Every finding on record at Corrigan LTC Partners

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 out of 5 (Resident #1 and Resident #2) residents reviewed for enhanced barrier precautions (EBP) for infection control practices. 1. Hospice Aides A and B failed to put on EBP while providing ADL care for Resident #1 on 05/18/26.2. The facility did not implement EBP for Resident #2 after she returned to the facility with a surgical wound on 05/13/26. These failures could place residents at risk for cross contamination and the spread of infection.The findings included: 1.Record review of Resident #1's face sheet dated 05/19/26 indicated she was an [AGE] year old female, admitted on [DATE] and her diagnoses included chronic kidney disease (long term condition where kidneys gradually lose function), unspecified disorder of the skin, and Alzheimer's (brain disorder). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated was sometimes able to make herself understood, understood others, and had severely impaired cognitive skills. She had 2 stage 3 pressure ulcers. Treatment included application of nonsurgical dressing and ointments/medications. Record review of Resident #1's care plan dated 04/06/25 (revised 03/18/26) indicated Resident #1 had a stage 3 wound on her right shin and a stage 3 wound on the back of her right knee. Interventions included assess weekly and report declines to MD. There was no EBP care plan available for review. Record review of Resident #1's physician orders dated 05/18/26 indicated Enhanced Barrier Precautions: Staff to wear gown and gloves when doing any of the following for the resident: dressing, bathing/showering; transferring, providing hygiene; changing lines, changing briefs or assisting with toileting; device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and wound care (any skin opening requiring a dressing). Record review of Resident #1's physician orders dated 05/19/26 indicated:-admit to hospice (order date 12/18/24),-cleanse stage 3 wound to back of left knee with NS, apply skin prep and leave open to air, cleanse wound to right calf with wound cleaner, apply SilvaSorb gel, and cover with dry dressing daily (order date 04/02/26), and -cleanse wound to right ankle with wound cleaner, pat dry, apply collagen powder and cover with bordered foam dressing daily every shift (order date 04/18/26). During an observation on 05/18/26 at 12:10 p.m., Hospice Aide A went into Resident #1's room. She was wearing gloves. She did not have on a gown. There was EBP sign adjacent to Resident #1's door. The EBP sign specified Everyone Must: clean their hands before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities.Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device Care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing.Do not wear the same gown and gloves for the care of more than one person. The DON knocked and opened the door (at the request of the surveyor) and confirmed Hospice Aide A and Hospice Aide B were providing ADL care for Resident #1. Neither Hospice Aide A nor Hospice Aide B were wearing gowns as specified on the EBP sign. There was no observed EBP supplies available for use for Resident #1 (no cart with EBP supplies next to the room or other EBP supply delivery system). During an interview on 05/18/26 at 12:15 p.m., the DON said all staff were trained to use EBP as necessary. She said she was not aware if there was hand sanitizer in Resident #1's room. She said Resident #1 had been receiving hospice services, and she was not able to say who trained the hospice staff for EBP. She confirmed she was the Infection Preventionist. She said the residents that were placed on enhanced barrier precautions either had a Foley catheter (drains urine), an IV (intravenous therapy), a colostomy (allows waste to exit the body), pressure wounds, ports (dialysis access), fistulas (dialysis access), or g-tubes. She stated if the enhanced barrier precautions were not followed, it could contaminate clothes and pass from resident to resident. She stated staff should know because there were signs posted outside the door. She stated when wound care was being done, a gown and gloves should be worn, and at times a face mask depending on what was being done. She stated anyone that provided hands-on care should wear enhanced barrier precautions. The DON said not following enhanced barrier precautions could cause spread of infection or contamination. She said the signage was used to make outside providers aware of the EBP, as well as verbally. During an interview on 05/18/26 at 12:30 p.m., Hospice Aide A said she had provided care to Resident #1 for over 1 year and had never used a gown when providing care. She said she had never seen or noticed the EBP sign prior to 05/18/26. She said she cleaned her hands with hand sanitizer that was available in Resident #1's room. She said there was no EBP supplies in Resident #1's room. She said if EBP were not used as required, there was a risk of spreading infection in the facility. During an interview on 05/18/26 at 12:45 p.m., Hospice Aide B said she was filling in for the usual hospice aide and did not notice the EBP sign adjacent to Resident #1's door. She said she provided Resident #1 with a bed bath and incontinent care. She said she wore gloves and used hand sanitizer, as necessary. She said if EBP were not used as required, there was a risk of spreading infection in the facility. During an interview on 05/18/26 at 1:35 p.m., LVN D said she was trained on infection control. She said she thought there was an EBP supply cart outside of Resident #1's room but she could not be 100% positive. She said she did not direct the hospice aides to use EBP. She said if EBP were not used as required, there was a risk of spreading infection in the facility. During an interview on 05/18/26 at 2:02 p.m., CNA E said she was trained on infection control and EBP. She said an EBP sign meant you had to wear a gown and gloves for all resident care and transfers. She said there was an EBP supply cart outside of Resident #1's door on 05/17/26 but could not say where the cart was on 05/18/26. She said if she needed any EBP supplies and there was no cart, she would get supplies from the storge closet. She said if EBP were not used as required there was a risk of spreading infection in the facility. 2. Record review of Resident #2's face sheet dated 05/19/26 indicated she was a [AGE] year-old female, re-admitted on [DATE] (initial admit 3/25/26), and her diagnoses included chronic COPD, displaced intertrochanteric fracture of the left femur, history of falling, dementia (decline in cognitive function), and Alzheimer's (brain disorder). Record review of Resident #2's admission assessment date 04/02/26) indicated she was usually able to make herself understood and usually understood others and had severe cognitive impairment (BIMS-3). Record review of Resident #2's re-admission assessment dated [DATE], completed by LVN C indicated a left femur surgical incision. Record review of Resident #2's admission MDS dated [DATE] indicated she was usually able to make herself understood and usually understood others and had severe cognitive impairment (BIMS-3). Record review of Resident #2's physician orders dated 05/13/26 indicated cleanse wound at left hip with NS/WC, pat dry, apply TOA and dry dressing q day and PRN everyday shift until healed. Record review of Resident #2' physician orders dated 05/18/26 indicated Enhanced Barrier Precautions: Staff to wear gown and gloves when doing any of the following for the resident: dressing, bathing/showering; transferring, providing hygiene; changing lines, changing briefs or assisting with toileting; device care or use (central line- long, flexible catheter inserted into a large vein near the heart to deliver medications, fluids, nutrition, or to draw blood for testing, urinary catheter (drains urine from bladder), feeding tube (provides nutrition), tracheostomy (opening in the neck to facilitate breathing)/ventilator (medical machine that helps a person breath, etc.); and wound care (any skin opening requiring a dressing). Record review of Resident #2's care plan dated 05/18/26 indicated enhanced barrier precautions would be used. Interventions included gloves and gowns when performing contact activity. There was no EBP care plan available for review prior to 05/18/26. During an observation on 05/18/26 at 1:15 p.m., Resident #2 was in bed. There was no EBP or sign observed near or adjacent to Resident #1's door or room. During an interview on 05/18/26 at 2:12 p.m., CNA F said she was trained on infection control and EBP. She said EBP included gloves and gowns during resident contact and care. She could not say what happened to the missing EBP supply carts. During an observation on 05/19/26 at 8:30 a.m., Resident #2 was in bed. There was an EBP sign on the room door and EBP supplies available on the door. During an interview on 05/19/26 at 8:28 a.m., LVN C said she re-admitted Resident #2 on 05/13/26 from hospital after she had surgery for fracture of her hip. She said she was not aware EBP was required for surgical wounds. She said she was trained on infection control. She said the training did not include EBP. She said she should have placed an EBP sign on or adjacent to Resident #2's door and had the EBP supplies in a cart in place outside of Resident #2's door. She said if EBP were not used as required, there was a risk of spreading infection in the facility. During an interview on 05/19/26 at 8:42 a.m., the DON said after an audit of resident clinical charts completed on 05/18/26, there was no EBP signage or supplies for Resident #2. She said it was an oversite by the admitting nurse. She said the EBP sign and supplies should have been in place when Resident #2 was re-admitted from hospital on [DATE]. During an interview on 05/19/26 at 1:14 p.m., the RDC confirmed staff training for infection control did not include EBP. Record review of a facility's Enhanced Barrier Precautions policy dated August 2022 indicated Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug- resistant organisms (MDROs) to residents. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2 EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. A. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 8. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. 9.Staff are trained prior to caring for residents on EBPs.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement Resident #1's care plan for behavior towards other residents after he hit Resident #2 with a fly swatter on 11/18/25. This failure could place residents at risk of further incidents of aggression. Findings included: Record review of Resident #1's face sheet dated 01/07/25 indicated he was a [AGE] year old male admitted on [DATE] and his diagnoses included hemiplegia (severe paralysis) and hemiparesis (muscle weakness) following cerebral infarction (stroke) affecting left dominant side, intermittent explosive disorder (mental health condition characterized by sudden, impulsive outbursts of anger or violence that are disproportionate to the triggering situation), personality change due to known physiological condition, and anxiety disorder (persistent excessive worry). Record review of Resident #1's significant change MDS dated [DATE] indicated he was usually able to make himself understood and usually understood others. He was cognitive (BIMS-15). There was no aggressive behaviors noted. Record review of Resident #1's care plan dated 05/23/24 indicated he was aggressive and argumentative with staff. Interventions included administer medications as ordered, intervene as necessary to protect the rights and safety of others, and referred to counselling services. There was no review or update noted related to Resident #1 hitting Resident #2 with the fly swatter on 11/18/25. Record review of Resident #2's face sheet dated 01/06/25 indicated he was a [AGE] year old male, admitted on [DATE] and his diagnoses included Parkinson's (neurodegenerative disease), anxiety (persistent excessive worry), and schizoaffective disorder-bipolar type (mental health condition characterized by symptoms of both schizophrenia and mood disorders, particularly mania and depression). Record review of Resident #2's significant change MDS dated [DATE] indicated he was usually able to make self understood, was able to understand others, had moderate cognitive impairment (BIMS-9), had an acute change in mental status with fluctuating inattention and disorganized thinking. There was no aggressive behaviors noted. Record review of Resident #2's care plan dated 09/05/25 indicated he had a behavior problem related to bipolar disorder. Interventions included weekly counseling services. Record review of an incident report dated 11/18/25 at 4:28 p.m., completed by LVN C indicated Resident #1 was in the dining room and hit another resident (Resident #2) with a fly swatter. When asked what happened, Resident #1 stated He wanted to call me his kid brother and I wanted to aggravate him so I hit him with the fly swatter. Resident #1 was taken to his room to diffuse the situation and was placed on 1-1. Administrator notified of physical aggression. Physician and psychiatric services notified. Received order to send Resident #1 to behavioral hospital. Record review of the facility investigation dated 11/24/25 indicated Resident #1 hit Resident #2 with a fly swatter on 11/18/25 at 4:30 p.m. Resident #1 and Resident #2 were separated and assessed. There were no injuries. Resident #1 was placed on 1 to 1 supervision. Resident #1 was transferred to a behavioral hospital on [DATE]. The facility confirmed resident to resident altercation. Record review of Resident #1's behavioral hospital records dated 12/03/25 indicated the reason for his admission included hitting another resident with a fly swatter and intentionally aggravating the other resident. During an interview on 01/05/26 at 1:42 p.m. Resident #2 said Resident #1 hit him to bug (bother) him with a fly swatter because he said Resident #1 could be a little brother. He said he was not hurt. He said he was not afraid and he was friends with Resident #1. During an interview on 01/05/26 at 1:50 p.m., Resident #1 said he hit Resident #2 with a fly swatter because he wanted to irritate him after Resident #2 said he (Resident #1) should be his little brother. He said he was not trying to hurt Resident #2, he was only trying to irritate him. During an interview on 01/05/26 at 3:23 p.m., the Administrator said there was no history of Resident #1 showing aggression towards other residents. She said when Resident #1 was readmitted from the behavioral hospital on [DATE]. She said the incident and care plan was reviewed on 12/04/25 and changes were supposed to be made but it was not saved in the electronic record. She said the incident that occurred on 11/18/25 was also supposed to be added to the care plan on 11/20/25 however it did not update and save in the electronic record. She said if care plans were not reviewed and updated the risks included staff not being aware of appropriate interventions for behavior management. During an interview on 01/05/26 at 3:28 p.m., the DON said Resident #1 was supposed to attend outpatient services provided by the behavior hospital however he refused to go after 1 or 2 appointments. She said the care plan was not updated as required. She said the previous DON was supposed to review and update the care plan as required. During an interview on 01/06/26 at 10:30 a.m., LVN C said she did not witness the incident between Resident #1 and Resident #2. She said Resident #1 did not have a history of aggression toward other residents. She said Resident #1 said he wanted to aggravate Resident #2 to see what he would do. She said Resident #1 was placed on 1-1 immediately after the incident until he was transferred to a behavior hospital. During an interview on 01/06/26 at 10:55 a.m. the DON said a CNA told her of the incident on 11/18/25 but she could not recall which CNA. She said she went to the dining room and Resident #1 was still holding the fly swatter. She said Resident #1 was no longer near Resident #2. She said he was still holding the fly swatter. She said Resident #1 was placed on 1-1 and remained in his room until he was transported to the behavior hospital on [DATE]. She said the fly swatter was removed from Resident #1's possession and disposed. During an interview on 01/06/26 at 11:14 a.m., Resident #3 said he witnessed Resident #1 hit Resident #2 with a fly swatter. He said Resident #1 was trying to irritate Resident #2. He said Resident #2 was upset with Resident #1 and moved to another table. He said he never saw Resident #1 hit Resident #2 or any other resident before. Record review of a text message sent to the Administrator by the previous DON on 01/06/26 indicated she did not recall anything of the incident on 11/18/25 other than she sat 1-1 with Resident #1 until he went to the behavior hospital on [DATE]. The surveyor attempted to contact CNA A regarding Resident #1 hitting Resident #2 with the fly swatter on 01/06/26 at 11:05 a.m. by phone. A voice message was sent with the surveyor's contact information. As of the investigation exit, CNA A did not respond. The surveyor attempted to contact CNA B regarding Resident #1 hitting Resident #2 with the fly swatter on 01/06/26 at 11:08 a.m. by phone. CNA B's phone was not accepting calls. A text message was sent with the surveyor's contact information. As of the investigation exit, CNA B did not respond. Record review of the facility's policy Resident-to-Resident Altercations dated 2001 (revised 09/2022) indicated .4. If two residents are involved in an altercation, staff .f. make necessary changed in the care plan approaches to any or all of the involved individuals; g. document in the resident's clinical record all interventions and their effectiveness; h. consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team; .

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. Expired milk was not disposed of.2. Hairnets were not worn properly. 3. Meat was not thawed properly in the sink. These failures could place residents who received meals from the kitchen at risk for food borne illness. During an observation on 9/15/2025 at 8:20 a.m. while in the kitchen it was observed that a tube of hamburger beef was not being thawed properly. Hamburger meat was in a kitchen sink, submerged in hot water with no water continuously agitating the surface of the water. The water was steaming and hot to the touch. It was observed that a gallon of milk was out of date, September 13th, 2025. This milk was stored in an ice chest with mostly melted ice. During an observation on 9/15/2025 at 12:12 p.m., in the dining room it was observed that [NAME] E did not have all of her hair in a hairnet. [NAME] E hair went down her back and was hanging out of her hairnet while plating food. [NAME] E brought out a bowl that contained ice, mighty shakes, and a gallon of milk that was expired on September 13th. The gallon of milk was taken away after the surveyor took a photo of it. During an interview on 9/17/2025 at 8:44 a.m. RN D said that there could be foodborne illness if food was thawed improperly, hairnets were not worn properly, or expired food was served to residents. She said it was the responsibility of all kitchen staff to ensure that these issues were not occurring. During an interview on 9/17/2025 at 9:10 a.m., the Dietary Manager said that meat should be thawed under cold water, submerged, with cold running water agitating the water. She said that her staff should also secure all of their hair in a hairnet, and it should not hang out the bottom. She said that all expired foods including milk should be disposed of and not served. She said that all these issues could cause foodborne illness. During an interview on 9/17/2025 at 9:00 a.m., the Administrator said that she expects that her kitchen staff follow facility policy. She said that facility policy dictates that kitchen staff thaw meat properly. She said that meat should have had been submerged in cold water with water continuously running. She said that she expects that kitchen staff wear their hairnets properly and throw out any expired foods. She said that residents could potentially be placed at risk of foodborne illness if these policies are not followed. A policy provided by the facility titled, Food Preparation and Service and dated November of 2022 indicated that the purpose of this policy was, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Completely submerging the item in cold running water (70 Fahrenheit or below) that is running fast enough to agitate and remove loose ice particles.Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.

