for gas. During an observation on 08/19/2025 at 8:14 AM, this surveyor observed Licensed Practical Nurse (LPN) #12 administer Resident #35 one drop of [Other Brand Name] eye drops in each eye, for dry eyes. During an observation on 08/19/2025 at 8:57 AM, this surveyor observed Medication Assistant Certified (MAC) #11 administer one 125mg chewable anti-flatulent tablet to Resident #76. During an interview on 08/21/2025 at 10:10 AM, LPN #12 indicated Resident #35 was getting [Other Brand Name] eye drops because that was the only eyedrop available in the medication room. She indicated the eyedrops started 2-3 weeks ago, and she was not sure if the doctor was aware the ordered [Brand Name] eye drops were not available. During an interview on 08/21/2025 at 10:15 AM, the Assistant Director of Nursing (ADON) indicated the facility could not get [Brand Name] eye drops from the pharmacy. She then stated the order was not clarified with the Medical Director, and he was not notified the order for [Brand Name] eye drops was not available. The ADON revealed she was not sure when the order changed and confirmed the nurses gave Resident #35 the eyedrops that the facility had available. During an interview on 08/21/2024 at 3:15 PM, the Medical Director stated he should be contacted if an ordered medication was not available. He then stated he would order a substitution for an eye drop if the ordered medication was not available, and that the substitution of the eye drop should be documented. During an interview on 08/21/2025 at 3:51 PM, the Director of Nursing indicated the nurses should have contacted the doctor to get an order for eye drops that were in stock. During an interview on 08/21/2025 at 4:33 PM, the Administrator confirmed the nurses should contact the doctor if a medication is not available. A review of a policy titled, Preparation and General Guidelines indicated the medication record is used during medication administration. Prior to administration the medication record is compared to the medication label. When a medication is changed the change should be communicated to the pharmacy. A review of an in-service titled, Medication Administration revealed the medication order should be compared with the label three times: when getting the medication from storage, before removing the medication from the container, and before giving the medication to the resident. MAC #11 signed the in-service.

Based on observation, interview, and facility policy review, the facility failed to ensure one of four medication carts were always locked to prevent accidents. The findings include:During an observation on 08/20/2025 at 10:18 AM, this surveyor observed a medication cart was parked in front of the nurse's station, unlocked.During an observation on 08/20/2025 at 10:21 AM, the Director of Nursing walked by the medication cart and locked it. She confirmed medication carts should be locked, to prevent the residents from going into the carts.During an observation on 08/20/2025 at 10:28 AM, this surveyor observed Licensed Practical Nurse (LPN) #12 walk to the unlocked medication cart. She indicated the cart was for the residents on the 200 and 300-halls. LPN #12 stated she did not realize the medication cart was unlocked and confirmed the cart should always be locked for the safety of the residents.During an interview on 08/21/2025 at 4:33 PM, the Administrator revealed the medication carts should be always locked to keep the residents safe.A review of a policy titled, Medications Storage in the Facility, indicated that medications are stored safely, securely, and properly.

Based on record review, facility document review, interview, and facility policy review, it was determined that the facility failed to not discharge on e (Resident #81) of one sampled resident after an appeal was filed. The findings include: A review of Resident #81’s admission Record indicated the facility admitted the resident on 12/23/2024, with diagnoses which included anxiety disorder. A review of Resident #81’s discharge Minimum Data Set with an Assessment Reference Date of 07/24/2025, revealed a Brief Interview of Mental Status score of 15, which indicated the resident was cognitively intact. A review of Resident #81’s Care Plan Report, revised on 12/26/2024, revealed there were no discharge plans anticipated. Resident #81’s Care Plan Report indicated plans for the resident to remain in the facility for long-term care. Resident #81’s Care Plan did not indicate that the resident smoked. A review of a Discharge Notice, dated 07/23/2025 and signed by the Administrator, indicated that a decision had been made to discharge Resident #81 effective 30-days from 07/23/2025. The Discharge Notice also documented that Resident #81’s discharge may be appealed within seven days from 07/23/2025. A document titled, Resident #81’s Appeal, dated 07/23/2025, documented “I, [Resident #81], wish to appeal this involuntary discharge from [facility name].” A review of Resident #81’s progress note dated 7/22/2025 revealed Resident #81 refused to give up a pack of cigarettes and lighter. Her son was called, and he was informed that if Resident #81 have any other behaviors within the 30 days the discharge will be immediate. A review of a progress note dated 6/02/2025 indicated Resident #81 instigated conflict with another resident. [Resident #81 was in the hallway and would purposely stop in front of the other resident causing a collision with another resident. During an interview on 08/19/2025 at 2:54 PM, the Administrator indicated Resident #81 was admitted around December 2024, and the resident filed an appeal before they were discharged . The Administrator then stated the Ombudsman helped Resident #81 file the appeal. During a telephone interview on 08/19/2025 at 3:18 PM, the Ombudsman stated Resident #81 indicated they were not given a choice about discharging. The Ombudsman stated she informed Resident #81 and their family member, that Resident #81 did not have to leave if they wanted to appeal the discharge. The Ombudsman revealed she called and cancelled the appeal after the facility discharged the resident. She then stated she could not get in contact with Resident #81’s family member after she found out the facility had discharged the resident. The Ombudsman indicated that Resident #81’s family member did not want the resident discharged to a different facility. During a telephone interview on 08/20/2025 at 2:39 PM, Resident #81's family member revealed the resident filed an appeal before they were discharged from the facility, and Resident #81 was still discharged . The family member then stated Resident #81 did not want to be discharged . During a phone interview on 08/21/2025 at 11:15 AM, Resident #81 confirmed they were admitted to the facility December 2024 and did not know why they were discharged from the facility. Resident #81 revealed they informed the Administrator they wanted to file an appeal the day they were told they had to leave. The resident stated the Administrator informed them they had no choice. Resident #81 indicated she did not want to leave the facility, they never smoked in the facility, never had cigarettes or a lighter in their room, and the only drug they had ever taken, before being admitted , was marijuana. Resident #81 indicated they only had a urine test for a urinary tract infection and was never asked or informed of a drug test being completed. During an interview on 08/21/2025 at 1:50 PM, Certified Nurse Aide (CNA) #5 indicated Resident #81 was never witnessed being physically abusive to another resident. During an interview on 08/21/2025 at 2:03 PM, CNA #9 indicated she did not remember Resident #81 physically harming another resident. During an interview on 08/21/2025 at 2:34 PM, the Administrator indicated Resident #81 was discharged for improper behavior and for not following smoking policies. He revealed Resident #81 was issued a 30-day notice on 07/23/2025 and discharged to a different facility the next day on 07/24/2025. The Administrator indicated that he was aware that Resident #81 filed an appeal, and he chose to discharge the resident to another facility anyway. The Administrator then revealed Resident #81 never physically abused another resident, but there was a need for an immediate discharge because Resident #81 bumped their chair into another resident’s wheelchair. During an interview on 08/21/2025 at 2:53 PM, CNA #6 stated she did not know why Resident #81 was discharged from the facility. She revealed she had never witnessed Resident #81 physically abusing another resident or smoking in their room. During a phone interview on 08/21/2025 at 3:14 PM, the Medical Director stated he did not know why Resident #81 was discharged from the facility. A review of a facility policy titled, Admission, Transfer, and Discharge revealed, The nursing facility will not transfer or discharge a resident while an appeal is pending, unless the failure to discharge would endanger the health or safety of the resident or other individuals in the nursing facility.

Based on observation, interview and record review the facility failed to maintain a safe and homelike environment, ensuring safety from floor clutter, detached wall vinyl, and detached wall rails posing potential hazards for falls. The findings are: 1. Review of an undated policy titled, Accidents, Hazard Prevention, specified, the frailty of some residents increases their vulnerability to hazards in the resident environment and can result in life-threatening injuries. It is important that all facility staff understand the facility's responsibility, as well as their own, to ensure the safest environment possible for residents. 2. On 10/30/2023, at 9:15 AM, environmental rounds were made in the facility, the following were observed: a. Standing at the front of the 100 Hall, and facing room [ROOM NUMBER], in the middle of the room, on the floor, between Bed A, located horizontal on the left side of the room, against the wall and Bed B, located vertical under the wall light, on the right side of the room, were three (3) medium size full cardboard boxes, shoes, clothes, personal documents, books, magazines, and three (3) full size plastic grocery bags of clothes, spread out on the floor between and in front of the privacy curtain. In addition, the bed side table on the left side of the room, between the bathroom and closets, obstructed the sink pathway, with an upright television, detached cords lying on the floor just under the bedside table, which belonged to Bed B. b. Entering the dining room, on the 300 Hall, after leaving the nurses station, located in the center of the building, immediate to the right was 6-inch wall vinyl four feet in length, detaching from the wall of the dining room on the immediate right of the entrance. The floor had brownish-black discolored stains and debris. c. Standing in front of the 300 Hall, upon entering room [ROOM NUMBER], standing at the door, to the immediate left, the wall rail, eight (8) inches by five (5) feet detached from the wall, on the left side and held up by a bedside table. d. Standing at the entrance of room [ROOM NUMBER], on the left side of the room, between the sink and the bathroom, six (6) inches by two (2) feet vinyl trim was detached from the wall. On the left side of the room the bed was positioned horizontally against the wall, half-way between the bottom and top of the bed was a 6-inch gash in the middle of the wall, with fuzzy residue. Toward the head of the bed, on the left was 1 gash, 1 inch by 2 inches with white fuzzy residue exposing grainy white substance, next to resident ' s sleeping pillows. 3. On 10/30/2024, during a tour with the Administrator and the Corporate Nurse Consultant at 2:06 PM, in response to the questions, is maintenance available and are you aware of the difficulty walking in room [ROOM NUMBER], disconnecting vinyl in the dining room upon entering from the 300 Hall with the discolored stains and debris, hanging wall rail in room [ROOM NUMBER], and the disconnected vinyl trim and wall gashes next to the bed where the resident sleeps the Administrator stated, maintenance is not here. The Corporate Nurse stated that the repairs will be made immediately. 4. Review of the facility Maintenance Request Book obtained from the Administrator on 10/30/2024 with dates for current repairs, revealed no maintenance requests for the vinyl repair in the dining room, or any repairs requested for room [ROOM NUMBER], and 307.

According to observation, record review, and interview the facility failed to ensure residents were free from abuse with continuous altercations of verbal abuse and physical abuse between two residents (Resident #47 and Resident #54). This failed practice had the potential to affect all 66 residents currently in the facility to psychosocial harm from repeated resident to resident abuse altercations. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 03/12/2024 at 12:30 PM, when Resident #47 and Resident #54 had an altercation in the dining room. The altercation from witness statements began when Resident #54 was impatient at the coffee area and rammed into Resident #47, which caused an argument between the two residents. A few minutes later after separation Resident #47 bumped into Resident #54's wheelchair and another argument began in the dining area. The Administrator and Nurse Consultant were notified of the IJ on 05/03/2024 at 11:00 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 05/03/2024 at 05:32 PM. The IJ was removed after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F600 remained at the lower scope and severity of no actual harm with an isolated potential for more than minimal harm that was not immediate jeopardy: These were our findings: A review of the Care Plan indicates that Resident #47 had diagnoses of chronic inflammatory demyelinating polyneuritis, cerebral palsy, bipolar disorder, major depressive disorder, and post-traumatic stress syndrome (PTSD). A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/22/2024 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. A review of the Care Plan indicated Resident #47 makes false accusations against staff, yells at other residents without provocation, and will argue with others and get in their personal space. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/2024 indicated Resident #54 had a score of 7 (0-7 indicates moderate cognitive impairment) on a Brief Interview of Mental Status. A review of the order summary indicated Resident #54 had diagnoses of Down Syndrome, generalized anxiety disorder, and unspecified intellectual disabilities. A review of the medication administration record indicates no charting for behavioral symptoms. A review of the Care Plan indicated on 03/12/2024 a revision was made that stated, [Resident #54] is obsessed with certain other resident's and becomes physically and verbally aggressive towards them. placed on male secured unit for decreased stimuli . A review of the Care Plan with an initiated date of 05/04/23 and a revision date of 04/23/2024 indicated, .[Resident #54] can be disruptive. Yelling at other residents and staff, will throw food, plastic wrappers, other items on the floor. Also, will throw food on the walls. Sits in wheelchair in the middle of the hallway and watches television. Wants other residents doors closed. Grabs other residents. Goes into other residents rooms and yells at them, physically aggressive, agitated, frustration/anger at others, makes disruptive sounds, threatens others, anxious, exit seeking behaviors. Refuses bath. Scratches others .' A review of documentation from a care plan conference held on 03/19/2024 for Resident #54 stated, Care plan conference regarding behaviors - possible room change per family [the resident] perceives that somebody will take his stuff. Had a psych [psychological] eval which recommends [Facility Name]. [Resident #54] is going to return to regular room on 400 hall. Family does not want [Facility Name] placement. On 05/02/2024 at 10:55 AM, the Surveyor heard a commotion in the hallways, while walking toward the dining room on the 300 Hall side could hear raised voices. There were several staff members standing at the entrance, ten residents were in the dining room and residents around the nurse ' s station were looking around confused at where the raised voices were coming from. Two residents down the 300 Hall were in the hallway looking down the hall towards the dining room. Staff were standing around Resident #47. The Dietary Manager had a hold of Resident #47's wheelchair handles, the resident was saying if, [Resident #54] wants to [expletive] fight [Resident #54] can [expletive] fight, [Resident #54] said [Resident #54] was going to kill him. Resident #47 then stated, [Resident #54] kicked me, [Resident #54] kicked me I am telling you [Resident #54] kicked me. The Surveyor observed Resident #47 kept yelling as the Dietary Manager wheeled the resident over to a table to calm the resident down. Resident #47 was stating that [Resident #54] kicked me, and I did not do [expletive] to [Resident #54] him. The Surveyor observed Resident #54 was nowhere in sight. The Surveyor then observed Resident #47 wheeling over to the 400 Hall stating over and over again, I am going to [expletive] kill [Resident #54], if [Resident #54] wants to go, I will go. I am going to beat [Resident #54's] [expletives]. The Surveyor observed Resident #47 was red in the face, spit was flying from the resident's mouth, legs straight, and visibly shaking threatening to go down the hall to Resident #54's room with staff attempting to calm the resident down. The Surveyor heard Resident #54 yelling back down the hall threatening Resident #47. The Surveyor walked with Licensed Practical Nurse (LPN) #2 to Resident #54's room. LPN #2 asked what happened. The Surveyor heard Resident #54 stating, I am not going to lie, I kicked [Resident #47]. LPN #2 asked if [Resident #54] was good, the resident was calm. Resident #54 said yes and asked about the resident's cokes. LPN #2 said [Resident #54] was getting two boxes this afternoon. Resident #54 then started complaining about how cold the room was and wanting the vents closed. LPN #2 said what are we going to do when we see [Resident #47] again today. Resident #54 stated, I will beat [Resident #47's] [expletive]. LPN #2 said no we will not engage again. LPN #2 asked if the resident was good, [Resident #54] was calm. Resident #54 then said yes and started complaining about the vents being cold. LPN #2 asked if [Resident #54] wanted to stay in the resident's room to calm down for a while if maintenance will close the vents, and Resident #54 started rubbing the resident's stomach to ask for a snack being agreeable with staying in the resident's room as long as they closed the vents. On 05/02/2024 at 11:00 AM, Dietary Aide #2 stated, This happens all the time, it's only the two of them. The Surveyor asked what happened with today's altercation. Dietary Aide #2 stated, [Resident #54] was getting a cup of coffee and [Resident #47] wheeled into the dining room. When [Resident #54] saw [Resident #47], [Resident #54] pointed the resident's finger at [Resident #47] and yelled, I am going to kill you. Resident #54 then ran the resident's wheelchair into [Resident #47] and then kicked the resident in the left leg. On 05/02/2024 at 12:09 PM, the Surveyor interviewed Resident #9 and Resident #1 in the resident's room. The Surveyor asked if any interaction or incidents of yelling between residents has happened before. Resident #9 laughs and said, All the time. Constant hollering between Resident #54 and Resident #23 a lot of times they say they want to kill each other and cursing. I have never heard such filthy talking men. I don't go for that kind of stuff and when you say anything they say nothing they can do. The Surveyor asked who have you told, whoever is around, staff. Resident #9 said, yes, they holler and wake you out of a sound sleep. It is disturbing. I would not let a child do that in my home, it was never allowed. I'm told they can't help it. I hate when they start as you are falling off to sleep. I don't know the resident's name, but is handicapped and, in a wheelchair, and they hit the resident, and the resident's words are bad. The Surveyor asked how often the incidents occur. Resident #9 said off and on all the time and early afternoon and night too. The Surveyor asked what has been done to prevent the negative interactions. Resident #9 stated they try to keep them apart and it lasts maybe 2 minutes. The Surveyor asked does this ever involve or happen to other residents. Resident #9 said usually at the dining table and whoever is at the table. That is why [Resident #1] and I eat in here. (In room) I don't want to get in on that. The Surveyor asked do you feel safe here. Resident #9 said I do not feel safe here. I am teetering on my feet and now in a wheelchair. The Surveyor asked Resident #1 if there had been any incidents of yelling. Resident #1 said yes. It happens all the time, but I grew up in a house full of kids, so noise doesn ' t bother me. I hear [Resident #23] all the time. The Surveyor asked is that why you don't go to the dining room. Resident #1 said I don't ever leave my room. I don't feel good. The Surveyor asked do you feel safe here. Resident #1 said yes, I feel safe here. On 05/02/2024 at 12:30 PM, the Surveyor interviewed the Assistant Director of Nursing (ADON). The Surveyor asked if the interaction/incidents between Resident #47 and Resident #54 happened before. The ADON stated yes. The Surveyor asked how often has these incidents occurred. The ADON said April and March maybe. I would have to check. The Surveyor asked what has been done to prevent the negative interactions. The ADON said immediately separated, medication reviews, and psych visits for each. The Surveyor asked that is after the fact, what was done to prevent the incidents. The ADON said one intervention was to put coffee machine up front as Resident #54 usually eats in the resident's room. The Surveyor asked does this ever involve or happen to other residents. The ADON said just those two. The Surveyor asked if any other residents have complained. The ADON said yes in the dining room and a grievance was done from someone in a room. On 05/02/2024 at 1:23 PM, Certified Nursing Assistant (CNA) #3 had worked in the facility almost 1 month on the 7:00 AM to 3:00 PM shift. The Surveyor asked if interaction/incidents between Resident #47 and Resident # 54 had happened before. CNA #3 said yes, every other week. We try to keep them separated. The Surveyor asked what has been done to prevent negative interactions with these residents. CNA #3 said we keep an eye on Resident #54, was on monitor sheet for every 15 minutes. The Surveyor asked does this ever involves or happens to other residents. CNA #3 said Resident #47 is sweet to everybody else so is Resident #54. Resident #54 was yelling at Resident #44 his roommate that is dependent on care. Resident #47 and Resident #54 had an altercation on my second day here. They said they usually do that. The Surveyor asked who said they usually do that. CNA #3 said the other staff, Resident #54 usually doesn't eat in the dining room. The Surveyor asked has any resident told you they were tired of hearing the two of them. CNA #3 said no. On 05/02/2024 at 01:30 PM, during an interview with Dietary Manager, the Surveyor asked if this interaction between Resident #47 and Resident #54 had happened before. The Dietary Manager said yes. The Surveyor asked how often the incidents occur. The Dietary Manager stated it used to happen every other day. I talk to Resident #47 a lot and talk about the values the resident has, common sense, and calm the resident and redirect the resident. The Surveyor asked what has been done to prevent the negative interaction. The Dietary Manager said we put a coffee pot up front for Resident #54 to go get coffee. I ask Resident #47 to ignore Resident #54 when the resident points and makes noises. Resident #54 was at one point on the unit. Resident #47 wanted to go to another facility and referrals were sent out. The Surveyor asked who the aggressor was. The Dietary Manger stated, When I see them, it is usually [Resident #54] with finger pointing and words. The Surveyor asked why was Resident #54 taken off the unit. The Dietary Manager said I do not know why. The Surveyor asked does this ever involve or happen to other residents. The Dietary Manger said yes. Resident #23 and Resident #54. One gets loud and the other starts getting loud. I don't remember Resident #47 having physical issues with anyone else. Just verbal between Resident #54 and Resident #23. On 05/02/2024 at 1:30 PM, the Surveyor interviewed residents in the facility: The Surveyor asked Resident #19, have you heard any yelling and fighting. Resident #19 stated yes, three or four times a day. The Surveyor asked do you know their names. Resident #19 said no I do not. The Surveyor asked do you feel safe. Resident #19 responded yes; I do. The Surveyor asked when you saw the fighting, did you tell anyone. Resident #19 said no I have not. The Surveyor asked Resident #26 have you heard any yelling and fighting, Resident #26 said yes. The Surveyor asked how often does it happen. Resident #26 said every day, I think. The Surveyor asked do you know their names. The resident indicated no. The Surveyor asked, have you told anyone? Resident #26 said no they have never asked me. The Surveyor asked do you feel safe. Resident #26 said yes. The Surveyor asked Resident #12 if the resident had heard any yelling and fighting, Resident #12 said in the dining room. The Surveyor asked how often this happens. Resident #12 said every day, it keeps me up and I can ' t sleep. The Surveyor asked do you know their names. Resident #12 said no I do not but its men and women. The Surveyor asked, have you told anyone. Resident #12 said yes, I tell the Certified Nursing Assistants and it makes me feel like they do not care for me as they cannot make them go to bed or to their room that is what they said. The Surveyor asked do you feel safe. Resident #12 said yes, I think I do. The Surveyor interviewed Resident #42, who had been in the facility 6 months and was Resident Council President. The Surveyor asked has there been any interactions or incidents with residents. Resident #42 said at lunch today Resident #23, and Resident #14 hollered during the meal and Resident #47 got in the wheelchair got a little loud. No peace or quiet while eating here. The Surveyor asked do you feel safe here. Resident #42 said sure. The Surveyor asked what has been done to prevent the negative interactions. Resident #42 said nothing. It needs something done. The Surveyor interviewed Resident # 24 who stated he had heard a resident named (Resident #54) and a resident named (Resident #47) that yell and cuss at each other. That I've heard, but I've never seen it happen and 2 males that yell and cuss each other. Resident #24 was asked what the staff does when this happens. Resident #24 stated, Staff separate them. Resident #24 denied feeling afraid to be here in the facility, and no resident has cussed him or hit him. Resident #24 said this happens every other day. On 05/02/2024 at 2:58 PM, the Administrator was asked about [Facility Name] placement. She said no referral, it was just a suggestion in the care plan meeting that was shut down by the family. The Administrator was asked about why Resident #54 was placed on the unit then taken out. She stated it was to see if a decrease in stimuli would help. (Resident #54) ended up getting hit back there, so it was not helping. We ended up placing him back in the hall. The Administrator was asked what do you feel is the underlying cause of these altercations. The Administrator said they had a time frame and it usually occurred in the dining room but was not sure what the underlying issue was. The Administrator was asked what they were doing to protect the other residents. The Administrator said that they redirect and separate during altercations and that no other residents have been involved. The Administrator was asked what they were doing to protect Resident #54's vulnerable roommate. The Administrator said, I do not know of any issue or incident with his roommate. The Surveyor informed the Administrator that during interviews, a CNA said that they have witnessed Resident #54 yelling at their roommate. The Administrator said I was not informed of this and will look into it. Dates and Times of the Incidents: 03/11/2024 at 12:30 PM, the Witness Statement completed by Dietary Aide #3 stated, [Resident #54] got mad at [Resident #47] cause [Resident #47] was at the coffee table getting coffee. [Resident #54] rammed [the residents] wheelchair into [Resident #47] wheelchair. This is when the argument started between them. The facility then in-serviced on managing behaviors, filled out witness statements, separated, and redirected the residents. 04/10/2024 at 12:45 PM, the Witness Statement completed by Restorative CNA (RCNA) stated, [Resident #54] started to enter dining room. I stopped [Resident#54] to remind [the resident] to be nice. I turned away to help assist a resident eating. [Resident#54] entered the dining room, wheeled .up to [Resident #47], the two started to argue. The resident, [Resident #47] hit [Resident #54]. [Resident #54] kicked [Resident #47], me, and other staff member separated the two. The facility then in-serviced on managing behaviors, filled out witness statements, separated, and redirected the residents. 04/12/2024 at 10:45 AM, the Witness Statement completed by Medication Attendant Certified #1 stated, [Resident #54] was getting coffee while [Resident #47] was coming in from smoking. [Resident #54] did not say anything to [Resident #47], but [Resident #47] said Do you have a problem to [Resident #54]. That is when [Resident #47] started wheeling towards [Resident #54] as I was taking [Resident #54] out of the dining room I asked [Resident #47] to please stop yelling and [the resident] would not. [Resident #54] then started to yell back stating, I kill [Resident #47]. I removed [Resident #54] away from [Resident #47]. A facility policy titled, Abuse, Neglect and Maltreatment Investigation and Reporting stated, The facility will endeavor to protect Resident/Elders from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of Resident/Elder property. such maltreatment is strictly prohibited' This policy recognizes Resident/Elder rights to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints. Removal Plan: 1. On 5/2/2024, Resident #47 was placed on 1 on 1 observation by nursing staff for verbal altercation that occurred in the dining room at 11:00 a.m. 2. On 5/2/2024, Resident #54 was placed on 1 on 1 observation by nursing staff for verbal altercation that occurred in the dining room at 11:00 a.m. 3. On 5/2/2024 at 5:04 p.m., Resident #47 was transported to [local hospital] for medical clearance to be evaluated and treated for behavioral health. 4. Nurse consultant in-serviced Administrator, Assistant Administrator, and the Assistant Director of Nursing (ADON) on ensuring any resident-to-resident altercation and any residents that witness the altercation are assessed for psychosocial affects and offered Mental Health Services if needed. This was completed 5/3/2024 at 11:40 p.m. 5. Assistant Administrator in-serviced all staff on duty on Resident-to-Resident altercations, to stop the altercation immediately, and protect the resident involved. This includes any resident that witnessed the altercation to ensure an assessment is completed to ensure their psychosocial wellbeing is addressed and any Mental Health issues are assessed. Assistant administrator will in-service all oncoming employees before starting assigned shifts. This was completed 05/03/2024 at 3:40 p.m. 6. On 05/03/2024, the Assistant Administrator interviewed all residents that are interviewable for any psychosocial distress and offered mental health care as needed. There were no negative findings noted. This was completed on 05/03/2024 at 3:45p.m. 7. On 05/03/2024, at 12:15 p.m., the Nurse consultant contacted our behavioral health provider to immediately see any residents that have been negatively affected and were available as needed. There were no negative findings and Mental Health services provider was notified 3:48 p.m. on 5/3/2024. 37878 Onsite Verification: On 05/06/2024 between 9:30 AM and 2:00 PM, the Surveyor was in the facility for verification of removal of Immediate Jeopardy. 1. Record Review of Resident #47's 1 on 1 monitoring log began 05/02/2024 at 11:00 AM and ended at 4:45 after other resident sent out at 5:04 PM. 11:00 AM, resident crying, upset. 11:15 AM calm. no other documentation of emotional upset. 2. Record Review of Resident #54's 1 on 1 log sheet that began on 05/02/2024 at 11:00 AM and ended at 5:04 PM with documentation that Resident #54 was sent out. 3. Record Review of Resident #54's Discharge Instructions & Summary; Sent to local emergency department for medical clearance, then to be transferred to behavioral health facility. Resident #54 continued to have explosive behaviors and is at risk for self-injury and injury to others. All appropriate notifications made. 4.Record review of inservice education provided by Nurse Consultant included: If a resident-to-resident altercation occurs any resident that witnesses or is a part of the altercation should be assessed for any psychosocial injury. If the resident-to-resident altercation occurs with the same resident repeatedly, effective interventions should be implemented to protect the resident. signed by Administrator, Director Of Nursing, Assistant Administrator. 5. Record Review of facility staff in-service conducted on 05/03/2024, the education included: Stop altercation, protect residents involved in altercation as well as residents that may have witnessed altercation for psychosocial well-being, and notify charge nurse, Director of Nursing, and/or Administrator. Reviewed staff audit of all staff inserviced. Between 11:00 AM and 1:00 PM, interviewed the Staff that work various shifts, who confirmed they received inservice training related to resident-to-resident altercation and were able to verbalize understanding of separating/stopping, protecting residents involved as well as any resident that may have witnessed altercation that could affect their psychosocial wellbeing, notify charge nurse, Director of Nursing or Administrator of altercation. Nine Certified Nursing Assistants, 6 Licensed Practical Nurses, 1 Registered Nurse, 2 Medication Assistants, 3 Housekeeping staff, the Activity Director and occupational therapist were the staff interviewed. 6. Reviewed residents interviewed for psychosocial effect of Resident to Resident altercation, documented no negative effects, residents clamed no affect. Between 1:00 PM and 1:40 PM, interviewed 7 alert and oriented residents who reported being aware of or witnessed altercations between residents. They were asked if they were upset, worried, or felt fearful due to witnessing the altercations. All residents verbalized feeling safe now that the resident is no longer in the facility. 7. Reviewed Nurse Consultant note on 05/03/2024, contacted our Behavioral health Provider to be available for possible Telemed Psychosocial eval and treatment for any resident that may have been affected negatively by any Resident-to-Resident altercation. After Resident interviews, there were no noted negative findings. Behavior Health Providers were notified that there were no negative findings from Resident interviews. At 1:06 PM, the Nurse Consultant reported education was provided to all staff through audit to ensure all staff had received inservice, confirmed the Mental Health Consultants were notified of possible need to have residents referred for evaluation and treatment. At 11:58 AM, the Assistant Administrator confirmed that all staff were inserviced and that she participated in the resident audit to ensure all residents were evaluated for psychosocial effects. At 12:57 PM, the Administrator was interviewed and confirmed any altercation between residents are to be reported, all residents are to be protected and assessed for any effect and referred to Mental Health consultants for evaluation and treatment. The Administrator and the Regional Nurse Consultant were informed of the Immediate Jeopardy Plan of Removal with a completion date of 05/03/2024, verified removal on 05/06/2024 at 2:00 PM.

Based on observations, interviews, record reviews, facility document review, and facility policy review, it was determined that the facility failed to ensure hand hygiene was performed between resident rooms while delivering clean laundry. This failed practice had the potential to affect 14 residents residing on the secure unit, and the facility failed to keep a trash barrel covered to prevent residents from digging through trash on the secure unit for 1 (Resident #32) of 1 sampled resident observed. This failed practice had the ability to affect 14 residents residing on the secure unit. Findings include: A review of a document to Environmental Services Account Managers and Laundry Employees on 05/02/2024 at 09:40 AM regarding Reminder - Handling, Transport and Storage of Laundry, with a revised date of 10/2023, indicated, Page 2 Transport of Laundry indicates laundry will be handled and transported with appropriate measures to prevent cross-contamination and prevent the spread of infection. During an observation on 04/30/2024 at 12:07 PM, Laundry #1 entered the unit with a laundry cart containing clean laundry. Laundry #1 stopped at Resident room [ROOM NUMBER], covered her mouth with two ungloved hands, and coughed into hands. Laundry #1 then exposed clean laundry on cart by lifting the front cover of the cart and folding it back across the top of cart. Laundry #1 removed several items of clothing on hangers, entered Resident room [ROOM NUMBER], delivered the laundry, exited the room with empty hangers and placed them on the left side of the pole in the cart. Laundry #1 pushed the laundry cart to Resident room [ROOM NUMBER], removed clothing on hangers from the cart and entered Resident room [ROOM NUMBER]. Laundry #1 exited room [ROOM NUMBER] with empty hangers, hung the hangers on the left side of the cart on the pole. Laundry #1 pushed the laundry cart to Resident room [ROOM NUMBER], knocked, and announced, and entered Resident room [ROOM NUMBER] with laundry. No hand hygiene was done during this observation. During an interview on 04/30/2024 at 12:16 PM, Laundry #1 stated she had worked for facility for 11 1/2 years. Laundry #1 did not believe it was necessary to sanitize while delivering clean laundry. Laundry #1 stated, I should be, I guess. I just don't think about it. Laundry #1 was asked about the hangers being removed from the resident's rooms and said, I put the hangers here, and indicated to the far left of the bar under the cover. Laundry #1 further stated hangers and cart are sanitized after returning to laundry room. During an interview conducted on 05/01/2024 at 03:55 PM, the Administrator stated the laundry personnel were contracted and are expected to follow the same rules, policies, and procedures as all other staff. Review of the laundry and housekeeping schedule, provided on 05/01/2024 at 04:08 PM, by Laundry #4, documented Laundry #1 was a scheduled laundry employee on 04/30/2024. During an interview on 05/02/2924 at 08:24 AM, Laundry #3 was asked to describe appropriate laundry handling, washing, drying, and delivery of laundry to the halls/the resident rooms. Laundry #3 stated, during delivery, the cart is covered, and hands are to be sanitized before entry to a resident's room and after delivery of clothing. Laundry #2 agreed hands are sanitized prior to entry and after exit. After all laundry is delivered, return to each room to pick up empty hangers and place in clear trash bag to return to laundry for sanitizing. On 04/30/24 at 10:31 AM, Resident # 32 was observed bending over the rim of a gray trash barrel on wheels, and digging/moving garbage around, lifting a white piece of paper with the right hand and dropping it back into the barrel. There was no lid on the barrel located just inside the locked unit to the right of the double door, outside of the dayroom door. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2024, revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment and indicated the resident had Alzheimer's Disease and Non-Alzheimer's Dementia. A review of Resident #32's Care Plan, revised 04/15/2024, revealed the resident digs, pilfers with hands around the resident's bed, between the bed and the wall, and under the mattress. Interventions included, Please provide me with supervision for my safety. with an initiation date of 08/21/2019. A review of Order Summary Report, revealed Resident #32 was to be monitored for behaviors including stealing. Order date of 08/15/2019, start date of 08/15/2019, and no end date entered. During an interview on 05/01/2024 at 09:15 AM, Certified Nursing Assistant (CNA) #2 said a lid should be on the trash barrel and that she spoke with administration Thursday, last week, about getting a lid on the barrel for this and she was going to order one. On 05/01/2024 at 10:04 AM, Dietary #1 was observed placing a lid on the trash barrel. During an interview on 05/03/2024 at 03:25 PM, the Assistant Director of Nursing (ADON) said trash barrels should have lids and be covered to prevent infection and prevent residents from getting into the barrels. The ADON was not aware of who was responsible for having the trash barrels covered. During an interview on 05/03/2024 at 03:28 PM, the Administrator stated if the barrels are the large ones they should have a lid, the CNAs are responsible for the barrels being covered, and lids were recently ordered. 42016