Based on observations, record reviews, and interviews, the facility failed to treat each resident with respect and dignity in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 14 residents (Resident #3 and Resident #18) reviewed for resident rights. The facility failed to protect and value Resident #3 and Resident #18's dignity when their catheter urine collection bags either did not have a privacy bag on it or it was not properly placed on the catheter bag. This failure could place residents at risk for decreased quality of life, increased anxiety, embarrassment and increased stress. Findings included:1. Record review of Resident #3's admission Record dated 8/15/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Streptococcal Sepsis (a life-threatening infection caused by bacteria known as Streptococcus), Muscle Weakness (Muscle weakness can have causes that aren't due to underlying disease. Examples include poor physical conditioning, intense exercise, recovery from strength training, or malnutrition), and Type 2 Diabetes (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels).Record review of Resident #3's admission MDS dated [DATE] revealed that the resident had a BIMS score of 13 which indicated no cognitive impairment. The MDS also revealed, Resident #3, required maximal assistance for transfers. Record review of Resident #3's Care Plan dated 8/18/25 , revealed a problem initiated on 8/18/2025 for impaired visual function. It also indicated that Resident #3 has an ADL self-care performance deficit .During an observation and attempted interview on 9/15/2025 at 8:53 a.m. Resident #3's catheter bag was exposed to the public. There was no cover over his urine collection bag. When asked about this he did not understand the surveyor's question. During an observation on 9/16/2025 at 8:10 a.m. Resident #3 was observed lying in bed with his catheter bag viewable to the public. His door was open and there was no privacy bag over his urine collection bag. 2. Record review of Resident #18's admission Record dated 2/21/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia (a general term describing a group of conditions that cause a progressive decline in cognitive abilities, including memory, thinking, reasoning, and judgment, which interfere with daily life), Hydronephrosis (a condition where the kidneys become enlarged due to a buildup of urine), Schizoaffective Disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder). Record review of Resident #18's MDS dated [DATE] revealed that the resident had a BIMS score of 10 which indicated moderate impaired cognition. The MDS also revealed , Resident #18, was dependent for all her needs. Record review of Resident #18's Care Plan revealed a problem initiation on 8/18/2020 Resident #18 was dependent on staff for activities, cognitive stimulation, social interaction related to immobility. She actively participated in group activities as desired. She kept a semiactive independent activity level.During an observation on 9/15/2025 at 9:05 a.m., Resident #18 was observed with her catheter bag exposed to the public. There was a privacy bag on her urine collection bag, but it was only half on exposing the bottom half of the bag. Resident #18 was developmentally disabled and was unable to give an interview. During an observation on 9/15/2025 at 3:12 p.m., Resident #18 was observed with her catheter bag exposed to the public. There was a privacy bag on her urine collection bag, but it was only half on exposing the bottom half of the bag . During an interview on 9/17/25 at 8:44 a.m., RN D said that it was the responsibility of nurses and CNAs to ensure that privacy covers were on catheter bags to prevent them from being exposed to the public. She said that not having a privacy bag on a catheter was a resident rights and dignity issue as a resident whose catheter bag that was exposed could be embarrassed . During an interview on 9/17/2025 at 9:00 a.m., the Administrator said the CNA or whichever nurse was assigned the hall that resident resided on should ensure residents' privacy covers were on their catheter bags. She said that it could be embarrassing to the resident if their catheter bag was exposed to the public. She said it was the facility policy to ensure that resident's dignity was maintained. Record review of a facility policy titled, Resident Rights dated February 2021 indicated that, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence.

Based on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents (Resident #35) reviewed for unnecessary medications. The facility failed to ensure Resident #35 had an appropriate rationale for declining a gradual dose reduction for her Lexapro (antidepressant medication) and Seroquel (an antipsychotic medication) medications. This failure could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.Record review of Resident #35's face sheet, dated 09/16/25, indicated she was a [AGE] year-old female, originally admitted to the facility on [DATE], and most recently readmitted on [DATE]. Her diagnoses included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #35's annual MDS assessment, dated 08/14/25, indicated she was usually able to understand others and she was usually able to make herself understood. She had a BIMS score of 15, which indicated intact cognition. She also had a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). She took antipsychotic medications on a routine basis only, a GDR had not been attempted, and the physician had not documented the GDR as clinically contraindicated. Record review of Resident #35's Order Summary Report, dated 09/16/25, indicated she had the following orders:*Escitalopram Oxalate (Lexapro) Tablet 10 MG Give 1 tablet by mouth one time a day related to anxiety disorder. The start date was 10/24/23.* QUEtiapine Fumarate (Seroquel) Tablet 100 MG Give 1 tablet by mouth two times a day related to other schizoaffective disorders, anxiety disorder. The start date was 07/07/22. Record review of a Consultant Pharmacist / Physician Communication, dated 05/14/25, reflected: .Resident is receiving the following psychoactive medication(s) that are due for review:Lexapro 10mg [daily]Seroquel 100mg [twice daily]Per CMS regulations, please evaluate resident for a trial dose reduction or if a dose reduction is clinically contraindicated. Please document in the clinical progress note below if a dose reduction is not indicated.Physician/Prescriber ResponseDisagree. [continue with] same dose. During an interview on 09/16/2025 at 12:43 PM, the DON provided the most recent GDR for Resident #35. She said the provider response indicated Disagree. Continue with same dose. She said she felt like that was not a good rationale for not attempting a gradual dose reduction.During an interview on 09/17/25 at 9:38AM, the DON said she spoke with the doctor on this day and the rationale was now fixed. She said the DON at the time started in April and did not check the GDR. She said she expected the previous DON to check the GDR and ensure that it had a good rationale. She said she felt like the doctor did not give a proper rationale before she spoke with the doctor. She said the risk of not having a proper rationale was that the resident could be on unnecessary medications.During an interview on 09/17/2025 at 11:19 AM, the Administrator said she had worked as the administrator of this facility since April 7th. She said the doctor should have provided a proper rationale for continuing the dose. She said the risk was that the resident could be on an unnecessary amount of medication and/or suffer side effects. Record review of the facility's policy, Tapering Medications and Gradual Drug Dose Reduction, last revised July 2022, reflected: .2. All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as gradual dose reductions.3. Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.5. The physician will review periodically whether current medications are still necessary in their current doses; for example, whether an individual's conditions or risk factors are sufficiently prominent or ensuring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medications, or with a lower dose.6. The physician will order appropriate tapering of medications, as indicated. 10. Residents who use psychotropic medications shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. Pertinent behavioral interventions will also be attempted.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 15 residents reviewed for infection control practices (Resident #38). The facility failed to ensure CNA A changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #38. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of Resident #38's undated face sheet indicated she was a [AGE] year-old-female that admitted [DATE], with a readmit date of 7/9/23. Record review of the physician's orders dated 9/16/25 indicated Resident #38 had diagnoses that included: hypertension (the force of blood against the arterial walls is too high), diabetes (the body cannot properly regulate blood sugar), dementia (characterized by loss of at least 2 brain functions, such as memory loss and judgment), and Alzheimer's Disease (a progressive brain disorder-most common cause of dementia, characterized by memory loss, difficulty with thinking and problem solving that gets worse over time). Record review of the annual MDS dated [DATE] indicated Resident #38 had clear speech, was sometimes understood by others and sometimes understood others. The MDS revealed she had a BIMS score of 3 indicating severe cognitive impairment. Resident #38 was always incontinent of bowel and bladder. Record review of the care plan dated 6/13/25 indicated Resident #38 had impaired cognitive function/dementia and bowel and bladder incontinence. During an observation and interview on 9/16/2025 at 1:19 PM, CNA A performed incontinence care for Resident #38 with CNA B assisting. CNA A did not change her gloves or sanitize her hands until she had finished and had repositioned Resident #38. CNA A touched Resident #38's clean brief, gown, sheet, blanket, her legs, and the remote control for the bed with her dirty gloves. CNA A said We failed. I forgot to change my gloves. During an interview on 9/16/25 at 1:29 PM, CNA A said she got confused and touched Resident #38's clean brief, legs, gown, sheet, blanket, and the bed remote control with dirty gloves and that was a risk of contamination to residents and staff. She said it was an infection control issue. She said she had been trained to change her gloves and sanitize her hands when going from dirty to clean and should have changed her gloves after cleaning Resident #38 front peri area and before going to her backside, then again after cleaning her backside and before touching anything considered clean. During an interview on 9/16/25 at 1:31 PM, CNA B said CNA A should have changed her gloves after she cleaned Resident #38's front peri area because her gloves were dirty and she could have been contaminating everything she touched which was an infection control problem for staff and residents. She said staff had to change gloves anytime they were considered to be dirty. During an interview on 9/17/2025 at 7:54 AM, LVN C said during incontinent care staff would need to change their gloves after cleaning a resident's front peri area and before going to the back area. She said not changing dirty gloves and touching clean items or the resident would spread infection. She said all CNA's know they have to change their gloves before going from dirty to clean, otherwise it could spread serious infection to residents and staff. During an interview on 9/17/2025 at 8:01 AM, RN[VT1] D said during incontinent care staff should change their gloves anytime when going from dirty to clean to prevent infection and contamination. She said staff should never use the same gloves without changing them during an entire incontinent care. She said dirty gloves touching a resident or clean items could contaminate and cause illness to staff and or residents. She said all staff have been trained and educated to change their gloves and sanitize their hands when going from dirty to clean. During an interview on 9/17/2025 at 9:00 AM, the Regional RN said during incontinent care staff should change their gloves and sanitize their hands after cleaning the front peri area and before going to the back, and again after cleaning the back area, and anytime gloves would be considered dirty. She said there was a risk of spreading infection and contamination to staff and residents when staff touched clean items with dirty gloves. During an interview on 9/17/2025 at 9:11 AM, the ADM said when performing incontinent care staff should change their gloves and sanitize their hands after cleaning the front peri area and before going to the back. She said they should change their gloves again and sanitize their hands after cleaning the back area. She said not changing their gloves and touching clean items with dirty gloves could cause a transfer of bacteria and cause infection to staff and residents. Record review of a Nurse Aide Proficiency dated 4/15/25 indicated CNA A was proficient in handwashing and perineal care. Record review of Policies and Practices - Infection Control with a revised date of October 2018 indicated: Policy StatementThis facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Record review of Perineal Care with a revised date of October 2018 indicated: After performing incontinent care .9.Discard disposable items into designated containers.10.Remove gloves and discard into designated container.11.Wash and dry your hands thoroughly.12.Reposition the bed covers. Make the resident comfortable. Record review of Handwashing/Hand Hygiene with a revised date of October 2023 indicated: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Policy Interpretation and ImplementationAdministrative Practices to Promote hand Hygiene1.All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2.All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors[VT2] . [ [VT2]Good job!

Based on interview and record review, the facility failed to ensure that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 13 residents (Resident #28) reviewed for pharmacy services. The facility failed to ensure that 8 tablets of Resident #28's prescribed morphine (opiate pain medication) were properly accounted for and not missing on 09/15/25. This failure could place residents at risk for decreased quality life and unrelieved pain.Findings included: Record review of Resident #28's face sheet, dated 09/16/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions.), peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel) and poly-osteoarthritis (characterized by the degeneration of cartilage and the underlying bone within a joint, leading to pain, stiffness, and impaired movement). Record review of Resident #28's annual MDS assessment, dated 07/24/25, indicated a BIMS score of 99 which indicated the resident was unable to complete the BIMS interview. She was sometimes able to make herself understood and she was sometimes able to understand others. She was taking an opioid medication. Record review of Resident #28's Order Summary Report, dated 09/16/25, reflected this order:*Morphine Sulfate Oral Tablet 15 mg Give 1 tablet by mouth every 12 hours as needed for pain/dyspnea. The start date was 08/07/25.Record review of Resident #28's MAR for the month of August 2025, printed on 09/16/25, indicated the morphine sulfate medication was not administered during the month of August to Resident #28.Record review of Resident #28's MAR for the month of September 2025, printed on 09/16/25, indicated one dose of the morphine sulfate medication was administered to Resident #28 on 09/12/25 and 09/13/25. Record review of an undated investigative report completed by the Administrator and provided to the survey team on 09/16/25 reflected: .Around 5PM on 09/15/2025 [RN F] from [hospice company] was routinely reviewing medications for refills on [Resident #28] when it was discovered that the remaining Morphine Sulfate tablets were missing, not only was the card missing but the narcotic count sheet was gone as well. A search for the medication, card, and narcotic sheet was initiated on all carts, med room, drug destruction areas, medication storage, and shredder box. When the medication was not found we looked at the EMR to see when it was last given, per administration record it was given the evening of 09/13/2025 [at] 1945 (7:45 pm) by [LVN G]. [LVN G] was phoned by the facility and was interviewed by [the DON], [LVN G] stated that she gave the last pill in the card, took the empty blister pack and the narcotic count sheet and put them in the Business Office's box before end of shift. Day shift nurse [LVN H] was also contacted and stated that there were more pills on the card when she used it prior to [LVN G] on 09/12/2025. [The hospice company] was contacted via phone for order information on the Morphine Sulfate oral tablets, that were ordered from [Resident #28's Pharmacy] on 08/05/2025 in the amount of 10 tablets and was delivered to the facility by hospice on 08/07/2025 when the order was initiated. Medication administration record shows 2 tabs were given to the resident between 08/07/2025 and 09/13/2025. We presume 8 tablets are missing but we have no count sheet to verify this information.At approximately 6pm this administrator met with [an officer of the police department].Information regarding missing count sheet and controlled drug by name of Morphine 15mg tablets- 8 tabs missing- was reviewed. [an officer of the police department] contacted [LVN G] via phone and interviewed her. [Police Officer and Police Sergeant] concluded that it would be a he said she said situation and no evidence was available to pinpoint to one person. [Police Sergeant] requested list of nurses with access and phone numbers from night shift 09/13/2025 to day shift 09/15/2025, the last time the medication was seen up to the time when it was discovered missing. This administrator sent an email to the [police department] with names and numbers as requested.[Facility's Legal Department] was contacted regarding follow-up on drug testing for nurses that may have been involved, and facility was advised to not drug test at this time due to the police report stating that too much time had passed between the drug being on hand and discovery of the missing drug. During an interview on 09/17/25 at 7:56AM, LVN H said she administered morphine to Resident #28 on 09/12/25. She said there were 8 or 9 pills left in the card after her administration of the medication. She said when her and the other nurse reconciled the medications at the end of her shift the count was correct. A phone call was attempted to LVN G on 09/17/25 at 8:29AM. LVN G did not answer, and the voicemail box was full. The call was not returned prior to exit. During an interview on 09/17/25 at 9:03AM, RN F said she visited the facility on 09/15/25 to check on Resident #28. She said she was a hospice nurse for Resident #28. She said during her visit she checks the resident's medication supply against her list to ensure there is enough supply on hand. She said during her check she was unable to locate the morphine medication. She said the other controlled medication the resident was taking was in the cart, but the morphine was not there. She said the last time she visited the facility there were 10 pills in the morphine card. She said she immediately notified the nurses and the facility's administration. She said the records showed that the morphine was administered 2 times in September and there should have been 8 pills left. She said she ordered more and was going to bring it on 09/17/25. During an interview on 09/17/25 at 8:54AM, the DON said she was alerted by the hospice nurse on 09/15/25 that Resident #28's morphine medication was missing. She said she reviewed the MAR and it had been administered twice by two different nurses over the past weekend. She said she spoke with LVN G and she had given the last dose on 09/13/25. She said the nurse was part time at the facility and was not sure where to put the sheet and card after administering the last dose. She said the nurse gave the last dose and put the card in the Business Office Manager's box. She said they searched the facility and were unable to locate the morphine medication or the count sheet. She said she in-serviced LVN G on the proper procedure for disposal of controlled medications. She said LVN G also told her she had also put a timesheet in the Business Office Manager's box before that had gone missing. She said the policy was that the nurse should have given the count sheet to the DON, or slid under the door of the DON's office, or placed in the DON's box. She said the empty medication card should have been torn and shredded. She said the resident was monitored for pain and did not have pain while they did not have the morphine medication. She said she notified hospice and other pain medications were already ordered. She said she spoke with LVN H and she was unsure how many pills were left after she administered a dose of the medication. She said they were unable to identify an alleged perpetrator and it was ultimately a he said/she said situation. During an interview on 09/17/2025 at 11:19 AM, the Administrator said she had been the administrator in this facility since April 7th, 2025. She said she has no new information to add to the statement provided to the surveyor. She said the nurse should have followed the policy and ensured that an empty medication card and narcotic sheet was properly disposed of. She said the risk was a medication could go missing and since they do not have the count sheet they are unable to reconcile the drug. Record review of the Facility's policy, Controlled Substances, last revised November 2022, reflected: .Dispensing and Reconciling Controlled Substances1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following:a. Records of personnel access and usage;b. Medication administration records;c. Declining inventory records; andd. Destruction, waste and return to pharmacy records.3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.7. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards for 2 of 14 residents (Resident #3 and Resident #31) reviewed for accidents and hazards.1. The facility failed to keep prohibited items, Povidone-Iodine 10% solution, out of Resident #3's room.2. The facility failed to keep prohibited items, chemical cleaning solution, out of Resident #31's room.This failure could place residents at risk for injury, harm, and impairment or death.This failure could place residents at risk for injury, harm, and impairment or death.Findings included:1. Record review of Resident #3's admission Record dated 8/15/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Streptococcal Sepsis (a life-threatening infection caused by bacteria known as Streptococcus), Muscle Weakness (Muscle weakness can have causes that aren't due to underlying disease. Examples include poor physical conditioning, intense exercise, recovery from strength training, or malnutrition), and Type 2 Diabetes (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels).Record review of Resident #3's admission MDS dated [DATE] revealed that the resident had a BIMS score of 13 which indicates no cognitive impairment. The MDS also revealed, Resident #3, required maximal assistance for transfers. Record review of Resident #3's Care Plan dated 8/18/25, revealed a problem initiation on 8/18/2025 for impaired visual function. It also indicated that Resident #3 has an ADL self-care performance deficit.During an observation and interview on 9/15/25 at 8:53 a.m. it was observed that Resident #3 had a bottle of Povidone-Iodine 10% solution in his room on a dresser next to his refrigerator. Resident #3 did not know what the solution was for. There was no staff in the room performing any type of care . 2. Record review of Resident #31's admission Record dated 6/9/2022 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), General Anxiety Disorder (Severe, ongoing anxiety that interferes with daily activities), Adult failure to thrive (a condition in older adults where there is a significant decline in physical, mental, and social well-being)Record review of Resident #31's MDS dated [DATE] revealed that the resident had a BIMS score of 06 which indicated severe cognitive impairment. The MDS also revealed, Resident #31 was dependent or required moderate assistance with most ADLs. Record review of Resident #31's Care Plan revealed a problem initiation on 5/11/2021 that Resident #31 had impaired cognitive function/dementia or impaired thought processes.During an observation on 9/15/2025 at 8:42 a.m. Resident #31 was observed to have a bottle of all-purpose chemical cleaning solution in her room. There was no staff in the room actively cleaning . During an interview on 9/17/2025 at 8:44 a.m., RN D said that it was not allowed for residents to have Iodine or chemical cleaning solutions in their room. She said that these items should be stored in separate places. She said that Iodine should be stored on the nurse's treatment cart. She said that chemical cleaning solutions should be kept by housekeeping. She said that residents could harm themselves if they improperly misuse a chemical product. She said that residents could get sick and need medical attention. She said it was the responsibility of all staff to ensure that residents do not have chemicals in their rooms. During an interview on 9/17/2025 at 9:00 a.m., the Administrator said that Iodine and brand-named chemical cleaning solutions should not be left in residents' rooms. She said that they contract out their cleaning supplies and a brand name cleaning supply should not have even been in the building. She said that housekeeping should keep and maintain all cleaning products. She said that Iodine solution should not be left in residents' rooms it should be kept on the nurses' medication cart. She said it was likely used for wound care and left by a nurse. She said Iodine should not have been left in a resident's room. She said that residents could potentially be harmed if they misused a chemical that was left in their room especially if that resident had a cognitive decline. Record review of a facility policy titled, Storage Areas, Maintenance dated December 2009 indicated that, Maintenance storage areas shall be maintained in a clean and safe manner. Cleaning supplies, etc., must be stored in areas separate from food storage rooms and must be stored as instructed on the labels of such products.Record review of a facility policy titled, Accidents/Incidents dated April 2013 indicated that, Our facility shall provide a safe and secure environment for staff and residents. Therefore, all accidents or incidents occurring on facility premises or to facility employees while performing their jobs shall be reported and investigated.

Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for supervision to prevent elopement. RN A failed to ensure Resident #1's wander guard (a device designed to prevent wandering in the elderly) was functioning as required. The facility was unaware that on [DATE], Resident #1 eloped from the facility with a wander guard sometime after 8:15 p.m. (approximately) and was found on the ground at an apartment complex adjacent to the facility by EMS at approximately 10:30 p.m. Resident #1 was returned to the facility by EMS on [DATE] at approximately 10:45 p.m. An IJ was identified on [DATE] at 1:45 p.m. While the IJ was removed on [DATE] at 1:30 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not being properly supervised resulting in serious injury or death. Findings included: Record review of Resident #1's face sheet dated [DATE] indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included unspecified psychosis (indicates the presence of psychotic symptoms that don't perfectly align with a specific diagnosis), lack of coordination (a condition characterized by difficulty in performing physical movements smoothly and accurately), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), and paranoid schizophrenia (mind doesn't agree with reality). Record review of quarterly MDS assessment dated [DATE] indicated she was usually able to make herself understood, usually understood others, had severe cognitive impairment (BIMS-3). Wandering was not indicated. Record review of Resident #1's care plan dated [DATE] indicated she was an elopement risk and wander guard was placed on [DATE]. Interventions included distract Resident #1 from wandering and identify pattern of wandering. Record review of Resident #1's care plan dated [DATE] indicated she was an elopement risk, the wander guard was removed. Interventions indicated Resident #1 was placed on the secure unit due to poor safety awareness and wander risk. Record review of Resident #1's physician orders dated [DATE] indicated may have wander guard due to poor cognition and poor redirection. Record review of Resident #1's physician orders dated [DATE] indicated monitor placement for function wander guard QD and pm every shift. Record review of Resident #1's physician orders dated [DATE] indicated monitor placement of wander guard bracelet at left wrist every shift. Record review of Resident #1's Elopement Risk assessment dated [DATE] indicated a score of 11 (high risk). Record review of Resident #1's Elopement Risk assessment dated [DATE] indicated a score of 17 (high risk). Record review of Nursing Progress note dated [DATE] at 2:39 a.m., completed by RN A indicated on [DATE] at 10:45 p.m. EMT F with (named service) arrived at facility and approached RN A asking, Do you have a resident named (Resident #1)? RN A confirmed this. EMT F said, Well she fell at the apartment complex across the street; a resident of the apartments saw her fall and called 911. She's on my truck right now. She told us she stays here, and that she walked out the back door. Her only complaint is that she says she got bitten by ants on one of her hands. Do you want me to transport her, and if so, to which facility? RN A asked him, Does she have ant bites on her hand? He replied, I didn't see anything, but my partner is assessing her on the truck now. RN A printed up the Resident #1's face sheet and order summary for the EMS crew and a copy for the ER staff and asked him to transport her to (named hospital) for evaluation. RN A contacted the Administrator and DON by 10:58 p.m. Made facility-wide head count = 41. At 11:51 p.m. left detailed VM with RP. At 12:56 a.m., RN A received phoned report from (named hospital RN) and CT scans were negative, fractures were ruled out, and no injuries had been noted. At 1:57 a.m., Resident #1 returned to facility via EMS. At 2:12 a.m. RN A contacted NP. Received orders as follow: Maintain Q 15 monitoring and consider admission to The Secure Unit. RN A did not address Resident #1's wander guard placement or functionality. Record review of the facility investigation dated [DATE] and completed by the Administrator, indicated the facility became aware of Resident #1 missing from the facility at 10:45 p.m. on [DATE] after she was returned to the facility by EMS. She was transported to the hospital by EMS for evaluation and treatment. The facility initiated a head count for all residents, obtained a list of all residents with wander guards, wander guards were checked for expiration dates. Resident #1 returned to the facility and had no injuries. Resident #1 was placed on 15 minute checks upon return from the ER. Resident #1's wander guard was working upon return from the hospital but it was replaced while facility obtained orders and permission from family to transfer resident number one to the secure unit. All doors and alarms were assessed and found to be in working order. The facility confirmed Resident #1 as a Missing Resident. The investigation does not include investigation of the completion or verification of wander guard placement or checks. Record review of RN A's undated statement indicated On the 6 pm to 6 am shift of [DATE] CNA B was assigned to a hall at the facility I was the charge nurse assigned to the A hall and to 1/2 of the B hall from 6 pm to 10:45 pm this night while performing my own tasks on a hall and during what time I worked at the nurses station I did observe CNA B make several trips down a hall including completing her 6 pm, 8 pm, and 10 pm rounds, as well as answering call lights. In fact she only very recently had returned from A hall to the vicinity of the nurses' station when the EMT entered the facility to inquire as to the residency of Resident #1. The statement does not include information related to Resident #1's location or to the wander guard checks for placement or functionality. Record review of CNA B's statement dated [DATE] indicated At approximately 6:00 p.m. on [DATE]nd 2025, I (CNA B) made my round checking and changing all residents. Resident #1 appeared to be sitting up in her bed watching TV. At approximately 8:15 p.m. I began my next round checking/changing and getting other residents bathed. I completed this round at approximately 10:30 (p.m.) and returned to the desk to fill out shower sheet and fill the cooler with ice to pass during my next round. Then at 10:45 p.m. EMT came into the facility stating Resident #1 made her way the apartments across the street and fallen with no apparent injuries. No alarms of any of the doors had sounded off at any point . The statement does not include information of Resident #1's location after 6:00 p.m. rounds. Record review of the facility weekly door alarm check and wander guard alarm dated [DATE] indicated all alarms were in working condition. During an interview on [DATE] at 11:21 a.m., the Administrator said Resident #1 had a wander guard on due to her risk for elopement. She said the doors alarms were checked that night on [DATE] and the next day on [DATE] and were in working condition. She said she was informed Resident #1's wander guard was also in working condition. She said Resident #1's wander guard was discontinued, and she was placed on the secure unit effective [DATE]. She said staff were retrained from [DATE] though [DATE] on elopement risk, elopement protocols, abuse and neglect, and resident rights after Resident #1 eloped from the facility. She said the facility also ran elopement drills. She said the facility began locking the entrance and exit doors at certain times to keep the resident safe. She said the facility did not determine how Resident #1 eloped with no notice. She said it appeared Resident #1 left out the door adjacent to kitchen (back door) and walked over to the apartment complex across the street. She said Resident #1 tripped and someone saw Resident #1 trip and called 911. She said Resident #1 was placed on 1-1 until she was moved to the secure unit on [DATE]. During an observation and interview on [DATE] at 12:45 p.m., Resident #1 was laying in bed watching TV on the secure unit. She said she was fine and had no complaints. She said she did not remember leaving the facility or falling on the ground. She said she did not remember going to the hospital. She appeared calm and displayed no signs of agitation or anxiety. During an interview on [DATE] at 9:55 a.m., the DON said the wander guard scanners were locked in her office and not available for staff to use after 6:00 p.m. She said to check for wander guard functionality, the staff would assist residents to the doors with wander guard alarms to assess the functionality. She said nursing staff were expected to check the wander guards for functionality and placement. The DON said the facility exit doors were locked from 8:00 p.m. through 5:00 a.m. after Resident #1 eloped. She said the facility did not have a policy to address wander guards, placement, functionality or testing prior to the incident on [DATE]. During an interview on [DATE] at 10:00 a.m. the Administrator said Resident #2 was currently the only resident in the facility with a wander guard. She said he was not available because he was discharged to the hospital. She said Resident #2's wander guard was found to be expired and was replaced after Resident #1 eloped. She said the facility was not able to determine how Resident #1 eloped. She said wander guard checks were supposed to be completed every shift. She said it was her understanding the wander guard was working when Resident #1 returned from the hospital on [DATE]. During an observation on [DATE] from 10:15 a.m. through 10:30 a.m., conducted with the facility Administrator and Maintenance Director indicated all door alarms and wander guard alarms were in working condition. During an interview on [DATE] at 10:15 a.m., the Maintenance Director said prior to the incident on [DATE], the door alarms and wander guard door alarms were checked weekly for functionality. He said 3 doors of 6 doors had exit alarms and the other 3 doors had wander guard alarms. He said the doors with exit alarms have a code that was used to turn off the alarm. He said the front door, the dining room door and the back door had wander guard alarms. He said he did not check residents' wander guards for placement or functionality. During an interview on [DATE] at 10:49 a.m., RN A said he was the nurse assigned to Resident #1 on [DATE]. He said he did not see Resident #1 leave the facility. He said he did not hear any door alarms. He said he was on this assigned halls completing his duties. He said he was aware Resident #1 was in her room at the end of the hall. He said it was determined within 14 hours of Resident #1 leaving the facility that her wander guard battery wasn't working. He said he did not check for wander guard functionality. He said he was not going to come on his shift at 6:00 p.m. and get Resident #1 up from her bed to walk to a door with the wander guard alarm to check the battery. He said he did not know of a scanning device to check the wander guard batter for functionality. He said he marked off on the MAR that he checked Resident #1's wander guard for placement and functionality but he did not compete the task per physician orders. He said he was aware the maintenance staff checked the door alarms weekly. He said he was pretty sure Resident #1 left the facility through the back door adjacent to the facility kitchen while staff were busy with tasks because no heard the wander guard alarm go off. During an interview on [DATE] at 12:28 p.m., LVN C said she would take Resident #1 to the door on the hall closest to her room and open the door and the alarm would go off. She said she would turn the alarm off with a code. She said she was not aware the door adjacent to Resident #1's room did not have a wander guard alarm. She said she worked form 6:00 p.m. until 6:00 a.m. and did not have access to the scanner to check wander guards for functionality. During an interview on [DATE] at 6:00 p.m., CNA B said she finished her fist rounds at approximately 8:15 p.m. on [DATE] and Resident #1 was in bed watching TV. She said she finished her second rounds at approximately 10:30 p.m. She could not recall the last time she saw Resident #1. She said she was completing shower sheet documentation and getting ice ready for the next rounds when EMS arrived at the facility at approximately 10:45 p.m. There was no alarm sounds when Resident #1 left the building and there was no alarms sounding when Resident #1 returned to the facility. She said Resident #2 also had a wander guard. She said Resident #2 was woken up and taken to a door with a wander guard alarm and his wander guard was not working because the alarm did not go off. Record review of the facility's policy Safety and Supervision of Residents dated 2001 (revised [DATE]) indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Resident Risks and Environmental Hazards1. Due to their complexity and scope. certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: a. Bed Safety: b. Safe Lifting and Movement of Residents: c. Falls; d. Smoking; e. Unsafe Wandering; . Record review of the facility's Wandering and Elopements policy dated 2001 (revised [DATE]) indicated The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. An Immediate Jeopardy/Immediate Threat was identified on [DATE] at 1:45 p.m. The Administrator and the DON were notified of the Immediate Jeopardy and provided the IJ template on [DATE] at 2:00 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on [DATE] at 10:24 a.m. and reflected the following: On [DATE] (named facility) completed an Elopement Risk Assessment on every resident in the facility, audit was completed by ADON. Results were reviewed and actions taken per directions below. Resident #1 was taken by EMS to the emergency room ER for evaluation and care. Resident # 1 was cleared regarding significant injuries and was placed on the secured unit on [DATE]. Resident #1 physician was notified upon transfer to the ER and upon return to the facility for orders. To remedy concerns regarding resident elopement at (named facility), the facility implemented the following changes: 1. [DATE]-Wander guards will not be utilized at (named facility) in response to this identified immediate jeopardy situation. Any resident that meets the criteria for elopement risk were placed on the secured unit. Any resident admitted or readmitted to (named facility)that meets the elopement criteria will NOT be admitted outside of the secured unit. Residents are screened on admissions/readmission and with change of condition via the elopement risk assessment to determine elopement risk and placement on the secured unit if deemed an elopement risk. 2. In-services were started on: [DATE] Wandering & Elopement by DON for all staff to include focus areas that are *What to do if you see a Resident trying to leave the facility, *What to do if a resident is missing, and *What to do if a resident is returned to the facilityXXX[DATE] Abuse & Neglect by DON for all staff to include focus areas that are *Definitions of abuse, *Assessment and Recognition of Abuse, *Cause and Identification of Abuse, *Treatment and Management, and *Monitoring/Follow up. [DATE] Emergency Procedure/Missing Resident by DON for all staff to include focus areas that are *Policy interpretation and implementation, *Emergency procedure-missing resident, *Emergency job tasks-missing resident[DATE] Elopement Policy Interpretation & Implementation by DON for all staff to include the focus area of *Elopement policy to be followed in the event of an Elopement or Elopement attempts. [DATE] Changes of Condition policy and procedure by DON for all licensed nursing staff regarding recognizing changes in condition with a special focus on exit seeking behavior changes and monitoring and follow up actions to take with physician notification. A post test will be completed with licensed nursing staff regarding recognizing changes in behavior that present an elopement risk. [DATE] Safety and Supervision of Residents policy and procedure in-service was initiated by the DON and ADON with all clinical staff. The focus of this policy will be on resident safety and supervision with emphasis on page 2 letter g-unsafe wandering with notation of nursing staff rounding every 2 hours for resident supervision. 3. An elopement drill was initiated on [DATE] by the administrator with continuation across all shifts until [DATE].4. The identified RN A is suspended at this time pending investigation results. Facility will print out an employee roster to ensure every employee is educated and will not work until in-services are completed. Agency staff-if utilized will also be educated on the in-services as set forth above prior to working by the department head or designee. The facility medical director was made aware on [DATE] for QAPI purposes and on [DATE] at 2:45 pm regarding facility action plan review. This plan was implemented on [DATE] in response to the immediate jeopardy called and will be monitored through personal observation by the administrator with verbal reports to the regional director of operations on a weekly basis. All above items will be completed before [DATE] at 3pm. Any staff that are scheduled for oncoming shifts post that date will be in-serviced prior shift acceptance. Monitoring of the Plan of Removal included the following: Record review of all residents' Elopement Risk Assessments completed on [DATE] indicated Resident #1 was placed on the secure unit. A second resident was provided a new wander guard (resident was discharged to hospital and was not present during the investigation). Record review of Resident #1's clinical record indicated she was taken by EMS to the emergency room on [DATE] for evaluation and care. Resident # 1 was cleared regarding significant injuries and was placed on the secured unit on [DATE]. Resident #1's physician was notified upon transfer to the ER and upon return to the facility for orders. Record review of the facility's IJ interventions indicated effective as of [DATE] the facility discontinued the use of wander guards. There were no residents with wander guards as of [DATE]. Record review of facility in-services conducted by the DON included:[DATE] Wandering & Elopement by DON for all staff-*What to do if you see a Resident trying to leave the facility, *What to do if a resident is missing, and *What to do if a resident is returned to the facility.There were no concerns noted. [DATE] Abuse & Neglect by DON for all staff-*Definitions of abuse, *Assessment and Recognition of Abuse, *Cause and Identification of Abuse, *Treatment and Management, and *Monitoring/Follow up. There were no concerns noted. [DATE] Emergency Procedure/Missing Resident by DON for all staff-*Policy interpretation and implementation, *Emergency procedure-missing resident, *Emergency job tasks-missing resident. There were no concerns noted. [DATE] Elopement Policy Interpretation & Implementation by DON for all staff -*Elopement policy to be followed in the event of an Elopement or Elopement attempts. There were no concerns noted. [DATE] Changes of Condition policy and procedure by DON for all licensed nursing staff regarding recognizing changes in condition with a special focus on exit seeking behavior changes and monitoring and follow up actions to take with physician notification. A posttest was completed with licensed nursing staff regarding recognizing changes in behavior that present an elopement risk. All tested nursing staff received passing scores. There were no concerns noted. [DATE] Safety and Supervision of Residents policy and procedure in-service by the DON and ADON with all clinical staff. The focus of this policy included resident safety and supervision with emphasis on page 2 letter g-unsafe wandering with notation of nursing staff rounding every 2 hours for resident supervision. There were no concerns noted. Record review of an elopement drill initiated on [DATE] though [DATE] by the Administrator for all shifts indicated all staff followed the facility procedures and protocols as required. There were no concerns noted.4. Record review of RN A's personnel record indicated RN A was suspended as of [DATE] pending facility investigation of his failure to check Resident #1's wander guard placement and functionality on [DATE] and his alleged fraudulent documentation he completed the tasks per the MAR on [DATE].Interviews conducted on [DATE] from 10:30 a.m. through 1:25 p.m. indicated the Administrator, DON, ADON, Activities Director, BOM, LVN E, MDS LVN G, CNA H, CNA I, LVN J, CNA/MA K, CNA L, CNA M, HSK N, HSK O, CNA P, and CNA Q), who represented all shifts on all days of the week (6:00 a.m.-6:00 p.m., 6:00 p.m.-6:00 a.m., 7:00 a.m.-1:00 p.m., and 1:00 p.m. - 5:30 p.m.) indicated they were retrained and aware of the facility's policy and protocols for Wandering and Elopement, Abuse/Neglect Prevention and Reporting, Emergency Procedures/Missing Resident, Elopement Policy and Interpretation, and Safety and Supervision of Residents. All staff were able to give examples elopement risk and interventions, elopement policy and protocols, who to call when a resident is discovered missing and were able to identify wandering and exit seeking behaviors in residents. They were able to verbalize the appropriate interventions with residents who were elopement risk and to monitor all exits to ensure they were in good working order. Staff were aware all facility entrance and exit doors would be locked from 8:00 p.m. through 5:00 a.m. for resident safety. Nursing staff was aware resident census would be confirmed at the beginning and end of each shift. During an interview on [DATE] at 11:15 a.m., the DON said she, the ADON, and the Administrator would monitor risk assessments weekly. She confirmed all facility entrance and exit doors would be locked from 8:00 p.m. through 5:00 a.m. for resident safety. She said resident census would be confirmed at the beginning and end of each shift. During an interview on [DATE] at 11:25 a.m., the ADON said she, the DON, and the Administrator will monitor risk assessments weekly. She said resident census would be confirmed at the beginning and end of each shift. During an interview on [DATE] at 11:30 a.m., the Administrator said she would be monitoring all risk assessments weekly to ensure residents were appropriately placed. She confirmed the facility no longer utilized wander guards to prevent eloping and all residents assessed at risk of eloping would be placed on the secure unit. An Immediate Jeopardy (IJ) was identified on [DATE] at 1:45 p.m. The IJ template was provided to the facility on [DATE] at 2:00 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 2 of 7 residents (Residents #1 and #3) reviewed for accuracy of assessments. The facility did not accurately complete the MDS assessment to indicate Resident #1 eloped from the facility on 06/02/25. The facility did not accurately complete the MDS assessment to indicate Resident#3 displayed physical aggression toward another resident on 06/27/25. Findings included: Record review of Resident #1's face sheet dated 07/24/25 indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included unspecified psychosis (indicates the presence of psychotic symptoms that don't perfectly align with a specific diagnosis), lack of coordination (a condition characterized by difficulty in performing physical movements smoothly and accurately), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), and paranoid schizophrenia (mind doesn't agree with reality). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was usually able to make herself understood, usually understood others, had severe cognitive impairment (BIMS-3). Wandering was not indicated. Record review of Resident #1's care plan dated 02/1/2/25 indicated she was an elopement risk and wander guard was placed on 02/12/25. Interventions included distract Resident #1 from wandering and identify pattern of wandering. Record review of Resident #1's care plan dated 06/03/25 indicated she was an elopement risk, the wander guard was removed. Interventions indicated Resident #1 was placed on the secure unit due to poor safety awareness and wander risk. Record review of Resident #1's physician orders dated 04/07/25 indicated may have wander guard due to poor cognition and poor redirection. Record review of Resident #1's Elopement Risk assessment dated [DATE] indicated a score of 11 (high risk). Record review of Resident #1's Elopement Risk assessment dated [DATE] indicated a score of 17 (high risk). Record review of Nursing Progress note dated 06/03/25 at 2:39 a.m., completed by RN A, indicated EMT F with (named service) arrived at facility and approached RN A asking, Do you have a resident named (Resident #1)? RN A confirmed this. EMT F said, Well she fell at the apartment complex across the street; a resident of the apartments saw her fall and called 911. She's on my truck right now. She told us she stays here, and that she walked out the back door. Record review of the facility investigation dated 06/10/25 and completed by the Administrator, indicated the facility became aware of Resident #1 missing from the facility at 10:45 p.m. on 06/02/25 after she was returned to the facility by EMS. The facility confirmed Resident #1 as a Missing Resident. Record review of Resident #3's face sheet dated 07/23/25 indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included dementia with agitation (state of restlessness, irritability, and emotional distress that can lead to aggressive behavior and is commonly observed in individuals with cognitive disorders), dementia with behavioral disturbance (refers to the changes in mood, perception, and behavior that commonly occur in individuals with dementia, significantly impacting their quality of life and caregiving), unspecified mood disorder (symptoms of a mood disorder but doesn't meet the full criteria for a specific condition), restless and agitation (state of severe restlessness or inner tension, often accompanied by feelings of irritability and mental distress, while restlessness refers to an inability to remain still, often due to anxiety or discomfort), and schizoaffective disorder (depressive type) (chronic mental health condition that combines symptoms of schizophrenia (such as hallucinations and delusions) with symptoms of depression. It is characterized by a mix of both psychotic and mood disorder symptoms.) Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated he was sometimes understood and sometimes understood others and had severe cognitive impairment. There was no aggression toward others noted. Record review of Resident #3's care plan dated 06/27/25 indicated Resident #3 had the potential to be physically aggressive to peers and staff related to schizoaffective disorder depressive type and unspecified mood disturbance. Interventions dated 06/30/25 included assess and anticipate Resident #3's needs. Record review of facility investigation dated 07/02/25 indicated the facility reviewed the video play back and noted on 06/27/25 at 7:54 a.m., Resident #3 tried to grab food off of another resident's tray. The other resident pushed Resident #3's arm away and Resident #3 hit the other resident. A slap fight ensued and the other resident stood and punched Resident #3 in the left lower side of the face. The residents were separated. Resident #3 did not recall the incident. Resident #3 was placed on 1-1 until he was discharged to a behavioral unit for evaluation and treatment. During an observation and interview on 07/22/25 at 12:35 p.m., Resident #3 was sitting at a dining table. He did not respond to questions. He did not appear agitated or anxious. During an interview on 07/24/25 at 12:48 p.m., MDS LVN G said she was responsible for all MDS completed in the facility. She said she was educated on completion of MDS and accuracy. She said she missed adding Resident #1's elopement and Resident #3's physical aggression to MDS assessment. She said error on her part and she would submit corrections for Resident #1 and Resident #3's MDS. During an interview on 07/25/25 at 1:00 p.m., the DON said she reviewed Resident #1 and Resident #3's MDS assessments for accuracy. She said reviewed Resident #1 and Resident #3's MDS and she did not notice Resident #1's elopement and Resident #3's physical aggression were not added as required. She said residents were at risk of not receiving required services if their assessments were not accurate. During an interview on 07/25/25 at 1:10 p.m., the Administrator said the MDS nurse was responsible for all MDS completed in the facility and she was educated on completion of MDS. The Administrator said her expectation was all MDS would be completed accurately and time. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024 indicated the following . E0200: Behavioral Symptom-Presence & Frequency (cont.) . Steps for Assessment 1. Review the medical record for the 7-day look-back period. 2. Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visit frequently or have frequent contact with the resident. Observe the resident in a variety of situations during the 7-day look-back period. Coding Instructions Code 0, behavior not exhibited: if the behavioral symptoms were not present in the last 7 days. Use this code if the symptom has never been exhibited or if it previously has been exhibited but has been absent in the last 7 days. Code 1, behavior of this type occurred 1-3 days: if the behavior was exhibited 1-3 days of the last 7 days, regardless of the number or severity of episodes that occur on any one of those days. E0900: Wandering-Presence & Frequency Item Rationale Health-related Quality of Life . Steps for Assessment 1. Review the medical record and interview staff to determine whether wandering occurred during the 7-day look-back period. 2. If wandering occurred, determine the frequency of the wandering during the 7-day look-back period. Coding Instructions for E0900 Code 0, behavior not exhibited: if wandering was not exhibited during the 7-day look-back period. Skip to Change in Behavior or Other Symptoms item (E1100). Code 1, behavior of this type occurred 1-3 days: if the resident wandered on 1-3 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days. Proceed to answer Wandering-Impact item (E1000). Code 2, behavior of this type occurred 4-6 days, but less than daily: if the resident wandered on 4-6 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days. Proceed to answer Wandering-Impact item (E1000). Code 3, behavior of this type occurred daily: if the resident wandered daily during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days. Proceed to answer Wandering-Impact item (E1000).