Based on record review, observation and interview, the facility failed to ensure interventions were utilized to prevent worsening of contractures for 2 (Residents #40 and #66) of 2 sampled residents. The findings are: 1. A review of the Order Summary indicated Resident #40 had diagnoses of abnormal posture, stiffness of left shoulder, and stiffness of left elbow. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/2024 indicated Resident #40 had a Staff Assessment for Mental Status (SAMS) completed with a memory problem for short-term and long-term and has impairment on both sides of upper and lower extremities. A review of the Care Plan with an initiated date of 01/10/2024, indicated Resident #40 required, Problem: .is receiving a restorative program . Goal: Will maintain a ROM (range of motion), balance in order to reduce risk for contractures and skin breakdown by next review .Approaches/Tasks Left Elbow Extension [NAME] up to 4 hours . Further review indicates Resident #40 was to have cushion boots on at all times. On 04/30/2024 at 10:00 AM, the Surveyor observed Resident #40 in bed with no interventions in place for left arm or cushion boots on feet. On 05/01/2024 at 8:30 AM, the Surveyor observed Resident #40 in bed with no interventions in place for left arm or cushion boots on feet. On 05/02/2024 at 9:25 AM, the Surveyor asked Certified Nursing Assistant (CNA) #3 if Resident #40 had had a left elbow extension brace. CNA #3 stated, No. The Surveyor asked if Resident #40 wears cushion boots at all times. CNA #3 stated, No. The Surveyor asked, without interventions in place what could happen without the brace or cushion boots. CNA #3 said contracture could worsen and the residents' feet could get sores on them without interventions. On 05/01/2024 at 9:45 AM, the Surveyor asked Registered Nurse (RN) #1 what could happen if Resident #40 does not have interventions in place for contractures. RN #1 stated they could become worse. The Surveyor asked what could happen without interventions for feet such as cushion boots. RN #1 said the resident could develop pressure ulcers. 2. A review of the Order Summary indicated Resident #66 had a diagnosis of hemiplegia and hemiparesis after a cerebral vascular incident. Further review indicated an order with a start date of 12/09/2023 that stated, Ensure hand brace is in place at least 16 hours a day, every shift for brace. A review of Resident #66's May 2024 Medication Administration Record documented a check mark for every shift but the evening shift on May 2, 2024. A review of the Quarterly MDS with an ARD of 03/15/2024 indicated Resident #66 had a SAMS indicated Resident #66 was severely cognitively impaired and had no impairment of the upper or lower extremities. A review of the Care Plan with an initiated date of 05/01/2024, documented Resident #66 had a right hand contracture and right foot drop, and occupational therapy (OT) was to evaluate and treat as indicated for right hand splint. On 04/30/2024 at 10:05 AM, the Surveyor observed Resident #66 up in a geriatric chair in the resident's room, with a right-hand contracture. Resident #66 was unable to open the right hand and had no interventions in place. On 05/01/2024 at 8:30 AM Surveyor observed Resident #66 up in a geriatric chair up in room, with no interventions in place for right hand contracture. On 05/02/2024 at 9:25 AM, the Surveyor asked CNA #3 if Resident #66 had any interventions for the right hand contracture. CNA #3 said oh yeah, they were talking about changing it to a carrot, the contracture has worsened, and Resident #66 cannot hand the brace anymore. The Surveyor asked CNA #3 what could happen if interventions are not in place. CNA #3 said that the contracture could worsen. The Surveyor observed CNA #3 insert a washcloth in the right hand of Resident #66 after the interview. On 05/02/2024 at 9:45 AM, the Surveyor asked RN #1 what interventions were in place for Resident #66's right hand contracture. RN #1 said she would have to look. The Surveyor asked what could happen without interventions in place for the right hand contracture. RN #1 said the contracture could worsen. On 05/02/2024 at 10:34 AM, the Administrator reported there was no relevant policy.

Based on interviews and record review, it was determined that the facility failed to provide a pneumonia vaccine for 2 (Residents #63 and #69) of 2 residents reviewed for immunizations. Findings include: Review of a facility policy titled, Pneumococcal Vaccine (Series) with a Copyright date of 2022, specified, 1. Each resident will be assessed for pneumococcal immunization upon admission.2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders . A review of the Consent for Vaccinations dated 07/24/2023, documented Resident #63 authorized the facility to administer a one-time pneumococcal vaccine. A review of the Immunizations tab in, the electronic health record, Resident #63 did not have information entered that the pneumonia vaccine was received. A review of the Consent for Vaccinations dated 02/26/2024, documented Resident #69 authorized the facility to administer a one-time pneumococcal vaccine. A review of the Immunizations tab in the electronic health record, Resident #69 did not have information entered that the pneumonia vaccine was received. On 05/03/2024 at 02:43 PM, the Infection Control Preventionist (IPC) was asked to provide information on the administration of the pneumococcal vaccine to Resident #63 and Resident #69. During an interview on 05/03/2024 at 02:59 PM, the IPC stated Resident #63 and Resident #69 never received the pneumococcal vaccine. The IPC stated the facility was working on a process for vaccines due to IPC not receiving notification when residents request vaccines. During an interview on 05/03/2024 at 03:10 PM, Social Services stated when new residents enter the facility, they are given an opportunity to consent or decline vaccines for the flu, pneumonia, and COVID-19. Once the document is complete it is uploaded into their chart. Social Services notifies the nurse who then looks at the computer for the document and orders the vaccine. Social Services was not aware of who ensures the orders are done.

Based on observation, interview and record review, the facility failed to ensure dishes/utensils were stored under sanitary conditions and food preparation equipment was cleaned properly in the kitchen. These are the findings: A review of the Cleaning Schedule indicated the following were to be completed weekly: ovens inside and outside, Aide tables/microwave area, Outside of the refrigerator, Refrigerator inside cleaning, plate warmer, under cooks table, fryer-cleaning inside and outside, dish machine-cleaning on top of dish machine, steam table under, coffee pots and tea pots, carts-daily. The Dietary Manager stated on [DATE] at 3:30 PM, that this is the only cleaning schedule they use. On [DATE] at 9:10 AM, the Surveyor observed the hand washing station in the kitchen, the hot water side had water coming from the base, creating a red brown stain inside of the sink. The Surveyor then observed the eye wash station was covered in red/brown spots, and that the left cover was missing with debris on the inside of the gray plastic piece. On [DATE] at 9:18 AM, the Surveyor observed in a cardboard box at the bottom of the bread shelf a package of tortillas with a received date of [DATE] and expiration date of [DATE]. The Dietary manager stated there were five packages of 12 flour tortillas left in the box that were expired. On [DATE] at 9:20 AM, the Surveyor observed the backsplash spanning from the left of the oven to the prep table was covered in yellow/brown spots of various sizes. On [DATE] at 9:21 AM, the Surveyor observed a surveillance camera above the prep area that was covered in a brownish gray material, that was dripping off the cord. On [DATE] at 10:51 AM, the Surveyor observed a medium sized hole in the back right corner of the ceiling. On [DATE] at 10:52 AM, the Surveyor observed a white fan that is coated in gray matter on the outside and inside. On [DATE] at 10:52 AM, the Surveyor observed a secondary white fan close to the prep area that was coated in gray/black matter. The right hand corner was buckling from the ceiling, a sprinkler had been placed in the corner with a brown foam like matter surrounding the sprinkler head. On [DATE] at 10:53 AM, the Surveyor observed a small hole under the right hand corner of the venti hood. A nozzle that was over the fryer area was covered in yellow brown matter, and it was dripping off the orange rubber piece on the nozzle. A white plastic pipe was on the left hand side of the venti hood, towards the middle of the stove/oven area, was thickly coated in a yellow/brown matter. On [DATE] at 11:04 AM, the Surveyor observed in the dishwashing area the tile on the left hand side, under the dishwasher. The tile was discolored in gray black matter. The back wall had a large crack that forks in left and right directions, with missing tile directly underneath. In the back right corner under a shelf was a row of missing tiles, under the left side of the shelf, there was a red/brown stain on a tile with a hole in the middle of it, a cracked tile was observed on the left corner of the shelf. On [DATE] at 11:05 AM, the Surveyor observed the food processor coming out of the dishwasher. Dietary Aide #3 stated that it needed to run again as it had soap still on the inside. The Surveyor observed Dietary Aide #3 run the dishwasher with the food processor again. On [DATE] at 11:06 AM, the Surveyor observed the back wall of the three compartment sink was discolored, the shorter faucet was dripping continuously. On [DATE] at 11:15 AM, the Surveyor observed the Dietary Aide run the food processor through the dishwasher and bring it back to the prep area. The inside of the food processor had white soap bubbles and water inside. Dietary Aide #3 scooped 4 ounces of broth and the potatoes back into the food processor to finish pureeing for lunch. On [DATE] at 11:21 AM, the Surveyor observed two plastic clear bins filled with various ladles, scoops, tongs, spatulas, and whisks sitting with the handles in the bin and the kitchen silverware was exposed to kitchen contaminates. The Surveyor observed Dietary Aide #3 while preparing pureed foods, grab a #8 scoop and touch the inside of the scoop, then proceeded to use it to scoop the potatoes into the food processor for the residents on pureed foods. On [DATE] at 11:30 AM, the Surveyor observed Dietary Aide #3 bring the food processor back to the prep area with white soap suds and water in it. Using a 4 ounce scoop, Dietary Aide #3 added 8 scoops of California blend vegetables to the food processor and blended it for lunch.

Based on record review and interview, the facility failed to update a care plan regarding a resident's placement on the unit for 1 (Resident #54) of 1 sampled resident. The findings are: 1. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/2024 indicated Resident #54 had a score of 7 (0-7 indicates severe cognitive impairment) on a Brief Interview of Mental Status (BIMS). 2. A review of the Order Summary indicated Resident #54 had diagnoses of Down Syndrome, Generalized Anxiety Disorder, and Unspecified Intellectual Disabilities. 3. A facility review of the Care Plan indicated on 03/12/2024 a revision was made that stated, [Resident #54] is obsessed with certain other resident's and becomes physically and verbally aggressive towards them. placed on male secured unit for decreased stimuli . 4. A review of the Care Plan with a revision date of 04/23/2024 indicated [Resident #54] can be disruptive. Yelling at other residents and staff, will throw food, plastic wrappers, other items on the floor. Also, will throw food on the walls. Sits in wheelchair in the middle of the hallway and watches television. Wants other resident's doors closed. Grabs other residents. Goes into other resident's rooms and yells at them, physically aggressive, agitated, frustration/anger at others, makes disruptive sounds, threatens others, anxious, exit seeking behaviors. Refuses bath. Scratches others. 5. A review of a Care Plan Conference held on 3/19/24 for Resident #54 stated, Care plan conference regarding behaviors possible room change per family he perceives that somebody will take his stuff. Had a psych eval which recommends [Name of facility]. He is going to return to regular room on 400 hall. Family does not want [Name of facility] placement . 6. On 05/02/24 at 2:58 PM, the Administrator was asked about [Name of facility] placement, she stated no referral, it was just a suggestion in the care plan meeting that was shut down by the family. The Administrator was asked about why Resident #54 was placed on the unit then taken out. She stated it was to see if a decrease in stimuli would help. He ended up getting hit back there, so it was not helping. We ended up placing him back in the hall. The Administrator was asked what do you feel is the underlying cause of these altercations. The Administrator stated they had a time frame and it usually occurred in the dining room but was not sure what the underlying issue was. The Administrator was asked what they are doing to protect the other residents. She stated that they redirect and separate during altercations and that no other residents have been involved. The Administrator was asked what they were doing to protect Resident #54's vulnerable roommate. She said she did not know of any issue or incident with his roommate. The Surveyor then stated that the roommate was 100% dependent and non-verbal and Resident #54 had yelled at the roommate. The Administrator said I will look into that. 7. On 05/03/24 at 9:40 AM, during an interview with the MDS Coordinator the Surveyor asked why it is important to have an accurate care plan. The MDS Coordinator stated so that the best quality of care can be provided to the resident. The Surveyor asked what could happen if a care plan was not accurate. The MDS Coordinator said we may not be able to provide something that a resident needs.

Based on interviews, record review, and medication prescribing information, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medication for 1 (Resident #51) of 2 residents reviewed for unnecessary psychotropic medications. The findings include: A review of physician orders revealed Resident #51 had Depakote Oral Tablet Delayed Release (a medication used to treat manic episodes associated with bipolar disorder, seizures and migraine headaches) 250 milligrams (mg), Give 1 tablet by mouth three times a day for seizures/behaviors related to Alzheimer's disease with late onset. The order status is Active, with an order date of 03/08/2024, a start date of 03/08/2024, and no end date indicated. A review of medical diagnoses revealed Resident #51 had Alzheimer's disease with late onset, unspecified dementia, depression, post-traumatic stress disorder (PTSD), and unspecified convulsions. A review of the Depakote Full Prescribing Information, Revised March 2024, available through the Food and Drug Administration at www.accessdata.fda.gov, 1 Indications and Usage, revealed Depakote is indicated in the treatment for 1.1 Mania, 1.2 Epilepsy, and 1.3 Migraine. A review of the physician orders revealed Resident #51 had Quetiapine Fumarate (Seroquel) Tablet 50 mg (a medication used for the management of the manifestations of psychotic disorders and schizophrenia) Give 1 tablet by mouth two times a day related to Post-Traumatic Stress Disorder (PTSD), unspecified. The order status is Active, with an order date of 09/29/2022 and a start date of 09/29/2022, and no end date indicated. A review of the Quetiapine Full Prescribing Information, Revised October 2013, available through the Food and Drug Administration noted, 1 Indications and Usage, revealed Quetiapine is indicated for 1.1 Schizophrenia and 1.2 Bipolar Disorder. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/05/2024 revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. Section D Mood, D0500 Staff Assessment of Resident Mood, 2. J. Being short-tempered, easily annoyed did not indicate symptom presence or frequency. Section E Behaviors, E0200. Behavioral Symptom - Presence & Frequency A. Physical Behavioral symptoms directed at others, indicated, 1 the behavior of this type occurred 1 to 3 days. B. Verbal behavioral symptoms directed toward others, indicated 1, behavior of this type occurred 1 to 3 days. C. Other behavioral symptoms not directed toward others indicated, 1 behavior of this type occurred 1 to 3 days. Section I Diagnoses indicated Psychiatric/Mood Disorder, I5800. Depression (other than bipolar) and I6100 Post Traumatic Stress Disorder (PTSD). During an interview on 05/03/2024 at 04:33 PM, Licensed Practical Nurse (LPN) #3 stated Resident #51 was currently receiving Depakote for behaviors. LPN #3 stated clinical indications for the use of Depakote were seizures and behaviors. During an interview on 05/03/2024 at 04:42 PM, the Assistant Director of Nursing (ADON), stated Resident #51 was taking Depakote for seizures and behaviors but did not know the indications for the use of Depakote. During an interview on 05/03/2024 at 04:33 PM, Licensed Practical Nurse (LPN) #3 stated Resident #51 was currently receiving Quetiapine for behaviors and the clinical indication is to help Resident #51's mood and behavior. During an interview on 05/03/2024 at 04:42 PM, the ADON stated Resident #51 was taking Quetiapine for Post Traumatic Stress Disorder (PTSD) and the clinical indication was an antipsychotic. LPN #3 was asked how the Interdisciplinary Team (IDT) addresses unnecessary medications with the physician. LPN #3 stated, they would look at behaviors notes to determine if Resident #51 should be on it. The ADON was asked how the IDT addresses unnecessary medication with the physician. The ADON stated, sometimes try a gradual dose reduction (GDR) to see if they can go off of it. The ADON stated the physician would be questioned about prescribing for an off-label purpose. The ADON stated no residents in the facility were currently part of any drug testing study.

Based on observations, interviews, and record reviews, it was determined the facility failed to ensure residents call devices were in reach in the resident's room for 1 (Resident #29) of 1 sampled resident with call devices not in reach. The findings include: A review of Resident #29's Admission Record indicated the facility admitted Resident #29 on 05/17/2019 and listed diagnoses to included Parkinson's Disease with dyskinesia, Altered mental status, Repeated falls, Supraventricular tachycardia, Headache, Type 2 diabetes, and Unspecified pain. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 02, which indicated the resident had severe cognitive impairment. The resident was dependent on staff for oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and with transfers from chair/bed-to-chair transfer. Resident #29 was independent with eating and used a manual wheelchair for ambulation. A review of Resident #29's Care Plan initiated on 06/01/2020, revealed Resident #29 attempts to slide out of wheelchair, crawls out of bed, and is at risk for falls and falls with serious injury. Approaches/Tasks listed, Ensure call light is in reach. with a date initiated 12/02/2021. On 05/01/2024 at 10:16 AM, Resident #29 was sitting in the middle of the room in a wheelchair. The call light was lying across the bed on top of the linens. A fall mat was on the floor, parallel, next to the bed. Resident #29 was unable to reach the call light due to the fall mat impeding access to bed. During an interview on 05/01/2024 at 10:18 AM, CNA #2 stated all lights should be in reach and are in reach of the residents and if they are not the resident would not be able to call for assistance and they push the call light to get assistance. On 05/01/2024 at 10:19 AM, CNA #2 accompanied the Surveyor to Resident #29's room, Resident #29 was sitting in a wheelchair. CNA #2 stated the call light was not in reach and CNA #2 believed Resident #29 to be in bed. The call light should have been in reach. CNA #2 moved the resident's wheelchair closer to the bed in reach of the call light.