Based on interview and record review, the facility failed to ensure compliance and ethics training was completed for 4 of 4 new employees (LVN A, LVN B, CNA C, and CNA D) reviewed for orientation training. The facility did not ensure compliance and ethics training was completed by the LVN A, LVN B, CNA C, and CNA D during orientation. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed compliance and ethics training during orientation: * LVN A, hire date 03/29/24; * LVN B, hire date 04/22/24; * CNA C, hire date 07/25/24; and * CNA D, hire date 05/09/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said the ethics and compliance training was not included in the Required Orientation Trainings in the computer system, so it was not done during the orientation time period prior to working for LVN A, LVN B, CNA C, and CNA D. She said she had missed that it was not completed. During an interview on 08/28/24 at 01:05 p.m. the Administrator said she expected all new hire staff to have the required training done prior to working. She said the possible negative outcome could be staff would not know procedures for resolving issues in the facility or how to deal with residents in an appropriate manner.

Based on interview and record review, the facility failed to ensure training on behavioral health was completed for 4 of 4 new employees LVN A, LVN B, CNA C, and CNA D) reviewed for orientation training. The facility did not ensure behavioral health training was completed by LVN A, LVN B, CNA C, and CNA D during orientation. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not behavioral health training during orientation: * LVN A, hire date 03/29/24; * LVN B, hire date 04/22/24; * CNA C, hire date 07/25/24; and * CNA D, hire date 05/09/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said the behavioral health training was not included in the Required Orientation Trainings in the computer system, so it was not done during the orientation time period prior to working for LVN A, LVN B, CNA C, and CNA D. She said she had missed that it was not completed. During an interview on 08/28/24 at 01:05 p.m. the Administrator said she expected all new hire staff to have the required training done prior to working. She said the possible negative outcome could be staff would not know procedures for resolving issues in the facility or how to deal with residents in an appropriate manner.

Based on interview and record review, the facility failed to ensure CNAs completed dementia management training for 2 of 2 new CNAs (CNA C and CNA D) reviewed for orientation training. The facility did not ensure dementia management training was completed by CNA C and CNA D during orientation. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of employee files indicated the following had not completed dementia management training during orientation: * CNA C, hire date 07/25/24; and * CNA D, hire date 05/09/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said the dementia management training was not included in the Required Orientation Trainings in the computer system, so it was not done during the orientation time period prior to working for CNA C and CNA D. She said she had missed that it was not completed. During an interview on 08/28/24 at 01:05 p.m. the Administrator said she expected all new hire staff to have the required training done prior to working. She said the possible negative outcome could be staff would not know procedures for resolving issues in the facility or how to deal with residents in an appropriate manner.

Based on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 4 of 4 new employees (LVN A, LVN B, CNA C, and CNA D) reviewed for orientation training. The facility did not ensure QAPI training was completed by LVN A, LVN B, CNA C, and CNA D during their orientation. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings included: Record review of employee files indicated the following staff had not completed QAPI training during orientation: * LVN A, hire date 03/29/24; * LVN B, hire date 04/22/24; * CNA C, hire date 07/25/24; and * CNA D, hire date 05/09/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said the QAPI training was not included in the Required Orientation Trainings in the computer system, so it was not done during the orientation time period prior to working for LVN A, LVN B, CNA C, and CNA D. She said she had missed that it was not completed. During an interview on 08/28/24 at 01:05 p.m. the Administrator said she expected all new hire staff to have the required training done prior to working. She said the possible negative outcome could be staff would not know procedures for resolving issues in the facility or how to deal with residents in an appropriate manner.

Based on interview and record review, the facility failed to ensure employees received the required training on dementia management for 2 of 2 new employees (LVN A and LVN B) reviewed for orientation training. The facility did not ensure dementia management training was completed by LVN A and LVN B during orientation. This failure could place residents with dementia at risk of a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of employee files indicated the following staff had not completed dementia management training during orientation: * LVN A, hire date 03/29/24; and * LVN B, hire date 04/22/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said LVN A and LVN B had not done the dementia management training during the orientation time period. She said she had missed that it was not completed. During an interview on 08/28/24 at 01:05 p.m. the Administrator said she expected all new hire staff to have the required training done prior to working. She said the possible negative outcome could be staff would not know procedures for resolving issues in the facility or how to deal with residents in an appropriate manner.

Based on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 4 of 4 new employees (LVN A, LVN B, CNA C, and CNA D) reviewed for training. The facility did not ensure effective communication training was completed by LVN A, LVN B, CNA C, and CNA D during orientation. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed effective communications training during orientation: * LVN A, hire date 03/29/24; * LVN B, hire date 04/22/24; * CNA C, hire date 07/25/24; and * CNA D, hire date 05/09/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said the communication training was not included in the Required Orientation Trainings in the computer system, so it was not done during the orientation time period for LVN A, LVN B, CNA C, and CNA D. During an interview on 08/28/24 at 01:05 p.m. the Administrator said she expected all new hire staff to have the required training done prior to working. She said the possible negative outcome could be staff would not know procedures for resolving issues in the facility or how to deal with residents in an appropriate manner.

33460 Based on observation, interview, and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for the facility for 1 of 2 residents reviewed for isolation during med pass. The facility failed to ensure LVN G used enhanced barrier precautions while she administered medication for Resident #4 per gastrostomy tube ((g-tube) a tube inserted through the belly that brings nutrition directly to the stomach). This failure could place residents at risk for exposure to infections and communicable diseases. Findings included: 1. Record review of Resident #4's admission sheet dated 08/25/24 indicated she was admitted on [DATE] and was [AGE] years old with diagnoses of dysphagia (difficulty in swallowing). Record review of Resident #4's physician's orders dated August 2024 indicated her orders included NPO (nothing by mouth), was to receive all feedings and medications via g-tube. Record review of a care plan dated 08/14/2024 indicated Resident #4 had a feeding tube. Resident #4 had a history of Multi Drug Resistant Organism (MRDO). Interventions included: Contact isolation will be performed, and infection will not be spread throughout the facility. Gloves and gowns will be used when performing contact activity before entering the room. During an observation on 08/26/24 at 1:57 p.m., LVN G was administering medication to Resident #4. LVN G did not wear a gown while she administered medication to Resident #4. The door into Resident #4's room had a sign which indicated enhanced barrier precautions were to be used while providing direct care to the resident. During an interview on 08/26/24 at 2:00 p.m., LVN G said that she should have worn a gown when she read the sign (enhanced barrier precaution sign) on the door of Resident #4's room. She said she had been trained on contact isolation and enhanced barrier precautions. During an interview on 08/26/24 at 2:10 p.m., the DON said the nursing staff were to use enhanced barrier precautions with all the residents who have indwelling medical devices to prevent spread of MDRO (multi-drug-resistant organisms) . Record review of the policy titled Enhanced Barrier Precautions dated August 2022 indicated Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gowns, and gloves used during high contact resident care activities . 3. Examples of high - contact resident care activities requiring the use of gown and gloves for EBPs include: . g. device care or use (central line, urinary catheter, feeding tube and .)