Based on observation, interview, and record review, the facility failed to ensure residents were showered/bathed as scheduled, fingernails were kept clean, and male residents were shaved to promote good personal hygiene for 02 (Resident #02 and #03) sample mix residents. The findings are: Facility provided procedure document titled 'Bath (Shower)' with a Revision Date of 01/03 that documented, Basic Responsibility: Licensed Nurse and Nursing Assistant Purpose: 1. To cleanse and refresh the resident. 2. To observe the skin. 3. To provide increased circulation . General Guidelines for Assessment may include, but are not limited to: Condition of skin, range of motion limitation, ADL function, resident's preference for time of day, frequency and type of bath, skin allergies .Procedure . 12. Report any reddened areas, skin discolorations of skin breaks to the charge nurse. General documentation guidelines Frequency of documentation should follow facility policy. Date, time (or shift), as appropriate. Other documentation may include amount of assistance required, reports of unusual observations to the charge nurse, initial once completed on assignment sheet . A review of Resident #02's care plan dated 11/21/2023 documented, .ADL (Activities of Daily Living) self-care performance deficit .Bathing Schedule: Monday, Wednesday and Friday .Eating: Set up or clean up Assistance . Personal Hygiene: Combing hair, shaving, makeup, washing/drying face and hands: Independent .Shower/bathe self: Partial or Moderate assist . Review of progress notes documented, 02/16/2024 Alert Note Text: No documented shower/ bath X 5 days will try again on next shower day . 02/23/2024 11:03 Alert Note Text: No documented shower/ bath X 5 day-2/21 1000 per document. Was also showered Friday 02/23 .03/10/2024 14:15 Alert Note Text: No documented shower/ bath X 5 day WNL(within normal limits) for resident per current CNA . Resident #02 had diagnoses of Dementia and Intellectual disabilities. The Modification of Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/2024 documented, Section.GG0130. Self-Care E. Shower/ bathe self: The ability to bathe self, including washing, rinsing, and drying self . 03. Partial/ moderate assistance .GG0130. Self-Care I. Personal hygiene: The ability to maintain personal hygiene including combing hair, shaving, applying makeup, washing/drying face, and hands .Independent . Resident #02's shower log for the last thirty days dated 02/21/2024 through 03/15/2024 documented the resident received a shower on 02/21/2024; 02/26/2024; 02/28/2024; and 03/15/2024. The resident is not documented as refusing any shower/ bath. On 03/20/2024 at 08:12 AM, the Surveyor observed Resident #02 in the dining room during breakfast with dirty fingers that have a brown substance underneath the nails. Resident had a slight body odor and is not shaven. On 03/20/2024 at 08:32 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) #01 in the dining room where the resident was sitting in his/her wheelchair and asked, Are the resident ' s fingernails clean? She stated, No. When asked, Can you describe what is on and under [his/her] fingernails? She stated, It's brown with some black stuff. When asked, Can you tell why [his/her] fingernails should be kept cleaned? She stated, Because [he/she] needs good hygiene and not chance them going into his mouth. When asked, What does the resident smell like to you? She stated, Like [he/she] needs a bath. When asked, Do you know when [he/she] was last showered? She stated, No. When asked, Do you know where showers are documented? She stated, In (electronic chart system). When asked, Do you know when [he/she] was last shaved? She stated, No. When asked, Does [he/she] appear to need to be shaved? She stated, Yes, it's getting shaggy. On 03/20/2024 10:02 AM, the Surveyor interviewed Certified Nurse Aide (CNA) #01 in the dining room where the resident was eating and asked, How often are residents showered/ bathed? She stated, Three times a week, unless the resident refuses, or as needed as well. When asked, Are Resident #02's fingernails clean? She stated, No, they aren't. When asked, Can you describe what is on and under [his/her] fingernails? She stated, It looks like B.M. When asked, Can you tell me why [his/her] fingernails should be kept clean? She stated, Well, [he/she] is eating those chips, and they are dirty. When asked, What does the resident smell like to you? She stated, Like body odor. When asked, Do you know when [he/she] was last showered? She stated, I normally don't work two hundred (200) halls, so I don't know. When asked, Do you know where showers are documented? She stated, Yes, in the kiosk. When asked, Do you know when [he/she] was last shaved? She stated, It looks like it's been a while. Resident #03's care plan dated 11/03/2023 documented, ADL self-performance deficit . Bathing Schedule: Tuesday, Thursday and Saturday . Eating: Set up or clean up Assistance. Staff sets up and cleans up .Personal Hygiene: Combing hair, shaving, washing/drying face, and hands: Dependent with 1 staff .Shower/bathe self: Dependent with 1 staff assist . The Quarterly MDS with an ARD of 02/01/2024 documented, GG0130. Self-Care A. Eating: The ability to use suitable utensils to bring food and/ or liquid to the mouth and swallow food and/ or liquid once the meal is placed before the resident . 05/ Setup or clean-up assistance . GG0130. Self-Care E. Shower/ bathe self: The ability to bathe self-including washing, rinsing, and drying self . 01. Dependent . GG0130. Self-Care I. Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/ drying face, and hands 01. Dependent . Review of Resident #03's shower logs dated 02/20/2024 through 03/19/2024 documented the resident received a shower/ bath on 02/20/2024; 02/24/2024; 02/27/2024; 02/29/2024; 03/02/2024 03/05/2024; 03/07/2024; 03/09/2024; 03/16/2024. The resident is not documented as refusing any shower/ bath. Facility provided an Inservice Education Report titled 'Activities of Daily Living (ADL)' dated 02/23/24 documented, Include hygiene, grooming, dressing, fluid and nutritional intake, mobility, and elimination needs. See Figure 5.1 for an illustration of ADLs. Hygiene refers to keeping the body clean and reducing pathogens by performing tasks such as bathing and oral care. Grooming also keeps the body clean but refers to maintaining a resident's appearance through shaving, hair, and nail care. Showers should be given as scheduled. If resident refuses notify the nurse and return later and ask again. Document multiple attempts were made and by who. If you notice a shower is not scheduled, notify DON (Director of Nursing)/ADON (Assistant Director of Nursing). Nail care should be provided on shower days and prn (when needed). If diabetic, the nurse should clip. Ensure nails are cleaned under the nail and at the cuticle. Document refusals and notify nurse. Beards should be shaved after the shower, while in the shower room. Ensure women are assessed for facial hair and addressed. Documentation does not chart N/A (non-available) on showers unless out of the building and a note should be entered. Showers are NOT N/A. Yes or no it was given. If ever not given, you must enter an alert and notify nurse. On 03/19/2024 at 01:46 PM, the Surveyor observed Resident #03 with with a brown substance underneath his/her fingernails and dirty hands. Residents #03 had a noticeable body odor. On 03/19/2024 at 01:46 AM, the Surveyor interviewed Resident #03 and asked, Are you receiving your shower/ bath as scheduled? He/she stated, No, supposed to be a couple times a week. When asked, When was the last time you received a shower/ bath? He/she stated, It's been a while. On 03/20/2024 at 10:02 AM, the Surveyor interviewed CNA #02 at Resident #03's bedside and asked, How often are the residents showered/ bathed? She stated, Monday, Wednesday, Friday is a set and Tuesday, Thursday, Saturday is a set. When asked, Are Resident #03's fingernails and hands clean? She stated, No, they should be clean. When asked, Can you describe what is underneath [his/her] fingernails and on [his/her] hands? She stated, It's brown with some orange under the nails, but hot sauce on [his/her] hands. [He/she] eats with their hands during meals and uses lots of hot sauce. When asked What does the resident smell like to you? She stated, Like [he/she] hasn't had a shower. When asked, Do you know when [he/she] was last showered? She stated, I believe [he/she] is Tuesday, Thursday, Saturday and [he/she] should've had one yesterday. When asked, Where do you document shower/ baths? She stated, On the computer. On 03/20/2024 at 10:49 AM, the Surveyor interviewed the DON and asked, How often are residents showered/ bathed? She stated, They are on a schedule for Monday, Wednesday, Friday or Tuesday, Thursday, Saturday. A few requests a shower day one day a week and PRN as they request. When asked, Should residents who eat with their hands have their hands cleaned after each meal? She stated, Yes. When asked, Why should residents who eat with hands have their hands cleaned after each meal? She stated, Because they are going to be dirty. When asked, Should brown/ black substance be cleaned off of residents hands and fingernails? She, Yes. When asked, Why should those substances be cleaned off of residents hands and fingernails? She stated, They should be clean, but it could also be something else. When asked, Should staff verify that resident ' s hands and fingernails are kept clean? She stated, Yes. When asked, Should male residents be shaved? She stated, Yes. When asked, Is Resident #02 allowed to shave without supervision? She stated, [He/she] used to have an electric razor but told me [he/she] can't find it. To be shaved any with a razor staff would have to do it. When asked, Can you tell me the last time Resident #03 received a shower/bath? She stated, Last bath was 03/16, [his/her] days are Tuesday, Thursday, Saturday. When asked, Did the resident receive [his/her] bath on Tuesday 03/19/2024? She stated, I can only look at documentation and it's not documented. When asked, Can you tell me when Resident #02 last received a shower/ bath? She stated, Based on documentation it's not documented on the schedule, and [he/she] is Monday, Wednesday and Friday last shower on 03/15. When asked, Did the resident receive [his/her] scheduled bath on 03/18/2024? She stated, No. When asked, Where do staff document resident baths? She stated, In (electronic record system), in the kiosk.

Based on interview, and record review, the facility failed to ensure residents received notification that their Medicare Part A Services were being terminated for 1 (Resident #25) of 3 (Residents # 21, #25 and #124) sampled residents who were reviewed for beneficiary notification. The findings are: 1. Resident #25 had a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. The 5 Day Admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 01/09/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. The Beneficiary Protection Notification provided by the Administrator on 03/16/23 at 10:50 AM documented, .Medicare Part A Skilled Services episode start date: 1/04/23; Last covered day of Part A Service: 1/13/23 . b. On 03/16/23 at 10:50 AM, the Administrator stated, I don't have the forms that were given to him. The old Social Worker was in charge of that, and I'm not sure why she didn't scan it in, or what she did with the forms. c. On 03/16/23 at 11:02 AM, the Surveyor asked Resident #25, In January, did any of the staff inform you that you had Medicare Part A services that were being terminated? He stated, No, I've never heard of that. The Surveyor asked, Did they provide you with a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form, and a Notice of Medicare Non-Coverage Form? He stated, No, they didn't give me anything, and I've never heard of those forms. I didn't know I was getting Medicare. I know I get VA [Veterans Administration] benefits. No one has brought me any type of papers. d. On 03/16/23 at 12:16 PM, the Surveyor asked the Director of Nursing (DON), Can you tell me why [Resident #25] wasn't issued a Beneficiary Protection Notification? She stated, No I cannot.

Based on interview, and record review, the facility failed to ensure showers were given as scheduled for 1 (Resident #47) of 6 (Residents #5, #17, #26, #47, #51 and #58) sampled residents who were dependent on staff for showers. The findings are: Resident #47 had diagnoses of Major Depressive Disorder and Seborrheic Dermatitis. The Quarterly Minimum Data Set (MDS) an Assessment Reference Date of 01/09/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive two plus persons physical assistance with bed mobility, dressing and toilet use; was totally dependent of two plus persons physical assistance for transfers and required supervision with one person physical assistance with personal hygiene. Bathing activity was marked as did not occur during the 7 day look back period. a. The Care Plan with a completion date of 01/24/23 documented, .I have ADL [activities of daily living] self-care performance deficit . I will be clean and well-groomed daily throughout review date . Bathing: Extensive assist with 1 staff . b. On 03/14/23 at 10:21 AM, Resident #47 stated, I'm concerned about my showers. I talked with the Administrator, and they have been doing better. I ' m supposed to get them Monday's, Wednesday ' s, and Friday's. c. On 03/16/23 at 10:54 AM, the Director of Nursing (DON) provided a copy of Resident #47's bathing logs for February 2023 and March 2023. The February 2023 bathing log documented Resident #47 received a bath 4 times, 02/08/23, 02/10/23, 02/13/23 and 02/15/23. The March 2023 bathing log documented Resident #47 did not receive a bath on 03/03/23, 03/06/23 and 03/10/23. d. On 03/16/23 at 11:50 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1, How often does [Resident #47] get a shower? She stated, I believe it's three times a week. It's Monday's, Wednesday's, and Fridays. The Surveyor asked, Do you know why he's been missing some of his showers? She stated, We don't have a shower aide. We had someone coming in every other day, but she's called in the last couple of weeks. e. On 03/16/23 at 12:00 PM, a Grievance Report provided by the DON documented, .03/06/23 . [Family Member] to [Resident #47] called the Administrator to report his [Resident #47] isn't getting showers regularly and hasn't had one in several days . f. On 03/16/23 at 12:08 PM, the Surveyor asked CNA #2, How often does [Resident #47] get a shower? She stated, I don't normally work on the 200 Halls, but I believe his shower days are Monday's Wednesday's and Friday's. The Surveyor asked, Do you know why he hasn't been getting his showers? She stated, No ma'am, I don't. On 03/16/23 at 12:20 PM, the Surveyor asked the DON. How often does [Resident #47] get a shower? She stated, He is three days a week. The Surveyor asked, Do you know why he hasn't been getting his showers? She stated, I have to go by the charting, and do an in-service on charting. The Surveyor asked, Did you talk to [Resident #47] about his showers? She stated, I've spoken with him in the past, and the CNA's as well about him not getting showers. The Surveyor asked, What does it mean when the staff documents NA on the shower log? She stated, Not Applicable. The Surveyor asked, Why would the staff document not applicable? She stated, He didn't receive a shower.

Based on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 11 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 03/16/23. The findings are: 1. On 03/15/23 at 11:24 AM, Dietary Employee (DE) #1 placed 13 servings of polish sausages into a blender, added beef broth and pureed. At 11:26 PM, She poured the pureed polish sausages into a pan. She covered the pan with foil and placed it in the oven to serve to 11 residents who had Physician Orders for pureed diets. The consistency of the pureed polish sausage was gritty and was not smooth. 2. On 03/15/23 at 11:41 AM, DE #1 used a 4 ounce spoon to place 15 servings of fried potatoes into a blender, she added beef broth and pureed. At 11:46 AM, she poured the pureed fried potatoes into a pan. She covered the pan with a piece of foil and placed it in the oven to be served to the residents on pureed diets. The consistency of the pureed fried potatoes was lumpy and was not smooth. 3. On 03/15/23 at 12:31 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents. She stated, Pureed polish sausage and the pureed oven fried potatoes needed to be pureed some more for the consistency of pudding. 4. On 03/16/23 at 7:40 AM, for breakfast, pureed sausage and pureed cream of wheat were served to the residents on pureed diets. The pureed sausage and the cream of wheat were runny. At 7:49 AM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed sausage and the pureed cream of wheat served to the residents. She stated, There were a little runny.