Based on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility were completed for 1 of 4 new employees (CNA C) reviewed for orientation training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by CNA C during orientation. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of employee files indicated CNA C, hire date 07/25/24 had not completed Resident Rights training during orientation. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said CNA C had not done the Resident Rights training during the orientation time period prior to working. She said she had missed that it was not completed. During an interview on 08/28/24 at 01:05 p.m. the Administrator said she expected all new hire staff to have the required trainings done prior to working. She said the possible negative outcome could be staff would not know procedures for resolving issues in the facility or how to deal with residents in an appropriate manner.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate administering of medications for 1 of 14 residents reviewed for pharmaceutical services. (Resident #37) The facility did not administer Peridex mouthwash to Resident #37 twice daily as ordered by her physician. This failure could place the residents at risk of mouth infections and gum inflammation. Findings included: Record review of physician orders dated August 2024 indicated Resident #37, admitted [DATE], was a [AGE] year-old female with diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often leading to tremors) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). She was to receive Peridex mouth/throat solution 0.12% 15 ml by mouth two times a day related to specified prophylactic (intended to prevent disease) measures for 14 days beginning on 08/21/24. Record review of the most recent significant change MDS assessment dated [DATE] indicated Resident #37 had a BIMS score of 8 indicating moderately impaired cognition. The resident required supervision assistance with most ADLs. Record review of a care plan updated 06/12/24 indicated Resident #37 had oral/dental health problems related to poor oral hygiene. The goal was for the resident to be free from infection, pain or bleeding in the oral cavity. The interventions indicated to monitor/document/and report to physician and signs or symptoms of oral/dental problems needing attention. Record review of a dental treatment noted dated 08/21/24 indicated Resident #37 had an extraction of 4 teeth with a plan of removing all teeth over a 9-12 month period in preparation for dentures. Aftercare orders included: Peridex mouth/throat solution 0.12% 15 ml by mouth two times a day related to specified prophylactic measures for 14 days. Record review of a progress note signed by LVN E and dated 08/21/24 at 2:28 p.m. indicated: Dentist in facility making rounds. Teeth extraction performed on numbers 12-15. New orders for Tylenol 325 mg two tabs by mouth every 4-6 hours as needed for pain, Amoxicillin 500 mg one tablet by mouth every 8 hours for 7 days, and Peridex oral rinse 0.12% 15 ml two times daily for 14 days. Record review of a Medication Administration Record (MAR) dated August 2024 indicated Resident #37 was not given her Peridex mouthwash on 08/22/24, 08/23/24, 8/24/24, 8/25/24, and 8/26/24. During observation and interview on 08/26/24 at 9:55 a.m., Resident #37 was sitting at a dining room table and said she couldn't eat much this morning because her mouth was too sore. She said the dentist had pulled some teeth and the nurses were giving her something for pain when she asked for it. During an interview on 08/27/24 at 12:45 p.m., LVN E said she was working on 08/21/24 when Resident #37 had her tooth extractions. She said the dentist ordered amoxicillin and Peridex mouth wash. LVN E said she ordered both medications from the pharmacy and then was off work for 3 days. She said she returned to work on 08/26/24 and MA F informed her Resident #37's Peridex was not in the facility and could not be given to her as ordered. She said she called the pharmacy again and asked them to deliver the Peridex because it had not been delivered. During an interview on 08/27/24 at 1:15 p.m., MA F said Resident #37's Peridex was not on the medication cart on 08/26/24 and she notified LVN E that the Peridex was not in the facility to give to the resident. During an interview on 08/27/24 at 1:20 p.m., MA H said she passed medications on 08/23/24 and Resident #37's Peridex was not in the facility and was not given. She said she notified LVN I the mouthwash was not in the facility. During an interview on 08/27/24 at 1:32 p.m., LVN E said after surveyor intervention that she called Resident #37's dentist and physician and notified them that the resident was not given her Peridex as ordered on 8/22/24, 8/23/24, 8/24/24, 8/25/24 and 8/26/24. She said she received a new order to begin Peridex 8/27/24 and continue twice daily for 14 days. During a telephone interview on 08/27/24 at 7:05 p.m., LVN H said she was never notified that Resident #37 did not have Her Peridex as ordered. During an interview on 08/27/24 at 1:38 p.m., the DON said her expectations were for medications to be administered as ordered by the physician. She said she had not been told that Resident #37 did not receive her Peridex as ordered. She said the possible negative outcome of the delay in administering the Peridex could be increased infection and delayed healing. Record review of a Physician Orders policy revised June 2004 indicated: Physician orders must be given and managed in accordance with applicable laws and regulations.

Based on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 2 resident (Resident #4) reviewed for enteral feeding. The facility failed to ensure LVN G flushed Resident #4's gastrostomy tube (g-tube) (a tube inserted through the belly that brings nutrition directly to the stomach) with 30 cc water before and after medication by gravity. The failure could place residents receiving enteral nutrition and medications at increased risk of not receiving proper nutrition, infection, aspiration (breathing in a foreign object into the lungs), and possible injury. Findings included: Record review of Resident #4's admission sheet dated 8/25/24 indicated she was admitted on [DATE] and was [AGE] years old with diagnoses of dysphagia (difficulty in swallowing). Record review of Resident #4's physician's orders dated August 2024 indicated her orders included NPO (nothing by mouth), was to receive all feedings and medications via g-tube and placement check via aspiration and auscultation prior to medication administration, water flush or feeding. every shift with start date of 05/01/2024. Flush with 30 ml of water before and after administration of medications. Flush with 5 ml of water between each medication administered. Record review of a care plan dated 06/21/24 indicated Resident #4 had a feeding tube. Interventions included administering enteral feeding, medications, and water flushes as ordered. During an observation on 08/26/24 at 1:57 p.m., LVN G was administering medication to Resident #4. LVN G checked placement of Resident #4's g-tube per auscultation (medical procedure that involves listening to sounds in the body) and aspiration. LVN G pushed 30 cc of water into the g-tube, and she then administered medication per gravity. She then pushed 30 cc of water into the g-tube. During an interview on 08/26/24 at 2:00 p.m., LVN G said she should have given the water flush per gravity to prevent gastric complications. During an interview on 08/26/24 at 2:10 p.m., the DON said the water flushes should be given per gravity to prevent g-tube clogging or gastric issues. During an interview on 08/28/24 at 9:00 a.m., the Administrator said the nurses should follow their policy on giving medications and water per gravity per gastric feeding tube. Record review of the facility policy dated 09/21/11 titled Policy and Procedure Gastrostomy Feedings indicated, Objective: To provide nourishment and medication for residents requiring feeding through an artificial opening in the stomach. 7. Insert barrel of syringe into tube. 8. Pour 30-60 cc of water into the syringe. Give slowly, do not force.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA A did not verbally and physically abuse Resident #1 when she yelled, cursed and aggressively removed the resident's clothes, on 05/17/2024. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: Record review of Resident #1's face sheet, dated 07/29/2024, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), hypothyroidism (condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream), schizophrenia (mental health condition with a combination of symptoms of schizophrenia and mood disorder), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #1's quarterly MDS Assessment, dated 05/18/2024, indicated she was usually able to make herself understood and usually understood others. She had moderate cognitive impairment, identified with a BIMS score of 9. Record review of Resident #1's care plan, revised on 05/19/2024, indicated the resident was resistive to care related to she refused to go to bed, have personal care and clothes changed. The interventions included allow resident to make decisions about treatment regimen, to provide sense of control, encourage as much participation/interaction by the resident as possible during care activities, give clear explanations of all care activities prior to and as they occurred during each contact. Record review of the Grievance/Complaint Report, dated 05/18/2024, indicated Resident #1 was verbally abused by CNA A speaking to her in a verbally abusive tone. During the investigation, Resident #1 also reported physical abuse from CNA A the evening of 05/17/2024. On interview by LVN C and the Administrator, Resident #1 corroborated the statement. Resident #1 stated she had shoulder pain following the incident but denied pain medications or x-rays. Assessment of Resident #1 showed no signs of physical injury. Record review of a Facility Investigation Report, dated 05/22/2024, indicated the incident was reported on 05/18/2024 and occurred on the evening of 05/17/2024. The Administrator and Social Worker interviewed Resident #1 individually as part of the facility investigation and she reported feeling safe at the facility. Psychology services conducted an interview and counseling services provided. The alleged perpetrator (CNA A) was placed on suspension during the investigation and quit during the investigation process. Facility staff were in-serviced on Abuse Neglect and Resident Rights. During an interview on 07/31/2024 at 1:45 p.m., LVN C said CNA B reported to her on 05/18/2024 at 8:20 a.m. that she received a phone call from CNA A on 05/17/2024 around 8:30 p.m.- 9:00 p.m. questioning her why Resident #1 was not in bed. CNA could hear Resident #1 in the background telling CNA A no, could hear CNA A and Resident #1 arguing about removing clothing, and then she heard CNA A say, you are going to take the damn things off or I am going to take it off for you! LVN C said CNA B reported CNA A's voice changed from her normal voice to a voice whose tone was cruel and angry. LVN C said she immediately told CNA B to write a statement regarding the incident, reported the incident to the DON and the Administrator due to the allegation of verbal abuse. LVN C said she went to Resident #1's room and investigated and interviewed her regarding the allegation. LVN C said she confirmed with Resident #1 that CNA A had verbally and physically abused her by verbally telling her loudly and angrily you are going to take it off or I will take it off for you and forcing her to remove a jacket and shirt. CNA A physically forcefully removed the jacket and shirt after Resident #1 told her No multiple times and grabbed the jacket/shirt no allowing it to be removed. LVN C said during the assessment no marks or bruising was observed but Resident #1 did complain of mild shoulder pain related to the struggle between her and CNA A the night prior. LVN C said Resident #1 was a religious/devout Catholic, and she made statements she thought the abuse occurred because God was punishing her for a sin she had done. LVN C said the resident was upset during the statement process but refused any PRN pain medications or x-rays for her shoulders. During an interview on 08/01/2024 at 10:30 a.m., Ombudsman L reported she was aware of the allegation of abuse of Resident #1. She said she visited Resident #1 on 05/21/2024 and she reported to her that CNA A got angry with her because she asked to be put to bed, she was rough with her and had forced her to take off her jacket even when she said no because she was cold. Ombudsman L said Resident #1 said she did not feel safe with CNA A providing her care and she reported the findings to the facility ADM. She said the ADM informed her CNA A was suspended pending investigation and CNA A quit during the investigation process, so she would not be providing care to Resident #1. She said Resident #1 said she felt safe at facility since CNA A was no longer working there. During an interview on 07/30/2024 at 2:45 p.m., Resident #1 said she felt safe in the nursing facility. Resident #1 acknowledged the abuse incident occurred but would not provide details of the incident, would shake her head yes and avert her eyes when speaking to the state surveyor. Resident said, everything is ok now. Attempts to interview CNA A were unsuccessful, three attempts were made to reach her by telephone on 07/29/2024 at 12:15 p.m., 07/30/2024 at 12:00 p.m., and 07/31/2024 at 11:35 p.m No return call was received. Attempts to interview CNA B were unsuccessful, three attempts were made to reach her by telephone on 07/29/2024 at 12:30 p.m., 07/30/2024 at 12:05 p.m., and 07/31/2024 at 11:38 p.m During an interview on 07/31/2024 at 6:00 p.m., CNA E said she assisted CNA A with placing Resident #1 back to bed on 05/17/2024 at 8:30 p.m. CNA E said she assisted CNA A and when they were positioning the Hoyer lift sling under her they noticed Resident #1's shirt was wet and soiled with feces. CNA E said CNA A called CNA B to ask her why Resident #1 was heavily wet and soiled, and not put in bed prior to her leaving shift. CNA E said CNA A tried to take off the soiled shirt and jacket and Resident #1 resisted CNA A removing her shirt saying she was cold and wanted to sleep in the shirt. CNA E said CNA A tried to explain to Resident #1 the shirt and jacket were soiled, and she could not sleep in the soiled clothes. CNA E said Resident #1 became angry and began shaking her fists saying No, No I don't want it off. CNA E said CNA A told Resident #1 she needed to take the soiled clothes off and Resident #1 resisted. CNA E said Resident #1 was clinching the shirt and refused for it to be removed and was upset and made a fist. CNA E warned CNA A resident might hit her. CNA E said CNA A was able to convince Resident #1 to remove the soiled clothes and allowed them to provide care and assist her to bed. CNA E said she did not see CNA A actions as abusive but looking back at the situation, they should have notified the charge nurse and maybe let the charge nurse intervene or try to deescalate the situation by leaving the resident alone or talking with her more calmly. CNA E denied CNA A cussed at Resident #1. CNA E said Resident #1 did resist her jacket and shirt being removed and CNA A and Resident #1 were both pulling on the shirt, CNA A pulled to attempt to remove and Resident #1 pulling to keep it on. During an interview on 8/01/2024 at 11:30 a.m., the Administrator stated Resident #1 confirmed CNA A had verbally and physically abused her when she yelled and cursed at her regarding removing the residents clothes and physically aggressively removed her clothes. The Administrator stated the facility investigation confirmed verbal and physical abuse and CNA A was suspended during the investigation and quit during the investigation period. Record review of CNA A's employee file indicated she received training regarding abuse, neglect and misappropriation of property during initial orientation on 9/17/2021 and annually. CNA A was suspended on 5/18/2024 for abuse allegation, with last day of work on 5/17/2024 and called administrator on 5/23/2024 and quit. Record review of a statement from CNA A indicated CNA A said she and CNA E provided care and assisted Resident #1 back to bed on 05/17/2024 around 8:30 p.m. CNA A said she was at the nurses' station talking to the charge nurse when Resident #1 came out of her room saying she was waiting on CNA B to lay her in bed. CNA A said she and CNA E assisted Resident #1 to her room and began helping her take off her clothes because Resident #1 was a Hoyer lift/2 person assist transfer. CNA A said her clothes were soiled and she was wet, her shirt and jacket were soiled. CNA A said she and CNA E provided care (changes soiled clothes and diaper) to Resident #1 and transferred her to the bed. Record review of statement from CNA B indicated CNA B said she received a phone call on 05/17/2024 from CNA A asking her why Resident #1 was not in bed, and she told her Resident #1 was asked two times if she wanted to go to bed and she said no both times. CNA B said while she was on the phone with CNA A she could hear CNA A and Resident #1 arguing about taking her clothes off. CNA B said CNA A told Resident #1 that she was going to take the damn thing off or I am going to take it off for you. CNA B said CNA A voice changed from normal voice to a voice whose tone and inflection were very cruel and angry when making the statement. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 2021, indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on interview and record review the facility failed to implement policy to ensure the rights of residents to be free from abuse for 2 of 6 residents (Residents #1 and #2) reviewed for abuse. The facility failed to prevent Resident #1 from grabbing, hitting and slapping Resident #2 on 11/03/23. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began. The failure could place residents at risk for abuse, intimidation, fear, agitation, and decreased quality of life. Findings included: Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but is not limited to freedom from corporal punishment, involuntary seclusion verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; other residents; . Record review of facility policy Preventing Resident Abuse dated 2001 indicated 1. The facility's goal is to achieve and maintain an abuse-free environment. 2. Our abuse prevention/intervention program includes but is not limited to, the following: . g. Training staff to understand and manage a resident's verbal or physical aggression; . j. Assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; . striving to maintain adequate staffing on all shifts to ensure that needs of each resident are met; . Record review of Resident #1's face sheet indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included Alzheimer's (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance, psychotic disorder (serious illness that affect the mind) with delusions (a belief that is clearly false and that indicates an abnormality in the affected person's content of thought), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #1's MDS dated [DATE] indicated she was usually able to make herself understood and usually understood others. She had severe cognitive impairment (BIMS score of 3). She had physical behaviors directed at others. Record review of Resident #1's care plan dated 07/12/23 (revised 08/29/23) indicated Resident #1 has attempted and hit other residents. Interventions included assess and anticipate Resident #1's needs. Record review of Resident #2's face sheet indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's, schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior) depressive type, and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #2's MDS dated [DATE] indicated she was usually understood and sometimes understands others. She had severe cognitive impairment (BIMS score of 5). She had hallucinations and delusions. There were no behaviors directed at others. Record review of progress note dated 10/31/23 at 1:50 p.m., completed by LVN E (MDS) indicated Resident #1 was on secure unit. She was hitting, slapping, and pinching staff. LVN E spoke with staff at behavior hospital who said Resident #1 was at base line of needing one on one care with aggressive behaviors. The physician was notified and waiting for orders. Record review of a progress noted dated 11/03/23 at 7:29 p.m., completed by LVN A indicated Resident #1 attempted to pull walker away from Resident #2. Resident #1 hit Resident #2 on the top of her left hand, on her left wrist, and on the left side of her face. Resident #1 separated from Resident #2 and monitored one on one. Record review of a progress note dated 11/03/23 at 11:45 p.m., completed by LVN B indicated Resident #1's family member was notified of Resident #1's behaviors. Resident #1 was transported by the facility and discharged home at approximately 11:30 p.m. Record review of Resident #1's incident report dated 11/03/23 at 11:00 p.m. , completed by LVN A indicated Resident #1 attempted to pull Resident #2's walker away from her. When Resident #1 was not able to pull the walker away from Resident #2, Resident #1 hit Resident #2 on the top of her left hand, on her left wrist, and on the left side of her face. CNA C walked into the dining room while Resident #1 and Resident #2 were standing close together with arms locked. CNA C separated Resident #1 and Resident #2. Resident #2 hit CNA C. Residents #1 and Resident #2 were separated. Resident #1 placed on one to one monitoring. The DON, Administrator, RP, and MD were notified. Hospice was notified. There were no observed injuries. Record review of Resident #2's incident report dated 11/11/23 at 11:00 p.m., completed by LVN A indicated Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 said, She hit me. Did you see her? Resident #2 was grabbed on her left wrist by Resident #1. Unable to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. Resident #2 denied any pain. No distress noted. No bruising, [NAME], discoloration, or anything abnormal noted to Resident #2's left hand, wrist or face. No signs of pain noted upon passive ROM to LUE. Physician, DON, Administrator, and guardian notified. The surveyor requested to observe the video of the incident on 11/03/23. The facility was not able to provide access to the video because the system did not retain a copy. During an interview on 11/11/23 at 9:35 a.m., the Administrator said she was the abuse coordinator. She said Resident #1 resided on the secure unit. She said Resident #1 had a history of aggression towards staff and residents. She said the other residents were afraid of Resident #1. She said there were two CNAs on the secure unit when the incident occurred. She said staff were supposed to supervise and monitor Resident #1 but left her alone to provide care for another resident. Staff should have called for the nurse to provide the supervision when they were not able to supervise Resident #1. She said all staff were at risk of abuse from Resident #1 when there was no supervision. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all nursing staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said all new staff and any staff not trained would be trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. She said she (the Administrator) and the DON were responsible to ensure all staff were trained and to monitor to ensure compliance with the QAPI plan/PIP. During observation and interview on 11/11/23 at 10:25 a.m., Resident #2 sat at a dining table watching TV with other residents. When asked if she remembered anyone grabbing her walker or hurting her she smiled and replied with unintelligible words. There was no signs of anxiety or distress. During an interview on 11/11/23 at 11:57 a.m., LVN A said CNA C came off the secure unit and reported Resident #1 hit Resident #2. She said she went on to the secure unit and Resident #1 and Resident #2 were separated. She assessed Resident #1 and Resident #2 and there was no injuries. She said she reviewed the video and noted Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 was grabbed on her left wrist by Resident #1. She said she was not able to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. She said there was no assigned 1 to 1 staff on the secure unit. She said the staff should have called for help when they were providing care to any resident that required two staff. She said all residents were at risk of abuse from Resident #1 when there was no supervision. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors During an interview on 11/11/23 at 12:56 p.m., LVN E said she was the MDS nurse. She said she admitted Resident #1 back to the facility from a behavior hospital on 10/31/23. She said Resident #1 was combative with the transport driver. She said she did not want to readmit her to the facility and wanted to send her back to the behavior hospital. She said Resident #1 was sent back to the facility without report. She said the transport driver directed her to call the behavior hospital. She said the behavior hospital said Resident #1's combative and aggressive behavior was her baseline and if she required 1-1 staff then that is what the facility would have to implement. She said she argued with the behavior hospital and said it was not appropriate to send Resident #1 back to the facility. She said she called the NP and was told to send Resident #1 back to the behavior hospital but she could not because it was across state lines. She said she did not assign 1 to 1 staff. She said she did not get a physician order for one to one staff and was waiting for an order. She said other residents were at risk of abuse from Resident #1 if there was not adequate supervision. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. During an interview on 11/11/23 at 1:15 p.m., the RDO said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. He said the facility started retraining nursing staff on 11/03/23. He said all nursing staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. He said all new staff and any staff not trained would be trained by the DON or ADON prior to working their scheduled shift. He said there were no other residents in the facility who were abusive to other residents. During an interview on 11/11/23 at 2:55 p.m., the ADON said Resident #1 was readmitted to the facility from a behavior hospital. She said Resident #1 was more combative with care and not usually aggressive towards other residents. She said Resident #1 should have been placed on 1-1 when she returned. She said all residents were supposed to be protected from abuse. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said all new staff and any staff not trained would trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. During an interview on 11/11/23 at 3:11 p.m. the DON said when Resident #1 was readmitted to the facility from the behavior hospital on 10/31/23, the facility should have implemented one to one. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said she (the DON) and the Administrator were responsible to ensure all staff were trained and to monitor to ensure compliance with the QAPI plan/PIP. She said all new staff and any staff not trained would be trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. During an interview on 11/14/23 at 2:12 p.m., LVN D said Resident #1 was readmitted to the facility from a behavior hospital. She said Resident #1 was very combative. She said after CNA C reported Resident #1 hit Resident #2, she went on the secure unit and saw the aides had separated the residents. She said she viewed the incident on the video and saw Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 was grabbed on her left wrist by Resident #1. Unable to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. She said she notified the Administrator, the DON, the physician and Resident #1's family member. She said the residents were assessed and had no injuries. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. On 11/14/23, the surveyor confirmed the facility implemented appropriate measures to ensure the safety of residents after the incident on 11/03/23 involving Resident #1 and Resident #2 by: Review of QAPI notes dated 11/08/23 showed a meeting was held to discuss the incident with Resident #1 and Resident #2 on 11/03/23. Members present included the Administrator, DON, Medical Director, MDS Coordinator, and ADON. The interventions and plan for correction included : -obtaining emergency physician orders -resident to resident altercations -resident rights -discharge and IDT communication -abuse and neglect prevention and staff training Record review of the staff in-services dated 11/03/23 through 11/11/23 included: -obtaining emergency physician orders, -resident to resident altercations, -resident rights, -discharge and IDT communication, and -abuse and neglect prevention and staff training. During interviews on 11/11/23 9:30 a.m. through 4:00 p.m., and 11/14/23 from 9:30 a.m. through 2:20 p.m., 5 LVN's (on all shifts) 10 CNA's (on all shifts) and the ADON said they received training prior to the incident and after the incident on 11/03/23 from the Administrator or the DON regarding resident abuse, neglect, rights, dealing with residents with aggressive behaviors and resident supervision levels. The nursing staff verbalized understanding of the trainings and were able to give examples of dealing with behaviors and preventing abuse. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to prevent Resident #1 from grabbing, hitting and slapping Resident #2 on 11/03/23 . The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included Alzheimer's (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance, psychotic disorder (serious illness that affect the mind) with delusions (a belief that is clearly false and that indicates an abnormality in the affected person's content of thought), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #1's MDS dated [DATE] indicated she was usually able to make herself understood and usually understood others. She had severe cognitive impairment (BIMS score of 3). She had physical behaviors directed at others. Record review of Resident #1's care plan dated 07/12/23 (revised 08/29/23) indicated Resident #1 has attempted and hit other residents. Interventions included assess and anticipate Resident #1's needs. Record review of Resident #2's face sheet indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's, schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior) depressive type, and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #2's MDS dated [DATE] indicated she was usually understood and sometimes understands others. She had severe cognitive impairment (BIMS score of 5). She had hallucinations and delusions. There were no behaviors directed at others. Record review of progress note dated 10/31/23 at 1:50 p.m., completed by LVN E (MDS) indicated Resident #1 was on secure unit. She was hitting, slapping, and pinching staff. LVN E spoke with staff at behavior hospital who said Resident #1 was at base line of needing one on one care with aggressive behaviors. The physician was notified and waiting for orders. Record review of a progress noted dated 11/03/23 at 7:29 p.m., completed by LVN A indicated Resident #1 attempted to pull walker away from Resident #2. Resident #1 hit Resident #2 on the top of her left hand, on her left wrist, and on the left side of her face. Resident #1 separated from Resident #2 and monitored one on one. Record review of a progress note dated 11/03/23 at 11:45 p.m., completed by LVN B indicated Resident #1's family member was notified of Resident #1's behaviors. Resident #1 was transported by the facility and discharged home at approximately 11:30 p.m. Record review of Resident #1's incident report dated 11/03/23 at 11:00 p.m. , completed by LVN A indicated Resident #1 attempted to pull Resident #2's walker away from her. When Resident #1 was not able to pull the walker away from Resident #2, Resident #1 hit Resident #2 on the top of her left hand, on her left wrist, and on the left side of her face. CNA C walked into the dining room while Resident #1 and Resident #2 were standing close together with arms locked. CNA C separated Resident #1 and Resident #2. Resident #2 hit CNA C. Residents #1 and Resident #2 were separated. Resident #1 placed on one to one monitoring. The DON, Administrator, RP, and MD were notified. Hospice was notified. There were no observed injuries. Record review of Resident #2's incident report dated 11/11/23 at 11:00 p.m., completed by LVN A indicated Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 said, She hit me. Did you see her? Resident #2 was grabbed on her left wrist by Resident #1. Unable to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. Resident #2 denied any pain. No distress noted. No bruising, [NAME], discoloration, or anything abnormal noted to Resident #2's left hand, wrist or face. No signs of pain noted upon passive ROM to LUE. Physician, DON, Administrator, and guardian notified. Record review of CNA C's statement dated 11/08/23 indicated she was returning to the dayroom of the secure unit when she saw Resident #1 gripping Resident #2's arm. CNA C intervened and pried Resident #1's hand off of Resident #2. Resident #2 proceeded to attack CNA C. One on One was implemented on the other side of the day room. CNA C reported the incident to the charge nurse immediately. The surveyor requested to observe the video of the incident on 11/03/23. The facility was not able to provide access to the video because the system did not retain a copy. During an interview on 11/11/23 at 9:35 a.m., the Administrator said she was the abuse coordinator. She said Resident #1 resided on the secure unit. She said Resident #1 had a history of aggression towards staff and residents. She said the other residents were afraid of Resident #1. She said there were two CNAs on the secure unit when the incident occurred. She said staff were supposed to supervise and monitor Resident #1 but left her alone to provide care for another resident. Staff should have called for the nurse to provide the supervision when they were not able to supervise Resident #1. She said all staff were at risk of abuse from Resident #1 when there was no supervision. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all nursing staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said all new staff and any staff not trained were trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. She said she (the Administrator) and the DON were responsible to ensure all staff were trained and to monitor to ensure compliance with the QAPI plan/PIP. During observation and interview on 11/11/23 at 10:25 a.m., Resident #2 sat at a dining table watching TV with other residents. When asked if she remembered anyone grabbing her walker or hurting her she smiled and replied with unintelligible words. There was no signs of anxiety or distress. During an interview on 11/11/23 at 11:57 a.m., LVN A said CNA C came off the secure unit and reported Resident #1 hit Resident #2. She said she went on to the secure unit and Resident #1 and Resident #2 were separated. She assessed Resident #1 and Resident #2 and there was no injuries. She said she reviewed the video and noted Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 was grabbed on her left wrist by Resident #1. She said she was not able to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. She said there was no assigned 1 to 1 staff on the secure unit. She said the staff should have called for help when they were providing care to any resident that required two staff. She said all residents were at risk of abuse from Resident #1 when there was no supervision. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors During an interview on 11/11/23 at 12:56 p.m., LVN E said she was the MDS nurse. She said she admitted Resident #1 back to the facility from a behavior hospital on 10/31/23. She said Resident #1 was combative with the transport driver. She said she did not want to readmit her to the facility and wanted to send her back to the behavior hospital. She said Resident #1 was sent back to the facility without report. She said the transport driver directed her to call the behavior hospital. She said the behavior hospital said Resident #1's combative and aggressive behavior was her baseline and if she required 1-1 staff then that is what the facility would have to implement. She said she argued with the behavior hospital and said it was not appropriate to send Resident #1 back to the facility. She said she called the NP and was told to send Resident #1 back to the behavior hospital but she could not because it was across state lines. She said she did not assign 1 to 1 staff. She said she did not get a physician order for one to one staff and was waiting for an order. She said other residents were at risk of abuse from Resident #1 if there was not adequate supervision. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. During an interview on 11/11/23 at 1:15 p.m., the RDO said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. He said the facility started retraining nursing staff on 11/03/23. He said all nursing staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. He said all new staff and any staff not trained would be trained by the DON or ADON prior to working their scheduled shift. He said there were no other residents in the facility who were abusive to other residents. During an interview on 11/11/23 at 2:55 p.m., the ADON said Resident #1 was readmitted to the facility from a behavior hospital. She said Resident #1 was more combative with care and not usually aggressive towards other residents. She said Resident #1 should have been placed on 1-1 when she returned. She said all residents were supposed to be protected from abuse. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said all new staff and any staff not trained would trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. During an interview on 11/11/23 at 3:11 p.m. the DON said when Resident #1 was readmitted to the facility from the behavior hospital on 10/31/23, the facility should have implemented one to one. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said she (the DON) and the Administrator were responsible to ensure all staff were trained and to monitor to ensure compliance with the QAPI plan/PIP. She said all new staff and any staff not trained would be trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. During an interview on 11/14/23 at 2:12 p.m., LVN D said Resident #1 was readmitted to the facility from a behavior hospital. She said Resident #1 was very combative. She said after CNA C reported Resident #1 hit Resident #2, she went on the secure unit and saw the aides had separated the residents. She said she viewed the incident on the video and saw Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 was grabbed on her left wrist by Resident #1. Unable to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. She said she notified the Administrator, the DON, the physician and Resident #1's family member. She said the residents were assessed and had no injuries. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. Record review of facility policy Preventing Resident Abuse dated 2001 indicated 1. The facility's goal is to achieve and maintain an abuse-free environment. 2. Our abuse prevention/intervention program includes but is not limited to, the following: . g. Training staff to understand and manage a resident's verbal or physical aggression; . j. Assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; . striving to maintain adequate staffing on all shifts to ensure that needs of each resident are met; . Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but is not limited to freedom from corporal punishment, involuntary seclusion verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; other residents; . On 11/14/23, the surveyor confirmed the facility implemented appropriate measures to ensure the safety of residents after the incident on 11/03/23 involving Resident #1 and Resident #2 by: Review of QAPI notes dated 11/08/23 showed a meeting was held to discuss the incident with Resident #1 and Resident #2 on 11/03/23. Members present included the Administrator, DON, Medical Director, MDS Coordinator, and ADON. The interventions and plan for correction included : -obtaining emergency physician orders -resident to resident altercations -resident rights -discharge and IDT communication -abuse and neglect prevention and staff training Record review of the staff in-services dated 11/03/23 through 11/11/23 included: -obtaining emergency physician orders, -resident to resident altercations, -resident rights, -discharge and IDT communication, and -abuse and neglect prevention and staff training. During interviews on 11/11/23 9:30 a.m. through 4:00 p.m., and 11/14/23 from 9:30 a.m. through 2:20 p.m., 5 LVN's (on all shifts) 10 CNA's (on all shifts) and the ADON said they received training prior to the incident and after the incident on 11/03/23 from the Administrator or the DON regarding resident abuse, neglect, rights, dealing with residents with aggressive behaviors and resident supervision levels. The nursing staff verbalized understanding of the trainings and were able to give examples of dealing with behaviors and preventing abuse. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to ensure adequate supervision and assistance device was provided to prevent an accident for 1 of 5 residents reviewed for accidents. (Resident #1) The facility did not transfer Resident #1 according to their care plan and comprehensive assessment. Resident #1 required the assistance of two staff for transfers. CNA A transferred Resident #1 using a Hoyer lift without the assistance of another staff. A strap on the Hoyer lift came off causing the resident to fall and sustain a [MEDICAL CONDITION]. This failure could place residents who required assistance with transfers at risk for injury, discomfort, and decreased quality of care. This was determined to be past non-compliance with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. Findings included: The MDS dated [DATE] indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #1 is rarely/never understood and resident was unable to complete the interview. The resident was dependent for transfers and required the physical assistance of at least two staff for transfers. An updated care plan dated on 09/23/19 indicated Resident #1 required the use of a Hoyer lift for safe transfers with the participation of at least 2 staff members. A nursing note dated 09/18/19 at 6:41 PM indicated Resident #1 fell from the Hoyer lift while one CNA was transferring the resident from her Geri-chair to her bed. The note indicated Resident #1 was on floor lying on left hip. Resident #1 moaned when left hip was repositioned. X-ray report dated 09/19/2019 at 12:05 a.m. indicated a probable nondisplaced intertrochanteric left femoral neck fracture. A nursing note dated 09/19/19 at 2:46 a.m. indicated Resident #1 had an acute left femur fracture and an order was received to transfer the resident to the hospital. During an interview on 10/01/19 at 9:20 a.m., the administrator said CNA A did not follow the policy regarding Hoyer lift transfers for Resident #1 which resulted in Resident #1 being injured on 9/18/19. The administrator said the maintenance man inspected the Hoyer lift and sling, they were found to be in working condition. The administrator said the DON in-serviced and checked the CNA off for competency on the proper use of the Hoyer lift on 9/19/19. The administrator said the CNA was required to be accompanied by a licensed nurse during any Hoyer lift transfer for the next 6 weeks, through 10/31/19. She said all staff had been in-serviced again on the use of the Hoyer lift and one-on-one training was in progress for all staff on Hoyer lift transfers and skills check by the DON. The administrator said Resident #1 was discharged from the hospital to an in-patient hospice facility. During an interview on 10/01/19 at 11:16 a.m. CNA A said on 09/18/19 he hooked up the Hoyer lift sling to transfer Resident #1 from Geri-chair to the bed and waited on the other CNA to come to the room. He said when the other CNA did not come in to room to assist, he transferred Resident #1 alone. He said the sling strap came off of the Hoyer lift and the resident slid out of the Hoyer sling onto the floor her left side. The CNA said he thought he had hit the emergency lower button but realized the sling strap came off the Hoyer lift. He said he was trained on Hoyer lift transfers prior to the incident. The provider investigation report dated 09/19/19 indicated Resident #1 fell because the Hoyer sling strap detached from the hook on the Hoyer lift arm. The facility inspected the Hoyer lift and all slings were found to be in working condition. The report indicated CNA A transferred Resident #1 without the assistance of another employee to help with the transfer . CNA's, medication nurses, and nurses would receive education and complete competencies on safe Hoyer lift transfers. A policy titled Hoyer Lift dated (MONTH) (YEAR) indicating There must always be two people present for the portable lift while it is in use. Invocare Reliant .Battery Powered Patient Lift User manual included the sling instructions (undated) on page 26 indicated When elevated a few inches off the surface of a stationary object (wheelchair, commode, bed) and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. The surveyor determined the facility was in non-compliance from 9/18/19 to 9/20/19. The facility took the following actions to correct the non-compliance: *Hoyer lift in-services 9/19/19 for CNA A indicated he received one on one instruction from the DON on proper use of the hoyer lift. *Total Mechanical Lift Competency Checklist was completed on 9/19/19 for CNA A indicated he completed the training. *An all staff in-service dated 9/19/19 indicated all nursing staff were in-serviced on the proper use of the Mechanical Lift. *An all staff in-service dated 9/19/19 and 9/20/19 indicated all nursing staff completed the Total Mechanical Lift Competency Checklist.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents 4 of 5 residents reviewed for accidents. (Resident #s 1, 2, 3, and 4) The facility did not implement revised interventions to prevent falls for the following: Resident #1 had history of falls. Resident #1 fell and sustained a fracture of his left fibula (shin bone) and multiple skin tears. Resident #1 was restricted to walk for 6 weeks. Resident #2 had a history of [REDACTED].#2 fell sustaining lacerations and had to me sent to the emergency room . Resident #3 had history of falls. Resident #3 had physician orders [REDACTED]. The facility did not implement fall or safety measures to prevent Resident #3 from a fall related injury. Resident #3 was found at the foot of her bed bleeding from her head. Resident #3 was sent to the emergency room for treatment and required sutures. Resident #4 had history of falls. Resident #4 transferred without assistance and had repeated falls. The facility did not revise interventions to prevent falls. This failure contributed to Resident #1's left fibula (shin bone) fracture and being restricted from walking for 6 weeks. This failure could place 12 residents with falls and fall history increased injury and neglect. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, originally admitted [DATE] with [DIAGNOSES REDACTED]. Resident was readmitted [DATE] with a new [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 had clear speech, understood others and had the ability to make himself understood and had adequate vision. Resident #1 had severe cognitive impairment. This MDS indicated Resident #1 had falls and required extensive assistance with transfers. A care plan dated 12/20/16 indicated had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease. Resident #1 was at risk for falls and had an actual fall. The goal was for Resident #1 to be free from falls. The target date was 12/13/17. Listed interventions included . Anticipate and meet the resident's needs every shift. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Follow facility fall protocol . There were no revised interventions noted in response to the 08/31/17 injury to attempt to prevent falling. A Physical Therapy Evaluation and Plan of Treatment with the start of care dated 09/06/17 indicated Resident #1 was a fall risk and was referred due to a decline in strength, balance and functional mobility. This document indicated Resident #1 previously received therapy from 08/02/17 - 08/30/17, prior to fall and hospitalization on [DATE]. A nursing progress note dated 10/21/17 indicated Resident #1 was found on the floor by the foot of the bed by the dresser with .a laceration to the left forehead with heavy bright red bleeding . and .a large amount of blood on the floor . Resident #1 said he did not know what happened according to this note and was sent to the emergency room (ER) by ambulance. A hospital record with the admission date of [DATE] at 10:50 a.m., indicated Resident #1 was brought to the ER because of a fall at the nursing home. As a result of that fall, Resident #1 sustained a left frontal scalp laceration which was repaired by the ER physician. The note indicated Resident #1 complained of hip pain. The x-rays revealed Resident #1 suffered an acute left fibular (shin bone)fracture and was restricted from walking for six weeks. A physician orders [REDACTED].#1 was not to walk for six (6) weeks. The care plan for Resident #1 was updated on 10/25/17 to include interventions to .keep the bed in the lowest position with fall mat in place and no walking for six weeks . A physician orders [REDACTED].#1 was to be administered tramadol HCL tablet 50 mg every four (4) hours as needed for pain. A physician orders [REDACTED].#1's forehead 11/03/17. During an interview on 11/02/17 at 9:30 a.m., the administrator/abuse coordinator said Resident #1 had an unwitnessed fall in his room 10/21/17 and sustained a fracture. She said prior to the 10/21/17 fall, Resident #1 was able to independently transfer himself but now required staff assistance. She said Resident #1 was ordered a fall mat and the bed to be in the lowest position. She said Resident #1 had fallen previously. During an interview and observation on 11/02/17 at 9:50 a.m., Resident #1 had sutures to his forehead and bruising to his right and left hands. Resident #1 said he did not recall falling, but was not walking because his hip hurt every time I try to get up. Resident #1 said sometimes his bed was close to the floor and sometimes it was not but he did not need help transferring. During an interview on 11/02/17 at 11:39 a.m., RN X said Resident #1 had a history of [REDACTED].#1 had the same bed before and after the 10/21/17 fall. He said Resident #1 had always had the bed in the lowest position. RN X said Resident #1 was constantly reminded and encouraged to use his call light but would not because he has no short term memory. RN X said Resident #1 used to have an alarm to alert staff when he needed assistance but corporate made us get rid of all the alarms. We were told it was because of y'all, the state. Do you know anything about that? During an interview on 11/02/17 at 4:38 p.m., the DON and MDS Coordinator said the interventions implemented as a protection against falls for Resident #1 after the 08/31/17 fall with injury and hospitalization was for Resident #1 to have physical and occupational therapies. They said the facility implemented a fall mat and bed in lowest position after the 10/21/17 fall with fracture. During an interview on 11/02/17 at 4:44 p.m., the DON said Resident #1 was receiving therapy before he fell on [DATE] so he just continued therapy as a fall intervention. The DON said there was nothing else done in response to that fall. During observations on 11/02/17 at 10:00 a.m., 10:30 a.m., 10:45 a.m., 11:10 a.m., 11:40 a.m., 12:20 p.m., 2:00 p.m., 4:11 p.m. and 5:00 p.m., Resident #1 was in his wheelchair and not observed in bed. His bed was not in the lowest position and a fall mat was against the wall on the opposite side of the room from his bed. There were signs taped to Resident #1's wall and bedside table instructing him to call for assistance. 2. An admission record dated 11/02/17 indicted Resident #2 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 had adequate vision, clear speech, sometimes made himself understood and usually understood others. Resident #2 had severely impaired cognitive skills for daily decision making and disorganized thinking. This MDS indicated Resident #2 required extensive assistance of two staff persons for bed mobility, transfers and dressing and totally dependent for bathing. Resident #2 was always incontinent of bowel and frequently incontinent of bladder. A care plan dated 08/02/16 indicated Resident #2 was at risk for falls related being unaware of safety needs and refusing to wear shoes. Resident #2 preferred to go barefoot. The goal was for Resident #2 to be free of falls through the review date of 11/26/17. Listed interventions were to .anticipate and meet the resident's needs, follow facility fall protocol, for physical therapy to evaluate and treat as ordered and to be sure the resident's call light is within reach and encourage the resident to use it for assistance . An incident report dated 10/28/17 at 6:00 p.m., indicated Resident #2 suffered an unwitnessed fall with injury. This report indicated Resident #2 was found on the floor in another resident's room in the fetal position .and crying . with another unnamed resident .trying to help . The resident sustained [REDACTED].large amount of active bleeding . , but was unable to determine depth. Additionally, Resident #2 sustained 2 skin tears. Resident #2 was .unable to explain due to confusion . and the unnamed resident was .unable to recount what happened due to confusion This report indicated Resident #2 was moaning, groaning, crying and facial grimacing because he was in pain. Resident #2 was sent to the ER. As an intervention, the note section indicated staff would continue to .keep gripper socks and shoes on . Resident #2. A nursing note dated 10/28/17 at 6:00 p.m., indicated Resident #2 had an unwitnessed fall with multiple injuries and the facility received orders to send him to the ER. During an interview on 11/17/17 at 6:10 p.m., the DON said Resident #2 was not able to report how he sustained the injuries and there were no witnesses. The DON said there was no way to know if Resident #2 actually fell or if the other unnamed resident found with him may have pushed him or did something to cause Resident #2's injuries. She said, We have no way of knowing that. A Fall Risk assessment dated [DATE] indicated Resident #2 was disoriented at all times, had fallen 1-2 times in the past 3 months and was deemed to be a high risk for falling. During observations on 11/02/17 at 11:39 a.m., 11:43 a.m., 11:50 a.m., and 1:47 p.m., Resident #2 was ambulating continuously up and down the hall on the secured unit using his right hand to hold his sweatpants at his waste. His pants were too big and kept falling down. Resident #2 had one sock on his right foot and the left foot was bare. During an interview on 11/02/17 at 12:17 p.m., CNA F said Resident #2 preferred to be barefoot and would take off his his socks and shoes every time. She said Resident #2 was supposed to wear nonskid socks but they could not get him to keep them on. A care plan dated 01/05/17 indicated Resident #2 had an actual fall with the goal of resuming regular activities without further incident through the target date 11/26/17. Interventions listed were: .For no apparent acute injury, determine and address causative factors of the fall. Neuro-checks x 72 hours. Pharmacy consult to evaluate medications. PT consult for strength and mobility . 3. Physicians order summary report dated 11/02/17 indicated Resident #3 was an [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. This summary indicated Resident #3 had an order dated 07/14/17 to have a low bed with fall mat every shift. The most recent MDS dated [DATE] indicated Resident #3 had adequate vision, clear speech, usually made herself understood and usually understood others. Resident #3 had severely impaired cognitive skills. This MDS indicated Resident #3 demonstrated disorganized thinking was occasionally incontinent of bowel and bladder. A care plan dated 01/05/17 indicated Resident #3 was at risk for falls and would remove her fall mat and place a trash can on her bed to keep her bed alarm from alarming. The goal was for Resident #3 to be free from injury. Listed interventions included: .anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; educate the resident/family/caregivers about safety reminders and what to do if fall occurs; follow facility fall protocol; staff to monitor resident every 2 hours and prn for placement of fall mat and bed alarm . The care plan did not have new or revised interventions to prevent falls. A care plan dated 05/09/16 and revised 07/12/17 indicated Resident #3 was at risk for falls. The goal was for Resident #3 to be free of falls through the review date of 11/07/17. Listed interventions were .to anticipate and meet the resident's needs, follow facility fall protocol, to be sure the resident's call light is within reach and encourage the resident to use it for assistance, and the resident used bed electronic alarm and fall mat. Ensure the device is in place . The care plan did not have new or revised interventions to prevent falls since the revision date. A nursing progress note dated 08/31/17 indicated Resident #3 fell into a door frame and sustained a skin tear. An incident report dated 09/19/17 at 6:32 a.m., indicated Resident #3 had a fall with injury. Resident #3 was found with blood on her sock and pants and with a skin tear to her left knee approximately 2 cm X 1.8 cm X 0.1 cm with a moderate amount of bleeding. Resident #3 also was bleeding from an open area on the left side of her forehead. This incident report indicated Resident #3 said she fell . The report noted Resident #3 was .forgetful, had a lack of safety awareness, impulsive with confusion and impaired memory . The notes section indicated Resident #3 would be monitored. A nursing progress note dated 10/30/17 at 1:15 p.m., indicated Resident #3 was found with bruising of unknown origin to the lower left extremity and would continue to be monitored. An incident report dated 11/02/17 at 9:05 a.m. indicated Resident #3 had an unwitnessed fall with injury and was transferred to the ER for evaluation and treatment. Resident #3 was found on the floor in her bedroom bleeding from the front of her head. This report indicated Resident #3 sustained a laceration 4 cm X 2 cm when she fell and hit her head on the foot board. This report indicated Resident #3 complained of pain under her sternum, 911 was called and she was transferred to the ER. This report indicated Resident #3 was confused with impaired memory. According to this report, Resident #3 has been educated and reminded innumerable times regarding the importance of summoning assistance . A nursing progress note dated 11/02/17 at 9:40 a.m. indicated Resident #3 fell in her room and hit her head on the edge of the foot board and sustained a laceration. The note indicated Resident #3 complained of pain and was transferred to the ER per family request. A hospital discharge instruction sheet dated 11/02/17 indicated Resident #3 was to have sutures removed in 5-7 days and was given a tetanus shot due to the laceration. During an interview on 11/02/17 at 5:41 p.m., when asked about the facility's interventions in response to the 09/19/17 fall with injury, the DON said, We didn't do anything, I mean, she is an ambulatory resident. What do you want me to do with someone like that? The DON said Resident #3 used to have safety alarms but their corporate office told them all alarms had to be removed by 09/01/17 due to a new State regulation considering alarms as restraints. The DON said all residents who had fall alarms as interventions no longer had them. She said the only interventions the facility had to offer as fall prevention were the bed in the lowest position, fall mats and therapy evaluations. She said therapy evaluated after every fall. A Fall Risk assessment dated [DATE] indicated Resident #3 was disoriented at all times, had not fallen in the past 3 months but the category to indicate the resident's fall risk level was marked NA. During an interview on 11/02/17 at 10:50 a.m., CNA F said she heard Resident #3 yelling for help and found her on the floor in a puddle of blood at the foot of her bed. CNA F said Resident #3 had fallen and was sent to the ER. CNA F said Resident #3 had a history of [REDACTED]. CNA F said most of the time there were 3 staff but not always. She said they do the best they can. CNA F said most of Resident #3's falls were in the dining room or because she was trying to go to the restroom. During an interview on 11/02/17 at 11:49 a.m., RN X said Resident #3 fell on the secured unit this morning and sustained a laceration for her forehead. He said 911 was called and transferred to the ER. RN X said Resident #3 was confused and impulsive with an Alzheimer's diagnosis. He said she had a history of [REDACTED]. RN X said Resident #3 did not have a low bed or fall mat because she was independent with ambulation and was able to transfer herself in and out of bed. RN X said there were no fall precautions in place for Resident #3. During an interview on 11/02/17 at 5:39 p.m., RN X said Resident #3 returned from the hospital with sutures but he did not know how many. RN X said the staff used to be alerted to when Resident #3 was in need of help but now they found residents on the floor bleeding because all of the fall alarms were discontinued. RN X said the DON told them alarms had to be removed per State because they were considered restraints and this was a restraint free facility. RN X said all alarms had to be removed by 09/01/17. RN X said that made it more difficult to meet the needs of the residents who wandered or were at risk for falling. During an interview on 11/02/17 at 5:41 p.m., when asked what the facility did in response to Resident #3's the 11/02/17 fall with injury, the DON said the efforts to prevent future falls were (1) she had gotten an order for [REDACTED].#3 and (2) had spoken with the family about the possibility of a walker, if therapy deemed it appropriate. A nursing progress note dated 11/02/17 at 6:20 p.m., (after surveyor intervention) indicated the DON called Resident #3's daughter and got consent for physical therapy and for Resident #3 to use a walker. A physicians order dated 11/02/17 at 6:27 p.m., (after surveyor intervention), indicated the DON called the physician for an order for [REDACTED]. 4. An admission record dated 11/02/17 indicated Resident #4 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. Repeated falls was added as a [DIAGNOSES REDACTED]. A care plan initiated 06/26/17 with the revision date of 06/26/17 indicated Resident #4 had an actual fall with no injury due to poor balance. The goal was to resume usual activities without further incident through the review date of 09/23/17. Interventions listed were as follows: .Check range of motion every shift (initiated 06/26/17 and revised 06/26/17) For no apparent acute injury, determine and address causative factors of the fall (dated initiated 06/26/17) Skilled OTeval and treat 5 x week x 4 weeks for therex, theract, neuro, self cares and WC management as of 6-26-17 s/p falls (date initiated 06/27/17 and revised 06/27/17) . There were no new or revised interventions to prevent falls. A care plan dated 06/26/17 addressed Resident #4's impaired cognitive functioning and .confusional episode due to dementia . Listed interventions included .check urine every 2 hours during incontinent care for volume, color and odor and ensure toileting routine was enforced to encourage appropriate emptying of bowel and bladder . A nursing progress notes dated 08/03/17 at 9:30 a.m., indicated Resident #4 frequently attempt to toilet herself without assistance. There was not a care plan to address a toileting program for Resident #4. A nursing progress notes dated 08/04/17 at 9:33 a.m., indicated Resident #4 frequently attempt to toilet herself without assistance. There was not a care plan to address a toileting program for Resident #4. The nursing progress notes for Resident #4 indicated the following falls: 08/12/17 and had to be sent to the ER due to complaining of left hip pain. 08/14/07 - found in her room on the floor, her left hand had bruising at 6 cm X 2 cm and a scratch to the right knee. There were no new or revised interventions to prevent falls reflected in the care plans. 08/27/17 - found sitting on the floor outside of the exit door to the secured unit. 08/28/17 indicated bruising was noted to bilateral hands, left wrist and right buttocks. There were no new or revised interventions to prevent falls reflected in the care plans. The most recent MDS dated [DATE] indicated Resident #4 had clear speech, adequate vision, made herself understood and was usually understood by others. Resident #4 had severely impaired cognition and demonstrated wandering behavior. According to this MDS, Resident #4 required extensive assistance of one staff person with bed mobility, transfers, dressing and toilet use. Resident #4 was frequently incontinent of bowel and bladder and was not participating in a toileting program and was noted to have repeated falls. The nursing progress notes for Resident #4 indicated the following falls: 10/13/17 at 7:33 a.m. - staff witnessed resident fall in her room attempting to transfer without assistance and landed on her right hip. First aid was provided. There were no new or revised interventions to prevent falls reflected in the care plans. She complained of pain to her right hip on 10/16/17 at 1:20 p.m. There was swelling and bruising noted after a fall and orders received for x-ray which showed osteoarthritis. The incident reports for Resident #4 indicated: 10/10/17 at 7:28 a.m. - fell in her room attempting to transfer without assistance and landed on her right hip. There were no noted injuries. Resident #4 was unable to state what happened due to impaired memory and forgetfulness. 10/11/17 the DON documented in the notes section of this report instructed staff to encourage Resident #4 to call for assistance when transferring self. There were no new interventions to prevent falls. 10/14/17 at 7:40 p.m. - found on the floor in her room and sustained multiple skin tears and had a hard raised area noted to left superior head. According to this note, Resident #4 said she did not know why she fell due to lack of safety awareness, forgetfulness, confusion and impaired memory. 10/15/17 the DON documented in the notes section of this report instructed staff to monitor skin tears for signs or symptoms of infection. There were no new or revised interventions to prevent falls. 10/19/17 at 5:00 p.m. - was found on the bathroom floor with her head against the former of the wall and the wheelchair outside of the door. Resident #4 was not able to state what happened. Per this report, the nurse explained the significance of requesting help before ambulating without assistance. This report indicated the resident was confused with impaired memory. 10/20/17 the DON documented in the notes section of this report instructed to continue therapy and monitor for injuries the next 72 hours. There were no new or revised interventions to prevent falls. A fall risk assessment dated [DATE] indicated Resident #4 was categorized as a high risk for falls. This assessment indicated Resident #4 had 3 or more falls in the past 3 months. During an interview on 11/02/17 at 10:47 a.m., CNA T said Resident #4 has a lot of falls. She said the only fall intervention was to monitor her every 15 minutes but that could not always be done because they have so many other residents to take care of. CNA T said she did not know if Resident #4 was on a toileting program or not. She said they check on all of the residents every 2 hours. During an interview on 11/02/17 at 12:25 p.m., CNA F said Resident #4 constantly got out of her wheelchair or bed, especially at night. CNA F said she had a low bed and fall mat but no other interventions. CNA F said Resident #4 would use the restroom if staff reminded her, but denied she was on a toileting program. CNA F said it is almost impossible to keep up with Resident #4's location and needs one on one attention because she does not understand she can get hurt, she's confused. During an observation on 11/02/17 at 1:08 p.m., Resident #4 was laying in her bed, the bed was in the highest position, and the fall mat was partially on the floor while the other half was draped across the seat of the wheelchair. Resident #4's call light was not within reach. During an interview on 11/02/17 at 5:49 p.m., the DON said Resident #4 fell on [DATE] and 10/14/17 with fall intervention the same for both, which were to encourage her to ask for assistance and continue therapy initiated 08/30/17 as the result of a fall. The DON said no additional interventions were implemented because Resident #4 was to continue therapy and nursing would comply with any recommendations from that department once they were made. During an interview on 11/02/17 at 6:12 p.m., the DON said Resident #4 was placed on toileting program as an intervention to the 10/19/17 fall but did not know the date the program started. The DON said most of her falls were her attempting to toilet unassisted. She said Resident #4 was to be toileted every 2 hours, but if the staff would take (Resident #4) to the restroom she may not have as many falls. During an interview on 11/02/17 at 6:12 p.m., the MDS Coordinator asked the DON if she printed the correct care plans and the DON said she was rushing and did had not printed the updated care plans. They said Resident #4's care plans were updated with new interventions but the DON printed the old care plans. During an interview on 11/02/17 at 6:38 p.m., the DON and MDS Coordinator returned and said they printed the most recent care plans that showed the facility's fall interventions. A care plan initiated 06/26/17 with the revision date of 11/02/17 indicated Resident #4 had an actual fall with no injury due to poor balance. The goal was to resume usual activities without further incident through the review date of 09/23/17. Interventions listed were as follows: .Assess for injury, determine and address causative factors of the fall; (initiated 10/09/17 and revised 11/02/17) Check range of motion every shift; (initiated 06/26/17 and revised 06/26/17) PT recertification clarification orders. PT to treat 5 times per week for 4 weeks to meet P[NAME] requirements; (initiated 10/09/17) PT to treat and evaluate (initiated 10/14/17) . During an interview on 11/02/17 at 6:41 p.m., the DON said therapy was the fall intervention for Resident #4's fall on 10/14/17. When asked for therapy's evaluation, the DON said therapy was gone for the day and she needed a key to get their records. The ADON and MDS Coordinator said the records were on the computer and could be printed. During an exit interview on 11/02/17 at 7:00 p.m., the BOM, DON and MDS Coordinator were offered the opportunity to scan or fax Resident #4's 10/14/17 therapy notes to be submitted as evidence of addressing the fall. Those records were not received. A fall risk assessment policy dated 2001 indicated, .Based on previous evaluations and current data, the nursing staff in conjunction with the Attending Physician .will seek to identify resident risk factors for falls and will document the risk factors in the resident's medical record .especially falls in the last 90 days . The facility 802 dated 11/02/17 indicated there were 12 residents with a history of falls.