Based on observation, record review, and interview the facility failed to ensure all windows in the facility were secured so residents could not raise windows and climb out for 1 (Resident #1) of 7 (Residents #1, #2, #3, #4, #5, #6, and #7) sampled residents who were at risk for elopement. This failed practice resulted in immediate jeopardy which caused or could have caused serious harm, injury or death for Resident #1 who exited through his bedroom window and left the facility premises and had the potential to cause more than minimal harm to 64 residents who were at risk for elopement per a list provided by the MDS (Minimum Data Set) Coordinator on 07/28/2021 at 12:13 p.m. The Administrator was notified of the Immediate Jeopardy on 07/26/2021 at 8:28 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses of Dementia, Type 2 Diabetes Mellitus, [CONDITION(S)] and Hypertension. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/2021 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); exhibited wandering behavior 1 to 3 days, the wandering placed the resident at significant risk of getting to a potentially dangerous place and significantly intruded on the privacy of others; required supervision for bed mobility, transfer, walking in room, and in corridor, locomotion off unit, dressing, toilet use and personal hygiene per setup help only; extensive assistance for bathing per one person physical assistance; and was always continent of bowel and bladder. a. A Care Plan dated 07/15/2021 documented . I am at risk for elopement risk/wanderer. I sundown I may state I am headed to the office I believe this is my first day on my new job I would prefer to sit outdoors. I request we go walk to find my valuables I ask for assistance to locate my Cadillac keys I may wander from my room. I will remove Stop banner from door. I frequently pack/unpack my belongings. I arrange and rearrange my room frequently. I experience difficulty sitting still for any length of time. I am easily redirected but will forget quickly. 7/24/21 = Elopement by climbing through window during the night . 7/24/21 = 1:1 observation until able to be moved to the secure unit for his safety. Moved to room [room on 600 Hall] .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 7/15/2021 . b. An Admission Evaluation dated 07/15/2021 documented . Elopement Risk . Scoring - Score of less than 5 = Low Risk; Score of 5 or greater = High Risk . Is resident at risk for elopement? - Yes . c. An Elopement Risk assessment dated [DATE] documented . Elopement Risk Score 6 . Instructions - a. Assessment to be completed on admission, with Significant Change in condition and quarterly if applicable . b. Scoring: A score of less than 5 = Low Risk for elopement. Score of 5 or greater = High Risk for Elopement . d. An Incident Report dated 7/24/2021 documented . Nursing Description: At approximately 1930 [7:30 p.m.] this nurse entered resident room to administer dinner medication and was unable to find in bedroom. This nurse looked under bed, inside of the closet and in the restroom. I asked the Hall CNA and she stated that he was in his room at 1900 [7:00 p.m.], when she picked up his dinner tray. We searched his adjoining room as well and discovered that the screen had been torn from the window . Resident stated that he was trying to go fishing . Immediate Action Taken . Per CNA, Administrator and DON notified at approximately 1933 [7:33 p.m.] and local police department were called. The staff searched the outside perimeter of facility while waiting for police to arrive. Police came out to facility, took statement . e. A DMS (Division of Medical Services)-7734 (Office of Long Term Care (OLTC) Incident and Accident Report) form for Resident #1 dated 07/24/2021 at 7:30 p.m. documented . Summary of Incident . [Resident #1] had raised the window and went out and left the premises . Steps Taken to Prevent Continued Abuse or Neglect . I would like to commend the staff of [Facility Name] for quick action and following the Elopement Policy & Procedures, which resulted in quick recovery of resident. CNA had picked up meal tray at approx. [approximately] 7:00 p.m. At 7:30 p.m. LPN to resident room, and noticed resident was not in room. LPN asked CNA where resident was, then the LPN noticed a window was raised, and half of the mesh was missing from the screen. Staff began searching premises. CNA called Administrator, DON, and 911 at approx. 7:33. Administrator and DON, began calling off duty staff to come to facility to assist in search. Staff members were searching the 2 apartment complex buildings that adjoined the premises. At approx. 8:05 a police officer found resident behind [Clinic]; this building is approx. 1 block from the facility. Resident was brought back to building, the DON did a complete body audit on the resident and no skin tears, or bruising was noted on the resident. Staff in the facility ensured that all other residents were accounted for. Immediate Actions - All windows in the facility will be secured to ensure that no residents can raise windows and climb out . f. A DMS-762 (Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities) for Resident #1 dated 07/24/2021 at 19:30 [7:30 p.m.] documented . Complete Description of Incident . Resident had raised window and went out of the window. Left the premises . Findings and Actions Taken . I would like to commend the staff of [Facility Name] along with the [City] Police department for quick action and following the Elopement Policy & [and] Procedures, which resulted in quick finding of resident. CNA had picked up meal tray at approx. 19:00 pm [7:00 p.m.]. The LPN went to resident room and noticed resident was not in room. LPN asked CNA where resident was, and they noticed a window in adjoining resident room was raised and half of the mesh was missing from the screen. Staff began searching the premises. CNA called administrator, DON, and 911 at approx. 19:33 [7:33 p.m.]. Administrator on way to facility, and started calling off duty staff, to assist with search. A photo was utilized so staff members could use to aid in identification of resident. Staff were searching the 2 separate apartment complex that adjoined the facility. The Police was driving and searching, at approx. 20:05 [8:05 p.m.], the police phoned and stated they had located Resident. Resident was located approx. 1 block from facility. The Administrator, DON, along with 2 other staff members arrived at resident location. Resident was sitting on a slab and being questioned. Resident was dressed with his pants, and his underwear on the outside of his pants (which is normal), he had on a shirt, and his shoes was noticed beside him. Resident was asked what he was doing, and he stated he was going to go fishing. After ambulance assessed resident, the DON, then was checking resident. Resident had no apparent injuries and was released to staff for transport back to facility. Once at facility, the DON did a complete body audit on the resident and no skin tears, bruising or redness was noted on the resident. There had been no other attempts from this resident regarding leaving the facility, prior or after this incident. After body audit completed, resident was able to talk to his daughter, and he told her he was going fishing. A little later resident complained of side area hurting, so an x-ray was ordered, and all was normal (most likely sore from climbing out the window). Staff ensured that all other residents were accounted for. Elopement assessments began to identify residents at risk. Immediate intervention set in place, by placing screws in window was to ensure that no resident windows can raise enough that a resident can climb out of them. Another body audit was completed on the morning of 7/26/21, and there was still no redness or bruising noted on resident . g. A Nursing Note dated 7/24/2021 at 8:17 p.m. (related to earlier incident on 07/24/2021) by Licensed Practical Nurse (LPN) #4 documented, . Late Entry: Note Text: Resident back to facility with no distress noted. Given water po [by mouth] . Body audit performed with no abrasions, bleeding or new skin integrity issues noted. Lower pant legs are damp. Clothing removed in shower room with shower by CNA [Certified Nursing Assistant]. Again, no abrasions, new skin integrity impairment noted. Resident is pleasant and talkative. Given hydration after shower. Resident then spoke with daughter via [by way of] phone. Resident verbalized to Dtr [daughter] I'm okay. I wanted to go fishing. Resident stated rt [Right] lower rib area sore. This RN [Registered Nurse] assessed area with no abrasion or bruising noted . Call to on call with order for xr [x-ray] obtained. Resident offered food and he declined. Stated I ate good at supper. Resident to room with CNA to monitor. Hydration at bedside . h. A Nursing Note dated 7/24/2021 at 9:54 p.m. documented . Note Text: At approximately 1930 [7:30 p.m.] this nurse entered resident room to administer dinner medication and was unable to find resident in bedroom. This nurse looked under bed, inside of the closet and in the restroom. I asked the hall CNA if she knew where he was, and she stated that he was in his room at 1900 [7:00 p.m.] when she picked up his dinner tray. We searched his room again and the adjoining room as well and discovered that the screen had been torn from the window. Administrator and DON [Director of Nursing] notified at approximately 1933 [7:33 p.m.] and local police department were called. This nurse along with dietary staff searched the outside perimeter of facility while waiting for police to arrive. Police came out to facility, took statements, and conducted a search. Resident was located at approximately 2005 [8:05 p.m.] by police officers. An assessment was done upon arrival by DON. i. A Nursing Note dated 7/24/2021 at 10:00 p.m. (related to earlier incident on 07/24/2021) documented . Note Text: LPN #4 .Resident eloped this evening and was found approximately 30 mins [minutes] later. DON and [Administrator] aware . j. On 07/26/2021 at 7:45 p.m., Resident #1 was sitting in an armchair in his room on men's secure unit. Resident #1 was clean and well groomed. The window in his room had screws limiting the height that it could be opened. k. On 07/27/2021 at 10:12 a.m., Resident #1 was in the dining room on the men's unit eating a snack. A staff member was in dining room. l. On 07/27/2021 at 12:25 p.m., Resident #1 was in the dining room eating lunch. Resident #1 was clean and well groomed. 2 staff members were present in the dining room. m. On 07/28/2021 at 8:03 a.m., surveyor walked from the facility to where Resident #1 was found. The distance measured 0.2 miles. n. On 07/28/2021 at 9:05 a.m., Resident #1 was sitting in a chair in the dining room sleeping. o. On 07/28/2021 at 12:27 p.m., surveyors looked at the window Resident #1 had eloped through, the screen was torn. p. On 07/28/2021 the following interviews were conducted: At 9:03 a.m., CNA #2 stated, I am familiar with [Resident #1]. I remember resident being transferred to the unit. I work on the secure unit. Resident is not seeking exit currently. Resident is ambulatory. I have been trained on elopement, last week and yesterday. At 9:19 a.m., CNA #1 stated, I am not familiar with [Resident #1]. I have been trained on Elopement. I think the last one was Sunday. At 9:41 a.m., CNA #3 stated, I am familiar with [Resident #1]. I worked with the resident on the first day that he arrived. Resident was in quarantine. Resident never said that he wanted to leave. He did talk about his car and daughter. Resident did leave his room once or twice. We put a stop sign across his door. Resident was a super sweet guy. I have been trained on elopement. At 10:18 a.m., LPN #3 stated, I am familiar with [Resident #1]. He was admitted when I was off on vacation. I work the unit. I met resident for the first time on Monday. Resident is doing fine; he is not exit seeking. He will sit in the day room and watch TV. He will ambulate in the hallway. A staff member checks the windows for security. We have been told that if a window raises more than 6-8 inches that there are screws in the medication room. I have been trained on elopement. At 10:44 a.m., the Administrator stated, I am familiar with [Resident #1]. I had seen resident a time or two prior to the incident. I did not truly know resident. Resident was in quarantine on admission. I received a phone call on Saturday evening. They told me that they could not locate [Resident #1], they found his screen pushed out, and they called 911. I told them I was on my way. I received a text from the DON telling me that she was on her way. I started calling therapy staff and other staff members that I knew who lived close to come and help search for him. I was there before 8:00 p.m. I immediately ran behind the facility, the staff told me they had seen footprints in the grass. I had a picture of resident on my phone. I ran behind the dumpster and construction area. I then decided to get in my car. On return to the facility, I received a phone call that they had found him. The authorities were the ones that found him. I drove down the street to where the police car and ambulance were which was one block away. Resident was sitting on a concrete slab. The ambulance was already looking at him. The DON also looked at resident. Ambulance asked if we wanted him to come back to the facility. Resident drove back to the facility with the Social Service Worker. We assisted resident to the shower room for a full assessment. I gave instructions for paperwork to be done. I then remembered that the windows on the 500 Hall and 600 Halls were secured with screws and decided we needed to do this to the rest of the windows in the facility. I and the BOM secured all of the windows. I called the Maintenance Man to come in on Sunday to check all of the windows. Resident received a shower, [CNA #3] sat with resident. The DON took over the supervision until resident was swabbed. Resident was then transferred to the secure unit. Resident was on the phone with his daughter on Tuesday and he was laughing. Resident has had no attempts of any further exit seeking. While we were out looking, the nurses in the facility accounted for every other resident. The DON started the in-service on Elopement. We worked on the screws. I know that they started on resident assessments for elopement. We now have made a form for every hall; the department heads will be checking all of the windows on every hall. If they find anything negative, they are to report to me. I have placed screws and screwdriver in the medication room to use if any concerns arise with the screws. At 11: 29 a.m., Registered Nurse (RN) #2 stated, I am familiar with [Resident #1]. I have met with resident. I believe that actually the other MDS Nurse did the MDS. I am aware that resident was at risk for elopement on admission. Resident has Dementia and has sun downers in the evening. Prior to the incident, resident was exit seeking, he thought that he had to go to work. It started a week after admission. Resident was in quarantine; he would occasionally come out of his room. Resident would do almost anything for food. I am not responsible for all of the care plans; I try to review them when I can. I did not do resident's care plan. At 11: 36 a.m. CNA #3 stated, I was here on the evening of the incident with [Resident #1]. My mother came and got me when she was notified of the incident and we both came to the facility to help. I helped search for resident. Once resident was returned back to the facility, I gave him a shower and the DON did a body audit. Resident wanted to lay down. I sat with resident in his room and told the DON when I was leaving. At 11:53 a.m., CNA #4 stated, I have seen [Resident #1] maybe once. I know that if we can't find a resident, we notify the nurse. They call us to the nurse's station, and we all look for the resident. After 10 minutes the police are notified. At 12:10 p.m., LPN #4 stated, I am familiar with [Resident #1]. I know who he is. I had worked with resident on the weekend prior to the incident. Resident was in quarantine; he was trying to get out of his room but not the facility. On Saturday at 7:30 p.m., I went to give resident's medications in his room, and he was not there. I looked in the bathroom and under the bed. I looked behind the door and in the closet. I did not find resident. I went to the aide on the floor, she told me that she had just left out of resident's room about 30 minutes when she had picked up his supper tray and that he should still be in his room. So, we then both went to his room, we also looked into the room next door. There is an adjoining bathroom, we could not find resident. We called the DON and Administrator and the Police. The other nurse that worked with me and other staff searched the facility inside and out. The bedroom next door to residents had the screen pushed out. The other nurse working found footprints in the grass. It was the last room on the right. The Police came out, took a statement and they then searched. Other staff members went to search area. The police found resident. When resident returned the DON was here and she took over. I left at 11:00 p.m. At that time, we were doing one on one with resident. Resident upon return was stable. The next day resident was on the 600 Hall. We have had training on elopement. I did see resident that day at lunch when I gave him his lunch medication. Resident was fine at that point. At 12:32 p.m., CNA #5 stated, I took care of [Resident #1] last weekend. I was the only aide on the floor. I saw resident last about 7:00 p.m. when I picked up resident's supper tray. He seemed fine, he was on his bed. The nurse about 7:20 p.m. asked me if I knew where resident was. We started looking for him. I looked into the room next door to residents' room and the screen was broken. The nurse called the Administrator. I had to continue working with the other residents. I know that the Nurse called the police. We went down the 100 Hall looking into every room and could not find resident. Someone went outside to look for resident, the agency nurse and two kitchen staff. I believe the Police found him. I did see resident again that evening, I saw the DON and other staff giving resident a shower. The following day resident was transferred to the secure unit on 600 Hall. I had just finished my training on [Healthcare Training Website] on Friday on elopement. At 1:10 p.m., the DON stated, I am familiar with [Resident #1]. I had met resident prior to the incident. I always meet new residents. Resident was in quarantine when he first arrived, he had not been vaccinated. I am not aware of resident having any exit seeking behaviors prior to incident. I received a phone call from a CNA on Saturday evening that resident was not in his room, the screen was torn, and they had found footprints in the grass. When I received the call, other staff were actively searching the facility and grounds to try and locate resident. Resident went out of the screen in the adjoining room, that room was empty. I asked if she was sure that resident was missing. I tried to call the Administrator, I then sent her a text message. I was pulling out of the driveway when my daughter pulled in and we both came to the facility. I made phone calls on the way to the facility. I called the Kitchen Manager, the BOM, the Social Service Worker to come to the facility. I stopped at gas stations close to facility to check to see if they had seen resident. I drove to the apartments past the facility. I pulled back and turned right on [Street Name]. I went through the subdivision. When I went through the subdivision, I saw two police cars behind the clinic. I pulled back there, and resident was sitting on a small slab. I introduced myself. My daughter sat with resident. I then checked on resident. Resident said he fine, he wanted to go fishing, he pointed out that he was wearing his new shoes. Resident was dressed. I let the Administrator know that I was with the resident. The Social Service Worker and Administrator came to the area. We put resident into Social Service Worker vehicle to return him back to the facility. The EMT [Emergency Medical Technician] was also on sight. We got him back here to facility at approximately 8-8:15 p.m. We got resident inside, we got him into the shower, we gave him a drink. Before the end of the shower, I went in and did a full body audit with no negative findings. We dressed resident. We gave resident more water. Resident spoke to his daughter on the phone. [CNA #3] took resident back to his room and she sat with him. She stayed until approximately 11:20 p.m. I did the education, in-service with the staff. We started the investigation. I sat with resident after [CNA #3] left. A little after midnight I tested resident for COVID, the test results were negative, and resident was transferred to the 600 Hall, the secure unit which was the original intent after resident was removed from quarantine. Resident has been fine since transfer to 600 Hall, there have been no other attempts to leave the facility. All other residents were checked to make sure that they were where they were supposed to be. We did elopement assessments on all residents. The windows on Saturday evening were secured by the Administrator and BOM. I was not aware of any windows not being secure until surveyors entered facility on Monday. Windows are now being checked daily by management staff. The Administrator in-serviced staff on Monday when windows were found not secure. 2. Resident #3 was admitted to facility on 11/7/2017 with diagnoses of Type 2 Diabetes Mellitus, [CONDITION(S)], Dementia and Absence of Left Leg Below Knee. The Quarterly MDS with an ARD of 07/22/2021 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS; wandering behavior not exhibited; required extensive physical assistance of one person for bed mobility, transfers, toilet use and bathing; and was always incontinent of bowel and bladder. a. A Care Plan dated 06/16/2021 documented . The resident is an elopement risk/wanderer r/t [related to] polypharmacy . Ensure door lock/alarms in working order. Frequent hall rounds to ensure resident location . b. On 07/26/2021 at 7:35 p.m., Resident #3 was lying in bed awake. 3. Resident #4 was admitted to facility on 10/24/2021 with diagnoses of Alzheimer's Disease, Anorexia Nervosa, [CONDITION(S)] and Vascular Dementia. The Quarterly MDS with an ARD of 05/06/2021 documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status; wandering behavior not exhibited; required extensive physical assistance of two plus persons for bed mobility, transfers, and toilet use; extensive physical assistance of one person for locomotion on and off the unit dressing, eating and personal hygiene; and was always incontinent of bowel and bladder. a. A Care Plan dated 07/26/2021 documented . I am at risk for elopement/wanderer risk r/t polypharmacy. I have cognitive deficit. At risk for: 1. Leaving the facility unattended. Ensure door lock/alarms in working order. Frequent hall rounds to ensure resident location . b. An Elopement Risk assessment dated [DATE] documented, .Elopement Risk Score - 8 . a. Instructions: a. Assessment to be completed on admission, with Significant Change in condition and quarterly if applicable . b: Scoring - A score of less than 5 = Low Risk for Elopement. Score of 5 or greater = High Risk for Elopement . c. 07/26/2021 at 7:40 p.m., Resident #4 was up in a wheelchair in the dining room. 4. On 07/26/2021 at 7:35 p.m., CNA #1 went into Resident #3's and #4's room and lifted the blinds and opened the window while surveyor observed. The window opened all the way up with no resistance. 5. Resident #5 was admitted on [DATE] with diagnoses of Generalized Anxiety Disorder, [CONDITION(S)], Cerebral Infarction, Alzheimer's Disease, and Dementia. The Annual MDS with an ARD of 07/07/2021 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS; required supervision for bed mobility, transfers, walking in corridor, and locomotion on and off unit. a. The Care Plan dated 06/16/2021 documented .The resident is an elopement risk/wanderer r/t cognitive impairment and polypharmacy . The resident will not leave facility unattended through the review date .Staff to ensure exit doors alarm/locks in working order. Frequent rounds to ensure resident location . b. An Elopement Risk assessment dated [DATE] documented the resident scored 7 (a score of 5 or greater equals a high risk of elopement). 6. Resident #6 was admitted on [DATE] with diagnoses of [CONDITION(S)], Post-Traumatic Stress Disorder, Depression, Dementia and Alzheimer's Disease. The Quarterly MDS with an ARD of 05/13/2021 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a BIMS; required extensive assistance with two persons for bed mobility, transfers, dressing, toilet use, personal hygiene; and required supervision for locomotion on and off unit and walking in corridor. a. An Elopement Risk assessment dated [DATE] documented the resident scored 5 (a score of 5 or greater equals a high risk of elopement). 7. On 07/26/21 at 7:30 p.m., LPN #1 went into Resident #5's and #6's room, lifted the blinds and opened the window while surveyor observed. The window opened all the way up with no resistance. 8. Resident #7 was admitted on [DATE] with diagnoses of Alzheimer's Disease with Late Onset, [CONDITION(S)], Atherosclerosis and Hypertension. A Quarterly MDS with an ARDS of 07/01/2021 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a BIMS; required supervision for bed mobility, transfers, and walking in the room and corridor. a. An Elopement Risk assessment dated [DATE] documented the resident scored 6 (a score of 5 or greater equals a high risk of elopement). 9. On 7/26/21 at 8:10 a.m., LPN #1 went into Resident #7's room and lifted the blinds and opened the window while surveyor observed. The window opened all the way up with no resistance. 10. On 07/26/2021 at 7:44 p.m., this Surveyor and the Maintenance Supervisor checked the windows in Rooms 102, 206 and 207. The windows at this time were secure. 11. On 07/28/2021 at 9:59 a.m., the Maintenance Supervisor stated, I am familiar with [Resident #1]. I was actually out of town when the incident happened. I had seen resident in the hall prior to the incident. Resident was in quarantine, but he was the only resident down there. I got a call before dark on Saturday. They told me that they had an elopement. I told them I was 2 ½ hours away. I did receive a message later saying that resident had been found. I called the Administrator, she told me that her and the BOM [Business Office Manager] were going to put screws in the window. They wanted to know where the screws and screwdriver were. The windows prior to incident were not secured. I came to the facility at about 8:30 - 9:00 on Sunday Morning. Resident was on one on one. I checked all of the windows, some of the screws were not catching. When I left that day all of the windows were secured. On Monday evening I found the same three windows unsecured as the surveyors found. I put bigger headed screws on every window in the facility so that it would not happen again. I check the windows now every morning. I checked them all this morning. I am going to come up with a log to document this. 12. A Missing Resident Policy & Procedure documented, Purpose: The purpose of a Missing Resident Policy and Procedure is to ensure that all necessary steps are taken in the event that a resident wanders away from the facility . Procedures: 1. Any staff member who becomes aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse. 2. The high risk/wandering resident's charge nurse or department head shall assign direct care staff to look for the resident. 3. If the resident is not located in the buildings or the grounds within 15 minutes, the charge nurse shall notify the Director of Nursing and the Administrator to implement the plan to locate the resident. 4. The department or resident care staff person who identified a high risk/wandering resident as missing must notify all staff of the missing resident by announcing on the public address system. Code Green, Resident's Name Repeat three times. 5. Notify the appropriate parties: a. Police Department; b. Designated legal guardian; c. Attending physician. 6. Police are to be given description and information about the resident: a. Show photograph; b. What clothes the resident was wearing, c. When and where was the resident last seen, d. Does the resident have a usual route or a place he or she always talks about going, e. Resident's mood. 7. Missing Resident Policy & Procedure . Purpose: The purpose of a Missing Resident Policy and Procedure is to ensure that all necessary steps are taken in the event that a resident wanders away from the facility . Procedures: 1. Any staff member who becomes aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse. 2. The high risk/wandering resident's charge nurse or department head shall assign direct care staff to look for the resident. 3. If the resident is not located in the buildings or the grounds within 15 minutes, the charge nurse shall notify the Director of Nursing and the Administrator to implement the plan to locate the resident. 4. The department or resident care staff person who identified a high risk/wandering resident as missing must notify all staff of the missing resident by announcing on the public address system. Code Green, Resident's Name Repeat three times. 5. Notify the appropriate parties: a. Police Department; b. Designated legal guardian; c. Attending physician. 6. Police are to be given description and information about the resident: a. [NAME] photograph; b. What clothes the resident was wearing, c. When and where was the resident last seen, d. Does the resident have a usual route or a place he or she always talks about going, e. Resident's mood. 7. Facility Administrator or supervisor will inform regional CQI Director. 8. Regional CQI nurse will inform Regional Vice President. 13. An In-Service Education Report dated July 24, 2021 documented, .Thank you for following our elopement process, please review the following guidelines in the event an elopement is identified . Missing Resident Event . Post Elopement Actions . Monitoring . 14. The Immediate Jeopardy was removed and the scope and severity was reduced to an E when the following Plan of Removal was implemented: 1. Notified by OLTC [Office of Long Term Care] that the windows in rooms 102, 206, & 207 were able to raise all the way up. 2. Administrator had staff observing rooms 102, 206, & [and] 207, to ensure that residents did not attempt to open the windows in these rooms and exit out of them. 3. Administrator immediately phoned maintenance personnel on 07/26/21, at approx. [approximately] 8:20 p.m., and he came to facility, and placed larger head screws to ensure that windows would not raise. 4. Administrator began in-servicing staff All staff are to check windows at the beginning of the shift, to ensure that windows will not raise more than 8-10 inches. If a window is found to raise more than 8-10 inches, it is to be repaired immediately. 5. There will be screws and a screwdriver in the med [medication] room for immediate repair. 6. Staff will monitor windows at beginning of each shift, and negative findings will be corrected imm[TRUNCATED]

Based on observation, record review and interview, the facility failed to ensure the alarm on the exit door on the men's secured unit was functioning properly to alert staff a resident at high risk for elopement had exited the facility while unsupervised to prevent the potential for accident and or injury for 1 (Resident #6) sample resident who was at high risk for elopement. This failed practice resulted in past noncompliance at the level of immediate jeopardy which caused or could have caused serious injury, harm or death for Resident #6 who after exiting the men's secured unit to the secured courtyard placed a chair up against the privacy fence and climbed over. This failed practice had the potential to cause more than minimal harm to 2 residents on the men's secured unit who were at risk for elopement per a list provided by the Administrator on 6/17/21 at 1:20 P.M. The facility removed the Immediate Jeopardy and corrected the failed practice on 6/16/21 prior to the survey. The Administrator was notified of the Past Immediate Jeopardy on 6/17/21 at 1:15 P.M. The findings are: Resident #6 was admitted to the facility on [DATE] and had diagnoses of Alzheimer's Disease, Dementia and Wandering in Diseases Classified Elsewhere. The Admission Minimum Data Set with an Assessment Reference Date of 4/13/21 documented the resident scored 6 (0-7 indicates severely cognitively impaired) per a Brief Interview for Mental Status and had not exhibited signs of wandering. a. The Admission Evaluation dated 4/9/21 documented, . [Resident #6]: Description: Admission, Date 4/9/21 20:33 [8:33 P.M.] . Elopement Risk Scoring Score of less than 5 = [equals] Low Risk; Score of 5 or greater = High Risk . 13. Is resident at risk for elopement a. Yes 14. Care Plan Elopement Risk Problem: The resident is an elopement risk/wanderer (SPECIFY) r/t [related to] Goal: The resident's safety will be maintained through the review date. Approach: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversations, television, books, Resident Prefers: (nothing listed) . b. A DMS (Division Medical Services) - 7734 [Incident and Accident Next Day Reporting Form] documented, .Date and Time Submitted (if Known) 06/16/2021 03:00 [A.M.] Date and Time of Discovery: 06/16/21 12:20 [A.M.] . Page 4 of 4 documented, . At 12:10 [A.M.], CNA [Certified Nursing Assistant] was making rounds, and resident [Resident #6] came to her and she walked him back to his room and assisted him to bed. CNA then went to help another resident to his room. After she assisted this resident she then went back to check on [Resident #6], at this time she did not see him in his room, so she looked down the hall, and other room, then notified LPN [Licensed Practical Nurse] for assistance. An entire sweep of the facility was conducted by all staff. Staff noticed that a chair was against the privacy fence on the end of the hall, so staff then began searching the area around privacy fence, which is a small wooded area. Another staff member went to the apartments located next to facility and looked around parking lot. After the Administrator was notified by LPN, she called the DON [Director of Nursing], Maintenance, off duty staff, to go to facility to assist in search. Upon coming into Conway, the Administrator stopped at a gas station, at 1:10 a.m., 3 blocks from facility to see if resident was at a gas station. Administrator noticed paramedics at gas station, approached them, to ask for assistance, with search. Paramedics stated I just heard that someone picked a man up and taking him to [Hospital], which is located appx [approximately] 1 mile from the gas station. Administrator arrived at hospital ER [emergency room ] at 1:15 a.m. and noted resident setting in a wheelchair. Resident was identified by Administrator, and Administrator interviewed the man that picked resident up and brought him to ER. [Name of man who picked resident up], stated he picked him up about 15 minutes ago, which would have been about 1:00 a.m. on [Street Name] by [Store Name]. When Administrator was at ER, with resident, she asked resident what he was doing, and resident just stated going for a walk. Administrator and resident arrived back at facility at 1:30 a.m. Police Officer [Name of Officer] and 3 other police cars was at facility. Report taken by [Officer Name]. Upon return to facility, the DON assisted resident to room, and completed body audit, noted on resident's back was two small scratches, that most likely resulted from when resident scaled fence. Resident temperature was normal. Immediate actions, Chair was removed from privacy fence area. All moveable chairs located in privacy area, will be secure, so they cannot be moved to privacy fence and used to scale fence. Maintenance ensure that all exit doors were working correctly. c. On 6/17/21 at 9:00 A.M., this Surveyor and the Administrator went to the men's secured unit where Resident #6 had exited out of a door into the courtyard where there was a 6 foot privacy fence that had a gate with a pad lock on it. The Administrator stated, There was a chair against the fence, and he climbed over it. Any moveable lawn furniture now has rebar and a clamp around the legs of the furniture. The rebar is at least one foot long into the ground. This was verified by observing the area and attempting to move the furniture. After coming back inside, the exit door was checked in the presence of the Administrator. When pushing on the exit door, after approximately 20 seconds the door alarmed and then opened. The alarm stopped sounding when the door shut. The Administrator stated, After this, we put additional alarms on both secured units in addition to the existing alarms. We also put this Velcro stop sign to possibly keep someone from pushing on the door. d. On 6/17/21 at 9:15 A.M., LPN #1 was asked, Is there any other resident on the men's secure unit who could climb over the fence or who have attempted to exit through the doors? He stated, We have a couple back there that will kick at the door but have never tried to push on the door to get out. One in wheelchair . and the other one ambulates . [Resident #6] had never showed any signs of wanting to or attempting to leave. He helps sweeps back there and with other things. I had never seen him trying to exit through a door or even saying he wanted to leave. I have worked on that secure unit for about [AGE] years. I know I haven't had anyone try to get out. If they go through that exit door it goes into a secured courtyard with a gate that has a padlock. Emergency key is in the fire box if we need it. e. On 6/17/21 at 10:07 A.M., the Maintenance Director was asked, What can you tell me about the incident with [Resident #6] exiting the facility? He stated, [Administrator] called me at 12:40 A.M. on 6/16/21. She told me we have a resident missing on 600 Hall get to the building ASAP [as soon as possible]. I got here at 1:00 A.M. Came in and met [Nurse on that hall]. Got a picture of the resident. I went to exit door on 600 hall. It was not alarming. I checked the alarm. When I pushed on the door it did not alarm and it pushed open then alarmed. It did not continue to alarm when the door shut. I checked the courtyard at that time and found a chair to the right over by the gate against the fence. Back of the chair was against the fence. I stepped up into the chair to make sure he wasn't over the fence or laying on the other side and I didn't see anything. Staff were already walking the building and grounds when I got here. I came back in, re-set the door and it locked. He was asked, Did you push on it to see if it would alarm when pushed on? He stated, Not right that second. More worried at that time in finding the resident. When I was outside checking for him, I got the call he had been found. This was around 1:20 A.M. He was asked, What did you do then? He stated, I came back in and started to find out if anything was wrong with door. He was asked, What did you find? He stated, I found when you pushed on the door there was a low level tick but no alarm. I got my tools and took the cover off. There is a re-set button under it. When I hit the re-set button, the door went back to working properly. I did pull wires off and reconnected to make sure it was on properly. He was asked, As in working properly how? He stated, Working as it should. Alarm when door was pushed and would continue to alarm after it shut. I checked it three times yesterday and it was working on those times. I check them once a week and never had any issues like going on now. You beat me here or I would have already checked it for this morning. I did call and order the whole locking system for that door yesterday. I did ask the CNA on that hall that night and she said she never heard an alarm. f. On 6/17/21 at 10:36 A.M., CNA #1 was asked, Prior to noticing [Resident #6] was not on the hall did you hear an alarm? She stated, No I did not. She was asked, Did you open that exit door to see if he was out there? She stated, I pushed on the door just to see if I could hear anything and it didn't alarm. I waited just a little bit. I could hear a ticking, but it was very faint. So, I pushed in the code and went out the door. I noticed a chair up against the fence. I looked over the fence where the chair was and could not see him anywhere. I immediately notified the nurse. She was asked, How long had it been from the last time you saw him and when you realized he was missing? She stated, It wasn't more than 10 to 20 minutes. He had come up to me before this happened. I walked him back to his room and made sure he was settled in bed. He was not acting like he wanted to leave. I walked another resident back to his room and put him in bed. After I got done with that resident, I helped another resident to the bathroom and then I went back and checked on [Resident #6] and he was not in there. I looked in every room, bathroom, and closet. Then I went outside and looked around and didn't see anything. That's when I hollered at the nurse and at that time everyone started looking for him. That door has always alarmed when it was pushed on for about 20 seconds. She was asked, Would it alarm while being pushed on? She stated, It would alarm when it opened. She was asked, Did it continue to alarm when the door would shut? She stated, Prior to this incident the alarm would continue until you pushed the code in. She was asked, Have you worked on the secure unit a lot? She stated, Yes, that is the hall I work on all the time. I have been here for 6 years. She was asked, Has [Resident #6] ever attempted to exit before? She stated, Not to my knowledge. He never has on my shift. We don't have anyone back there that tries to get out that door. She was asked, Do you know if it had been reported in the past that the door didn't alarm when pushed on until it opens? She stated, No, not that I'm aware of, I guess I never really thought of it. That's always been a secure area out that door. She was asked, Did you check the door after [Resident #6] was missing? She stated, Yes, when I went out the door to look in courtyard I pushed on the door and it did not alarm, it ticked. I put the code in and went and checked for him. g. On 6/16/21 at 12:25 P.M., the Administrator was asked, When were you notified that [Resident #6] was not in the facility, and what was done and identified? She stated, Yesterday morning at 12:35 A.M. one of the nurses called and said we have a resident missing. I said have you checked everywhere, and she said, Yes. I told her, I'm on my way. On my way to the facility I was making phone calls to Maintenance, DON, Dietary Manager, another nurse, and Social Director. Had them all on their way. I called back and the nurse had called the cops and they had already initiated the Elopement Protocol. As I'm coming into [Name of town] on [Name of street] I slow down and I'm looking on the roads and sidewalks to see if I see him, I get close to the facility and there is a convenience store. I thought I need to go see if he's in there, it's well lit. When I pull up, I see ambulance getting gas. I go up to them and told them who I was and that I have a resident that has eloped and he said, I just heard someone called in they picked up a man on [Name of street] and took him to [Hospital]. The convenience store is 3 blocks from here. I go to [Hospital] which is about a mile from here. I pull up under the ER awning and I see them putting him in a wheelchair. I tell them, That's my resident and who I am. I asked who brought him and he was about to leave, and I asked him where the resident was when he found him. He said on [Name of street] going toward [Name of store] direction. I asked him how long ago did he pick him up and he said about 15 minutes ago. I checked the distance from here to [Name of store] and it's 1.3 miles, but all I know is he was going in direction of [Name of store]. Yesterday morning (6/16/21) the chair he placed up against the fence was removed immediately. All other lawn furniture was secured with rebar being driven into the ground and secured to legs of the furniture with clamps. All residents were re-assessed for elopement before anyone was allowed to go home. An elopement in-service was provided to all staff present and as they came into work. The door on the men's unit is being monitored 3 times a day for proper functioning and a new Dynalock was ordered. The 600 Hall daily rounds will now include exit door checks. h. On 6/17/21 at 12:46 P.M., the Maintenance Director was asked, When you did your checks of the door on 6/16/21 did you have to re-set it each time for it to work properly? He stated, No ma'am, I did not. He was asked, When did you secure the lawn furniture with the rebar? He stated, I did that yesterday morning about 9:00 A.M. I went first thing and bought the supplies. I called [name of company] yesterday morning and ordered the new Dynalock and it is supposed to be here Friday or Monday. There's a door here that is not an exit door and it is locked manually. I've put that alarm off that door until the other one comes in Friday since it was not working right this morning.

Based on observation, interview, and record review, the facility failed to ensure that a newly admitted resident was kept in isolation for 14 days after admission to prevent the potential spread of Coronavirus for 1 (Resident #222) of 2 (Residents #51 and #222) sampled residents who was a new admit. This failed practice resulted in Immediate Jeopardy that caused or was likely to cause serious harm, injury or death to 11 residents on the Secure Unit who were potentially exposed to the Coronavirus from Resident #222 who was a new admit and would not stay in his room in isolation. The Administrator was notified of the Immediately Jeopardy on 08/25/2020 at 3:50 P.M. The facility failed to ensure staff wore a mask at all times. This failed practice had the potential to affect all 74 residents per the Residents Census by Hall provided by the Administrator on 08/24/2020. The findings are: 1. Resident #222 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/25/2020 documented the resident was moderately impaired in Cognitive Skills for Daily Decision Making (SAMS) and required extensive assistance of 2 plus person assistance for dressing and toileting and 1 person assistance for eating and personal hygiene. a. The August 2020 physician's orders [REDACTED]. with a start date of 08/20/2020. b. On 08/24/2020 at 12:54 p.m., Resident #222 was in his room laying on his bed. His lunch tray was delivered to his room by Certified Nursing Assistant (CNA) #2. CNA #2 walked into his room with his tray and in approximately 3-5 minutes later came out of his room. The only Personal Protective Equipment (PPE) that was observed in use was a facial mask. No isolation precautions were observed to be established by his room. c. On 08/25/2020 at 1:39 p.m., Resident #222's room, had no isolation precautions established or signage by his door of the need for isolation precautions. d. On 08/25/2020 at 4:50 p.m., Licensed Practical Nurse (LPN) # 5 was asked to recall the events of the day (Resident #222) was admitted to the facility? She replied, When I came into work, he was already on the 600 hall. I knew he was a new admission, so I brought it up to (BOM) who said it was ran by (Nurse Consultant). I asked them what about my residents back in the unit, he's putting them at risk, don't they matter and (LPN #2) said it was better for him to be back there. She was asked, Who initiated the transfer? She replied, The BOM, she was told to after she called the Nurse Consultant. e. On 08/26/2020 at 6:45 a.m., LPN #2 was asked Why was (Resident #222) moved to the 600 hall? She replied, He was pacing, going into other resident's rooms. We tried to redirect him, but he wouldn't be redirected. They talked to someone and said move him to 600 hall. She was asked, Were isolation precautions established when he was moved? She replied, I don't know, I wasn't working on that hall. I was working on 100 and 200 halls. f. On 08/26/2020 at 2:18 p.m., the Nurse Consultant was asked, Do are you familiar with (Resident #222)? She replied, He was the one they had admitted last Thursday. They attempted to put him on 100 hall, but he was high risk for wandering so they called me. They asked what they could do if he was that much of a risk for elopement. So, I asked them if they had a room on 600 hall at the end of the hall, at the back, so they could isolate him, and they said yes. I told them to maintain isolation precautions as much as possible, and to try to get him to wear a mask as much as possible. She was asked, Did you know they had put him at the front of 600 hall? She replied, Not until yesterday. She was asked, Who contacted you when he was admitted , and issues were discovered? She stated, the (Business Office Manager), I texted the Director of Nurses and didn't get an answer, but she called me right back. She asked where was (LPN #7), and I told her she was on vacation. She was asked, What were the determining factors for moving him? She replied, He was wandering in and out of other resident's rooms. He was an elopement risk. She was asked, Do you know if isolation precautions were established when he was moved? She replied, I was not aware that they were not set up. She was asked, Do you know who was in charge of the facility that day? She replied, (Registered Nurse (RN) #1) the Minimum Data Set (MDS) Coordinator. She was the acting RN/DON at the time since the DON wasn't here. I called the facility and talked to RN #1 and asked her why she wasn't involved with the decisions up to this point and she told me that she had been busy with a situation involving a nurse and a medication, so I covered with her the things i had already covered with the others. She was asked, When the resident was admitted , did you have any COVID test results? She replied, He came from home with his wife, and protocol is to allow an admission and to swab him upon admission if he has not been in the hospital or another facility. g. 08/26/2020 at 2:40 p.m., LPN # 5 was asked, Remind me who you said initiated the transfer. She replied, I was told by the (BOM) that that was what the Nurse Consultant said. She also said that the admission had been approved by the Admission team and she named a few people off which included the Administrator. And I asked her, So (Administrator) knows? She said yes. She was asked, When you asked them what about your residents, what did they say? She replied, (LPN #2) said there's nothing that can be done about it, what's done is done. It's better than him running around out here infecting these people. She was asked, Was there any isolation precautions established when you came to work? She replied, No isolation was set up when I came on. I got here about 2:45 p.m. and he was already on 600 hall in room [ROOM NUMBER] bed B. h. On 08/26/2020 2:46 p.m., LPN #3 was asked, Please account for me the events of 08/20/2020 and (Resident #222's) admission? She replied. When I got here, they told me he had been admitted at 10:00 a.m. that day. She was asked, Do you know why he was moved from the 100 hall to the 600 hall? She replied, He was roaming outside of his room, going into other resident's rooms. She was asked, Do you know who approved him to be transferred to another hall? She replied, (Business Office Manager) said it was OK for him to go to 600 hall. She said he could have gotten out of the facility and into the road and gotten ran over. She was asked, How did his nurse feel about him being transferred? She replied, She was upset. But (Business Office Manager) told her that corporate had okayed it. She was asked, Who was responsible for establishing isolation precautions and setting up isolation equipment? She replied, (LPN #2) on the 100 and 200 halls. (LPN #4) should have been the one responsible for setting up the isolation precautions on the 500 and 600 halls. i. On 08/26/2020 at 2:52 p.m., the Business Office Manager (BOM) was asked to recount the events of 08/20/2020 regarding the admission of (Resident #222). She reported, He was admitted from home and was put on 100 hall in isolation. He kept wandering in and out of rooms and we were concerned about his safety. So, we called the Nurse Consultant and told her what was happening. She asked if we had a room on 600 hall that we could put him in that would be a private room, that we could set up isolation and have him wear a mask, and if we did, it would be ok to move him. So, we moved him to 600 hall. To my knowledge, no isolation bins were set up. When he was on 100 hall, there was an aide on that hall and she tried to redirect him, but his wandering was constant, and he was coming out of his room and having to be redirected every 3-5 minutes. The only room available on the 600 hall was room [ROOM NUMBER] at the front of the hall. The Administrator was contacted, and she told us to contact the Nurse Consultant. j. On 08/26/2020 at 3:01 p.m., RN #2, was asked to recall the event of 08/20/20 related to (Resident #222's) admission. She reported, He was admitted to 100 hall. He was continually going in and out of his room and into other resident's rooms. Redirection was attempted many times, but he was unable to be redirected. The BOM was the acting Administrator and talked to me about it, she called the Administrator and she said to call the Nurse Consultant. We called her on the phone from my office. She advised us to move him to 600 hall. We had to move another resident out of room [ROOM NUMBER] to make it a private room and put him in the bed B. I put a mask on him, and he immediately started pulling at it. I advised (Nurse Consultant) that we had tried a mask on him, but he wouldn't keep it on. We advised the aides to encourage him and to attempt to keep a mask on him. I notified the 100 hall and the 600 hall nurses to initiate the move and I notified the family. She was asked, What measures were taken to maintain quarantine/isolation while he was on 100 hall? She replied, He was very confused, we tried redirecting him, but that didn't work. That's when we called the Administrator and then the Nurse Consultant. She was asked, Should you have confirmed that isolation precautions were set up after he was moved? She replied, Yes. k. On 08/27/2020 at 04:24 p.m., LPN #4 was asked, Can you tell me about the events of the day of (Resident #222's) admission and his room change? She replied, I was working the lock down unit. When we admit someone, they normally go to the Medicare hall, but he just kept going in and out of his room, so another nurse suggested, I think it was (LPN #2), to put him back on the lock down unit. She was asked, Were isolation precautions established when he arrived on 600 hall? She replied, I didn't see any. She was asked, Did you find it odd that none were set up? She replied, Yes, it was odd. I told them he needed to be in isolation as I was leaving because he was sitting in the dining room and he needed to wear a mask when he out of his room. l. In-services for COVID 19, PPE usage, and Infection Control, including the protocol for 14 day isolation after admission was reviewed and all of the current nursing staff have been in-serviced. m. The New Admission 14 day Isolation policy provided by the Nurse Consultant on 08/28/2020 at 5:40 p.m. documented, .Put resident in standard, contact and droplet isolation following the ADH (Arkansas Department of Health) March 23, 2020 Guide . 2. The Immediate Jeopardy was removed on 08/25/2020 at 5:30 p.m. and the scope and severity reduced to an E when the following plan of removal was implemented: On 8/25/20 at 5:30 p.m., a Plan of Removal was received from the Facility Administrator that documented 1). Resident was admitted on [DATE] and was COVID tested upon admission. Any new admissions will continue to be tested upon admission by the DON/ designee, and placed in 14 day isolation as screening precaution for COVID. 2.) All Residents on the male unit will be screened by the DON/Designee on 8/25/2020 for signs and symptoms of COVID now and Q shift until Covid test results are received. 3.) Starting on 8/25/2020 the DON/designee will in-service all staff as they report to work on proper isolation requirements for new admissions. This will be continued until all direct care staff have ben (been) in-serviced. 4.) The DON/designee will review all new admissions and residents with orders for isolation to ensure that the facility is making every effort to isolate during the 14 day COVID screening period. Daily until substantial compliance is achieved. Any negative findings will be reported to the QA committee for review and recommendations. 5.) Resident will be placed back on 100 hall. Bisquine (Visqueen) will be placed on his door frame with a zipper. A Staff member will be placed outside of door to monitor resident. The patrician on 100 hall that separates the quarantined residents will be zipped closed. 3. On 08/24/2020 at 12:16 PM, an observation was made of Housekeeping Employee #1, on the clean side of the laundry room, without a face covering on the face. Housekeeping Employee #1 was asked, Why do you not have a mask on? She stated, I was told we are able to take them off when we are not around residents.

Complaint # (AR 843) was substantiated, all or in part, with these findings: A. Based on observation, record review and interview the facility failed to ensure a Certified Nursing Assistant (CNA) applied a seat belt to a resident being transported in the facility van in accordance with the manufacturer's instructions to prevent injury, and failed to stop the van immediately and call for assistance when a resident slipped from his wheelchair to the floor of the van to prevent further potential injury while riding on the floor of the van for 1 (Resident #1) of 2 (Residents #1 and #4) case mix residents who were transported in wheelchairs in the facility van. This failed practice resulted in past immediate jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who fell from his wheelchair during transport, resulting in a hairline fracture to thoracic vertebra #1 (T1), and had the potential to cause more than minimal harm to 11 residents who were transported in wheelchairs in the facility van, as per a list provided by the Administrator on 3/30/17. The facility removed the immediate jeopardy and corrected the failed practices related to van transportation on 2/11/17, prior to the survey. The Administrator was informed of the past immediate jeopardy condition on 3/29/17. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED].#1 through #4), Neuromuscular Dysfunction of Bladder, Hypotension, Injury Right Vertebral Artery - Sequela and Depressive Episodes. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/30/17 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, was totally dependent on the assistance of two plus people for bed mobility and transfers and had functional limitation in range of motion to the upper and lower extremities on both sides. a. A Care Plan dated 2/11/17 documented, .At risk for further falls as evidenced by fell in past 30 days, impaired mobility, presence of pain, muscle weakness, mobility r/t (related/to) dx (diagnosis) Quadriplegia .Frequently check on resident when he is outside .Encourage him to remain closer to building when outside . 2 staff using Hoyer lift for all transfers . Monitor his positioning needs closely and if changes or problems arise with his positioning report immediately . b. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities, Division of Medical Services (DMS) form 762 dated 2/11/17 documented .Complete Description of Incident . On 2/11/17 Resident slid out of wheelchair while on the van, during a transport to his home for a visit. When resident returned to facility via (Emergency Medical Services) transport, from the emergency room at 6:45 p.m., the Administrator and DON (Director of Nursing), visited resident to interview resident regarding the incident. Administrator ask resident to tell me what took place when he left the building: Resident stated that he got on the van, he maneuvered around, and she (Certified Nursing Assistant (CNA) #1) hooked the front and back straps up. I asked did the wheelchair move, and the resident said no. Admin (Administrator) ask resident, did she (CNA #1) fasten the seat belt around you, and he said, 'I thought she did, or it came un-done'. CNA reported to administrator, that she slammed on her brake, because a car pulled out in front of her, and this is when the resident slid to the floor . During interview with (Resident #1), he told the administrator, that during transport on 2/11/17, the first time that the driver came to a stop, he told her he felt like he was going forward. The 2nd time she stopped, he told her to slow down on the stops, because he felt like he was going to fall, and on the 3rd stop, it was abrupt and he fell out. (CNA #1) was terminated, because she failed to pull over and ensure the resident was safe, after he had told her that he was going forward . c. An Office of Long Term Care (OLTC) Witness Statement Form dated 2/11/17 at 12:00 p.m. and signed by CNA #1 documented, .I was taking (Resident #1) home for a visit with his family, I got him in the van, put locked straps on the front and back of wheelchair, then I put the seat belt on him and proceeded to take him home. About half a mile to his home, I was coming to a red light when a car pulled out in front of me, I put my brakes and my (Resident #1) went to the floor, I pulled over called van supervisor and my Administrator and then I called 911 . d. An Office of Long Term Care Witness Statement Form dated 2/11/17 at 6:45 p.m. and signed by the Administrator documented, .Admin interviewed Res (Resident) (at) 6:45 p.m. on 2/11/17, when he returned from ER (emergency room ) visit. Admin 'Myself' ask resident to tell me what took place, when you left bldg (building). Resident stated 'I got on van, maneuver around & (and) she (CNA #1) hooked the front & back up'. I asked 'the straps?' He said 'yes'. I asked, 'did your wheelchair move', & Res, said 'No!' I ask Res, 'did she (CNA #1) fasten seatbelt around you?' Resident stated 'I thought she did or it came un-done'. Resident said 'When she stopped the first time, I told her I felt like I was going forward. The 2nd time she stopped, I told her to slow down on the stops because I feel I'm going to fall. The 3rd stop was abrupt & I fell out'. e. An Office of Long Term Care Witness Statement Form dated 2/11/17 at 7:00 p.m. and signed by Registered Nurse (RN) #1 documented, .Res interviewed about fall in van. Res asked what happened when you left the building, got on van & I maneuvered around. Driver hooked front & back. Admin asked did w/c (wheelchair) move? No. Did she fasten seatbelt? He said I thought she did, or it came undone. Res said the 1st time she stopped; I said 'I feel like I'm going forward. The 2nd time she stopped, I told her to slow down on the stops. I feel like I'm going to fall. 3rd stop was abrupt & I fell out'. f. A Nursing Note dated 2/11/17 at 10:41 p.m. documented, .Rsd (resident) was being transferred home this morning and the CNA stated that she had to slam on the brakes and the resident fell out of his chair into the floor of the van. She immediately called (Emergency Medical Services), his wife, this nurse, the DON (Director of Nursing) and Administrator. He was transferred to (Hospital), he was accompanied by his wife. He returned to the facility at 6:36 p.m. with no apparent injuries. V/S (vital signs) are B/P (blood pressure) 136/88 Temp (temperature) 97.3 RR (respiratory rate) 20 pulse 68, O2 (oxygen) 96% on room air. Rsd is resting in bed at this time . all needs are met by staff will continue to monitor routine nursing rounds and document any acute changes in condition . g. An Emergency Medical Services report dated 2/11/17 documented, .UOA (upon our arrival) found pt (patient) on the floor of the van, van driver stated a car stopped suddenly in front of her at a red light and he fell out of his w/c (wheelchair) into the floor, driver stated she was slowing down from approx (approximately) 45 mph (miles per hour), pt is a quadriplegic from a moped accident in SC (South Carolina) June of last year, pt is a resident of (Facility Name) getting rehab (rehabilitation) before he returns home, pt was being transported to his home for the weekend to spend time with family. Pt denies any injury but due to nature of this accident the facility wants him checked out . h. A hospital Emergency Department Progress Note dated 2/11/17 at 2:01 p.m. documented, .presents with headache after falling out of his wheelchair in a van due to sudden stopping of the van. Patient denies LOC (loss of consciousness), Patient is quadriplegic and wants to make sure he is ok and his hardware in his back is ok. CT (computed tomography scan) of head shows edema of scalp, but rest is normal. CT of C (cervical) spine shows transverse spinous fracture of T1 and that his hardware is normal. Will discharge patient back to his nursing home and have him follow-up with his PCP (primary care physician) and spine doctor . Final Diagnoses: [REDACTED]. Fracture of spinous process of thoracic vertebra . i. On 3/27/17 at 4:15 p.m., Resident #1 was asked about the van incident. He stated he fell out of his wheelchair onto the floor of the van and believed his seat belt was not buckled. He stated he did not feel secure in his wheelchair and told the CNA / van driver twice, .but she did not do anything about it. He stated immediately after he told the driver a third time that he did not feel secure, she braked suddenly and he fell out of his wheelchair, onto the floor of the van. He stated the worst part of the whole thing was that after he fell , the van driver did not stop the van. She continued to drive the van another 4-5 miles to his house, then called 911. He stated during the time he was on the floor and the van driver continued to drive, he was rolling around on the floor in the back of the van trying to find things to hold onto and was very afraid. He also stated he had experienced some residual psychological problems related to the fall, and, .I really get nervous getting back on the van. j. On 3/29/17 at 1:00 p.m., the resident's wife was asked what she recalled about the date of the van incident involving her husband. She stated, My husband was to come home for a visit. The van driver called me and told me he had fallen to the floor of the van from his wheelchair when she had to slam on her brakes. She said he was still on the floor and that she was driving to our house. The resident's wife also stated she called her son-in-law and asked him to come to the house to help, thinking that they would have to get resident up off the floor of the van. She stated it took her son-in-law 5 to 7 minutes to get to the house and, .it was a good 10 minutes after that before the van arrived. She stated CNA #1 told her when the van arrived at the house that she did not pull over or stop when the resident fell . She stated that after arriving with the resident in the floor of the van, the CNA made a call to the facility and then called 911. She stated it took four men to pick up the resident from the floor of the van, and that he was then transferred to the hospital. She also stated, There is a seatbelt on the resident's wheelchair, but the facility does not use it. k. On 3/29/17 at 2:04 p.m., the Administrator was asked if she was aware that when Resident #1 fell from his wheelchair to the floor of the van, CNA #1 did not stop the van until after she arrived at the resident's house, and that the transport was completed with the resident lying on the floor of the van. She stated she was not aware of this until after she had mailed DMS form 762 to OLTC and that, after mailing the 762, the resident was having a conversation with her and told her of being on the floor of the van. She stated when the CNA called the facility, she was instructed to call an ambulance. l. On 3/30/17 at 2:40 p.m., the Maintenance Director was asked if CNA #1 had called him when Resident #1 fell from his wheelchair on the van. He stated, Yes, she did call me; I could not hear very well. She told me that (Resident #1) had slid out of his wheelchair, and I told her to call 911. He was asked if he was the van supervisor and stated he was not, but, .I assist with the training of the van drivers. m. The facility removed the immediate jeopardy, reduced the scope / severity to H and corrected the failed practices related to van transports on 2/11/17, prior to the survey, as evidenced by the following findings. (This reduced the scope / severity to H due to findings of harm due to Resident #1's T1 fracture caused by the van incident, plus findings of a past pattern of harm for Resident #8, related to injuries sustained from falls, as referenced in the findings beginning with the deficient practice statement in paragraph B, below): 1.) The DMS form 762 dated 2/11/17 (referenced above at paragraph b) documented, .Findings and Actions Taken . (CNA #1) involved with the transport, returned to facility, awaited at facility for administrator to come to facility to interview her, once interviewed and witness statement obtained, the administrator informed (CNA #1) that she was suspended pending investigation . (CNA #1) was terminated, because she failed to pull over and ensure the resident was safe, after he had told her that he was going forward . No other residents were transported using the facility van, until after the seat belts were checked to be functioning properly. When administrator arrived at facility, the seat belt was checked and appeared to be working; however the van was not to be used until maintenance could check out the van. On 2/13/17 at 8:15 a.m., the maintenance man was in a wheelchair and strapped in by the van driver on days (not suspended CNA) and the van was driven behind the facility and accelerated the van, then slammed on the brakes hard, this was done a total of 4 times, and all 4 times the straps and seat belt all worked properly. Also on 2/13/17, (qualified van maintenance company) did assessment on van, and seat belts were working properly. Van placed back in use. A re-in-service began immediately to all van drivers, which included written in-service, competency testing, and return demonstration, and what to do if a resident states something doesn't feel right, or something has become loose during the transport Residents interviews determined that no other residents had slid to the floor while being transported by the facility van . 2.) An In-service sheet dated 2/11/17 documented, .When transporting residents in the facility van, you must ensure that the seat belts are fastened properly, prior to leaving the parking lot. To ensure this is done you must pull on the seat belt, to ensure that both of the belts connected together. The front and rear straps must be properly attached to the wheelchair to ensure the wheelchair doesn't move during transports. At any time during a transport, if the resident tells you something is not right, or something has become loose, then you must stop at the first parking lot, check and ensure that your resident is safe, before you continue your destination. If something has happened, and you are unable to transport the resident safely, then call the facility for help . The sign-in sheet for this in-service documented 14 staff members attended this training. 3.) The facility's Transportation Program Safety Policy and Procedures, received from the Administrator on 3/28/17, documented, .If you are loading a resident in a wheelchair into a van using a mechanical lift, then .15. Position the non-ambulatory resident inside the wheelchair cabin area . 16. Lock both wheelchair brakes . 17. Install and attach rear retractable J-hooks to the wheelchair frame as instructed . 18. Install and attach front retractable J-hooks to the wheelchair frame as instructed . 19. Test to ensure that all retractable J-hooks have firm tension and the wheelchair is free from any movement . 20. Install, adjust and secure a lap and shoulder restraint around client / resident as instructed . 21. Attach wheelchair seat belt buckle tongue into the buckle . If an accident or injury occurs within the vehicle during transport: .1. If able, move the vehicle to a safe place out of any immediate danger . 2. Place vehicle in park and start emergency flashers . 3. If patient (s)/resident(s) or occupants appear to be injured, call 911 immediately and report location, occupant's visible condition and any visible injury to yourself or occupants/patient's/resident's. Do not move resident until resident has been properly assessed for injury by emergency personnel or professional personnel from facility . i.) The Q'Straint manufacturer's instructions for the facility's van restraints, received from the Maintenance Director on 3/29/17 at 9:09 a.m., documented, .A. Secure Wheelchair . 1. Place wheelchair facing forward in securement area; apply wheel locks or turn power off . 2. Attach tie-downs into floor anchorages and ensure they are locked in . 3. Attach the four tie-down hooks to solid frame members or weldments, near seat level; Ensure tie-downs are fixed at approximately 45 degrees, and are within angles shown in (Fig 2). Do not attach hooks to wheels, plastic or removable parts of wheelchair . 4. Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs (If present) to take up additional webbing slack . B. Secure Passenger . 1. Attach Lap Belts - use integrated stiffeners to feed belts through openings between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant . a. On the aisle side, attach belt with female buckle 1 to rear tie-down pin connector, ensuring buckle rests on passengers hip . b. On the window-side, attach belt with male tongue to rear tie-down pin connector and insert into female buckle . 2. Attach Shoulder Belt - Extend shoulder belt over passengers shoulder and across upper torso and fasten pin connector onto lap belt . Note: Combination/shoulder belts serve as both window-side lap belt and shoulder . 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort . ii.) On 3/28/17 at 10:10 a.m., CNA #2 was observed securing a non-case mix resident on the facility transport van. The CNA secured all restraints in accordance with the manufacturer's instructions. iii.) On 3/29/17 at 8:46 a.m., CNA #2 was again observed securing a non-case mix resident on the facility transport van. The CNA secured all restraints in accordance with the manufacturer's instructions. iv.) On 3/29/17 at 11:41 a.m. the Administrator stated when the incident occurred with the van, all van drivers were retrained, which included watching the Q'Straint video, a written in-service, competency testing and return demonstration. Stated that she monitors the return demonstration and documents them, and showed the surveyor a binder that contained check-off demonstrations for all of the facility's current van drivers. 4.) Interviews with current van drivers indicated staff were aware of the appropriate actions to take in the event of an incident on the facility van, as follows: i.) On 3/29/17 at 2:15 p.m., the Maintenance Director was asked, What would you do if you were driving the van and a resident fell ? He stated, I would pull over immediately and call 911. ii.) On 3/29/17 at 2:18 p.m., CNA #3 stated she had been driving the facility van for 5-6 months. She was asked, What would you do if you were driving the van and a resident fell ? She stated she would stop the van, call the facility and call an ambulance. iii.) On 3/29/17 at 2:53 p.m., CNA #2 stated she had been driving the facility van for 8 years. She was asked, What would you do if you were driving the van and a resident fell ? She stated she would pull over immediately, call 911 and check the resident. B. Based on observation, record review, and interview, the facility failed to ensure fall / injury prevention interventions were promptly developed and implemented after multiple falls and that the interventions were appropriate and individualized, based on the resident's cognitive and functional status to minimize the potential for further falls or injuries for 1 (Resident #8) of 8 (Residents #1- #3, #5 - #8 and #10) case mix resident who was at risk for falls. The failed practices resulted in a pattern of actual harm for Resident #8, who sustained hematomas to the head, rib fractures and a possible pubic ramus fracture due to multiple falls, and had the potential to cause more than minimal harm to 49 residents who were at risk for falls, as documented lists provided by the Administrator on 4/12/17. The findings are: 1. Resident #8 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/25/16 documented the resident scored 12 (8-12 indicates moderately impaired) on the BIMS, required extensive physical assistance of two plus people for bed mobility and transfer; required extensive physical assistance of one person for walking in room, locomotion off unit, dressing, toilet use and bathing, was independent in eating, required set up help only and had one fall with injury since prior assessment. a. A Care Plan 9/15/16 documented, .Problem Onset: (Resident #8) is at risk for falls due to 1) Dementia 2) History of falls 3) Use of psychoactive and pain medications 4) Unsteady gait . Approaches: Assist (Resident #8) with transfers and ambulation as needed . 11/2/16 - Bed alarm . b. A Resident Incident Report dated 11/18/16 at 6:20 p.m. documented, .Narrative of incident and description of injuries: .resident was sitting between the bed and wheelchair, when asked what he was trying to do he states 'I was trying to go to bed' appears resident slid from w/c (wheelchair) to floor .notified on call MD (Medical Doctor) due to resident c/o (complaining of) discomfort to rt (right) shoulder and left hip. Orders to X ray both . Immediate Actions Taken: will apply diason (Dysom) to w/c when available from supervisor. Will offer / encourage resident to go to bed immed. (immediately) after dinner . c. A Final Radiology Report dated 11/18/16 documented, Exam: XR (x-ray) left hip with pelvis when performed, 2 or 3 views .Impression: No acute findings . Exam: XR right shoulder, complete 2 or more views . Impression: No acute findings . d. A Resident Incident Report dated 12/2/16 at 9:46 p.m. documented, .Narrative of incident and description of injuries: .Resident was sitting in the floor on his bottom .and has a skin tare (tear) above lt (left) elbow .resident states, 'I was getting up to get my jeans so I could go to school.' Immediate Actions Taken: .wedge mattress on bed . e. A Resident Incident Report dated 12/7/16 at 1:00 p.m. documented, .Narrative of incident and description of injuries: .resident was found sitting on buttocks next to bed with both legs extended outward. Wheelchair next to resident with wheels locked. Resident states he was attempting to transfer self from wheelchair to bed without assist and lost his balance . Immediate Actions Taken: .Resident educated on importance of requesting assistance for transfers . There was no documentation of any fall prevention intervention, other than instructing the cognitively impaired resident to call for assistance with transfers. f. A Resident Incident Report dated 12/9/17 at 2:45 p.m. documented, .Narrative of incident and description of injuries: .observed resident in the floor leaning on the door facing with his head and sitting on his bottom . Immediate Actions Taken: .expressed that resident can't be getting up by himself that he was going to really hurt himself keeps trying to get up by himself and we didn't want him to get hurt . There was no documentation of any fall prevention intervention, other than instructing the cognitively impaired resident not to attempt to get up by himself. There was no documentation to indicate staff were instructed to monitor the resident more frequently due to the resident having experienced 3 falls within the previous 7-day period. g. A Resident Incident Report dated 12/9/16 at 6:00 p.m. documented, .Narrative of incident and description of injuries: .when I got to resident room, he was lying on the floor .does have a knot on the back of his head, applied ice pack assisted up to his bed . Immediate Actions Taken: .nonskid socks . Additional follow-up 12/10/16 .He is to have a low bed to replace current bed . Nurses Notes dated 12/10/16 at 2:08 a.m. documented, Rsd (resident) back from (emergency room ) .from a fall cat (computed tomography) scan done and was clear of any FX (fracture) but does have a DX (diagnosis) scalp hematoma to the back of his head . h. A Resident Incident Report dated 12/10/16 at 7:36 p.m. documented, .Narrative of incident and description of injuries: .Res (resident) found on floor in front of closet in supine position with walker on right side .res states 'I wanted some pants out of closet and lost my balance and fell over walker' . Immediate Actions Taken: .Bed alarm placed on bed and non-skid socks on res . A Care Plan intervention dated 12/10/16 documented, .Offer to go to bathroom on rounds and before and after meals . 1.) Nurses Notes dated 12/10/16 at 9:23 p.m. documented, .MD notified (of fall) with orders and ER (emergency room ) called with report of res. (resident). EMS (emergency medical services) called to transport . 2.) Nurses Notes dated 12/10/16 at 10:30 p.m. documented, res returned to facility at 9 p.m. res returned with rib fx (fracture) from fall . i. A Radiology Report dated 12/12/16 at 4:49 p.m. documented, .HIP UNILAT (Unilateral) W/ (with) PELVIS 2-3 V (views) AP (anterior to posterior view) / LAT (lateral view) / DUNN (anteroposterior view of hip with patient supine and hips / knees flexed) RIGHT. Reason: RT HIP PAIN fell on SATURDAY (12/10/16). Comparison: 11/18/16 .Impression: .2. Left inferior pubic ramus fracture versus artifact related to patient rotation . j. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/17 documented the resident scored 12 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS), was totally dependent of the physician assistance of one person for bathing, required extensive physical assistance of 2 plus people for bed mobility, transfers, locomotion off unit, and dressing; walk in room did not occur; and required limited physical assistance of one person with eating. The MDS also documented the resident had no falls since admission or prior assessment. This MDS reflected declines in the resident's ability with walking in room, locomotion off unit, dressing, eating and bathing. k. On 3/27/17 at 1:25 p.m., the resident was lying in a low bed, with a wedge mattress on the bed. An alarm was attached to the bed, and the resident's wheelchair had Dysem non-slip material in the seat. l. On 3/30/17 at 3:33 p.m., the DON was asked, Do you think the interventions were appropriate for (Resident #8) for the falls that happened on 12/7/16, 12/9/16, and 12/10/16? She stated, No, because we used the same interventions from a previous fall. We should have tried something else. There should always be an intervention (put in place). m. On 3/30/17 at 4:05 p.m., Licensed Practical Nurse (LPN) #1 was asked to provide Fall Risk Assessments completed for Resident #8 after each fall since November 2016. The LPN stated, We only have an assessment for 10/11/16, 12/7/16, and one was done yesterday (3/29/17). n. On 3/30/17 at 4:14 p.m., the Administrator was asked, Are Fall Risk Assessments to be done after each fall, as documented by your fall protocol? She stated, Yes. The Administrator was asked, Do you know why they (fall risk assessments) weren't completed for falls that happened on 11/18/16, 12/2/16, 12/9/16 and 12/10/16? The Administrator replied, No, I don't. They should have been done. This was before I got here and it will be addressed. o. The facility's Fall Protocol, provided by Administrator on 3/30/17, documented, .Assessment Tools: 1. Fall Risk Assessment and post fall assessment . Procedure: All residents will be assessed for fall risk using the Fall Risk Assessment upon admission . significant change in status and at the time of the fall. General Resident Care Plan Documentation Guidelines: .2. List new interventions developed for each fall with date of implementation . p. As of 3/30/17, the resident had experienced no further falls after 12/10/16, according to Nurses Notes dated 12/10/16 through 3/30/17. 1.) A Care Plan Intervention dated 12/28/16 documented, .PT (Physical Therapy) to treat as indicated . 2.) Nurses Notes dated 12/21/16 documented, Call placed to (family member) for permission for therapy to work with (Resident #8) . 3.) A Care Plan dated 2/7/17 documented, (Resident) is receiving PT restorative nursing program 3 x (times per) week x 12 weeks for . AROM (active range of motion) / exercise . Walking . Multiple falls . 4.) The March 2017 Physician order [REDACTED]. 5.) As of the 3/30/17 survey exit date, there were no other residents on the case mix who had current issues with failure to appropriate address falls or fall risk.