Based on observation, interview and record review, the facility failed to to develop and implement their written policies and procedures prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 3 of 5 residents reviewed for neglect. (Resident #s 1, 3, and 4) The facility did not implement and/or revise interventions to prevent falls for the following: Resident #1 had history of falls. Resident #1 fell and sustained a fracture of his left fibular (shin bone) and multiple skin tears. Resident #1 was restricted to walk for 6 weeks. Resident #3 had history of falls. Resident #3 had physician orders [REDACTED]. The facility did not implement fall or safety measures to prevent Resident #3 from a fall related injury. Resident #3 was found at the foot of her bed bleeding from her head. Resident #3 was sent to the emergency room for treatment and required sutures. Resident #4 had history of falls. Resident #4 transferred without assistance and had repeated falls. The facility did not revise interventions to prevent falls. This failure contributed to Resident #1's left fibula (shin bone) fracture and being restricted from walking for 6 weeks. This failure could place 45 residents diagnosed with [REDACTED]. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, originally admitted [DATE] with [DIAGNOSES REDACTED]. Resident was readmitted [DATE] with a new [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 had clear speech, understood others and had the ability to make himself understood and had adequate vision. Resident #1 had severe cognitive impairment. This MDS indicated Resident #1 had falls and required extensive assistance with transfers. A care plan dated 12/20/16 indicated Resident #1 had impaired cognitive function/dementia or impaired thought processes related to [MEDICAL CONDITION]. Resident #1 was at risk for falls and had an actual fall. The goal was for Resident #1 to be free from falls. The target date was 12/13/17. Listed interventions included . Anticipate and meet the resident's needs every shift. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Follow facility fall protocol . There were no revised interventions noted in response to the 08/31/17 injury to attempt to prevent falling. A Physical Therapy Evaluation and Plan of Treatment with the start of care dated 09/06/17 indicated Resident #1 was a fall risk and was referred due to a decline in strength, balance and functional mobility. This document indicated Resident #1 previously received therapy from 08/02/17 - 08/30/17, prior to fall and hospitalization on [DATE]. A nursing progress note dated 10/21/17 indicated Resident #1 was found on the floor by the foot of the bed by the dresser with .a laceration to the left forehead with heavy bright red bleeding . and .a large amount of blood on the floor . Resident #1 said he did not know what happened according to this note and was sent to the emergency room (ER) by ambulance. A hospital record with the admission date of [DATE] at 10:50 a.m., indicated Resident #1 was brought to the ER because of a fall at the nursing home. As a result of that fall, Resident #1 sustained a left frontal scalp laceration which was repaired by the ER physician. The note indicated Resident #1 complained of hip pain. The x-rays revealed Resident #1 suffered an acute left fibular (shin bone)fracture and was restricted from walking for six weeks. A physician orders [REDACTED].#1 was not to walk for six (6) weeks. A care plan for Resident #1 was updated on 10/25/17 to include interventions to .keep the bed in the lowest position with fall mat in place and no walking for six weeks . A physician orders [REDACTED].#1 was to be administered [MEDICATION NAME] HCL tablet 50 mg every four (4) hours as needed for pain. A physician orders [REDACTED].#1's forehead 11/03/17. During an interview on 11/02/17 at 9:30 a.m., the administrator/abuse coordinator said Resident #1 had an unwitnessed fall in his room [ROOM NUMBER]/21/17 and sustained a fracture. She said prior to the 10/21/17 fall, Resident #1 was able to independently transfer himself but now required staff assistance. She said Resident #1 was ordered a fall mat and the bed to be in the lowest position. She said Resident #1 had fallen previously. During an interview and observation on 11/02/17 at 9:50 a.m., Resident #1 had sutures to his forehead and bruising to his right and left hands. Resident #1 said he did not recall falling, but was not walking because his hip hurt every time I try to get up. Resident #1 said sometimes his bed was close to the floor and sometimes it was not but he did not need help transferring. During an interview on 11/02/17 at 11:39 a.m., RN X said Resident #1 had a history of [REDACTED].#1 had the same bed before and after the 10/21/17 fall. He said Resident #1 had always had the bed in the lowest position. RN X said Resident #1 was constantly reminded and encouraged to use his call light but would not because he has no short term memory. RN X said Resident #1 used to have an alarm to alert staff when he needed assistance but corporate made us get rid of all the alarms. We were told it was because of y'all, the state. Do you know anything about that? During an interview on 11/02/17 at 4:38 p.m., the DON and MDS Coordinator said the interventions implemented as a protection against falls for Resident #1 after the 08/31/17 fall with injury and hospitalization was for Resident #1 to have physical and occupational therapies. They said the facility implemented a fall mat and bed in lowest position after the 10/21/17 fall with fracture. During an interview on 11/02/17 at 4:44 p.m., the DON said Resident #1 was receiving therapy before he fell on [DATE] so he just continued therapy as a fall intervention. The DON said there was nothing else done in response to that fall. During observations on 11/02/17 at 10:00 a.m., 10:30 a.m., 10:45 a.m., 11:10 a.m., 11:40 a.m., 12:20 p.m., 2:00 p.m., 4:11 p.m. and 5:00 p.m., Resident #1 was in his wheelchair and not observed in bed. His bed was not in the lowest position and a fall mat was against the wall on the opposite side of the room from his bed. There were signs taped to Resident #1's wall and bedside table instructing him to call for assistance. 2. An admission record dated 11/02/17 indicted Resident #2 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 had adequate vision, clear speech, sometimes made himself understood and usually understood others. Resident #2 had severely impaired cognitive skills for daily decision making and disorganized thinking. This MDS indicated Resident #2 required extensive assistance of two staff persons for bed mobility, transfers and dressing and totally dependent for bathing. Resident #2 was always incontinent of bowel and frequently incontinent of bladder. A care plan dated 08/02/16 indicated Resident #2 was at risk for falls related to psychoactive drug use and being unaware of safety needs. The resident refused to wear shoes because he preferred to go barefoot. The goal was for Resident #2 to be free of falls through the review date of 11/26/17. Listed interventions were to .anticipate and meet the resident's needs, follow facility fall protocol, for physical therapy to evaluate and treat as ordered and to be sure the resident's call light is within reach and encourage the resident to use it for assistance . An incident report dated 10/28/17 at 6:00 p.m. indicated Resident #2 suffered an unwitnessed fall with injury. This report indicated Resident #2 was found on the floor in another resident's room in the fetal position .and crying . with another unnamed resident .trying to help . The resident sustained [REDACTED].large amount of active bleeding . , but was unable to determine depth. Additionally, Resident #2 sustained 2 skin tears. Resident #2 was .unable to explain due to confusion . and the unnamed resident was .unable to recount what happened due to confusion This report indicated Resident #2 was moaning, groaning, crying and facial grimacing because he was in pain. Resident #2 was sent to the ER. As an intervention, the note section indicated staff would continue to .keep gripper socks and shoes on . Resident #2. A nursing note dated 10/28/17 at 6:00 p.m. indicated Resident #2 had an unwitnessed fall with multiple injuries and the facility received orders to send him to the ER. A Fall Risk assessment dated [DATE] indicated Resident #2 was disoriented at all times, had fallen 1-2 times in the past 3 months and deemed to be a high risk for falling. During observations on 11/02/17 at 11:39 a.m., 11:43 a.m., 11:50 a.m., and 1:47 p.m., Resident #2 was ambulating continuously up and down the hall on the secured unit using his right hand to hold his sweatpants at his waste. His pants were too big and kept falling down. Resident #2 had one sock on his right foot and the left foot was bare. During an interview on 11/02/17 at 12:17 p.m., CNA F said Resident #2 preferred to be barefoot and would take off his his socks and shoes every time. She said Resident #2 was supposed to wear nonskid socks but they could not get him to keep them on. During an interview on 11/17/17 at 6:10 p.m., the DON said Resident #2 was not able to report how he sustained the injuries and there were no witnesses. The DON said there was no way to know if Resident #2 actually fell or if the other unnamed resident found with him may have pushed him or did something to cause Resident #2's injuries. She said, We have no way of knowing that. A care plan dated 01/05/17 indicated Resident #2 had an actual fall with the goal of resuming regular activities without further incident through the target date 11/26/17. Interventions listed were: .For no apparent acute injury, determine and address causative factors of the fall. Neuro-checks x 72 hours. Pharmacy consult to evaluate medications. PT consult for strength and mobility . 3. Physicians order summary report dated 11/02/17 indicated Resident #3 was an [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. This summary indicated Resident #3 had an order dated 07/14/17 to have a low bed with fall mat every shift. The most recent MDS dated [DATE] indicated Resident #3 had adequate vision, clear speech, usually made herself understood and usually understood others. Resident #3 had severely impaired cognitive skills. This MDS indicated Resident #3 demonstrated disorganized thinking was occasionally incontinent of bowel and bladder. A care plan dated 01/05/17 indicated Resident #3 was at risk for falls and would remove her fall mat and place a trash can on her bed to keep her bed alarm from alarming. The goal was for Resident #3 to be free from injury. Listed interventions included: .anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; educate the resident/family/caregivers about safety reminders and what to do if fall occurs; follow facility fall protocol; staff to monitor resident every 2 hours and prn for placement of fall mat and bed alarm . The care plan did not have new or revised interventions to prevent falls. A care plan dated 05/09/16 and revised 07/12/17 indicated Resident #3 was at risk for falls. The goal was for Resident #3 to be free of falls through the review date of 11/07/17. Listed interventions were .to anticipate and meet the resident's needs, follow facility fall protocol, to be sure the resident's call light is within reach and encourage the resident to use it for assistance, and the resident used bed electronic alarm and fall mat. Ensure the device is in place . The care plan did not have new or revised interventions to prevent falls since the revision date. A nursing progress note dated 08/31/17 indicated Resident #3 fell into a door frame and sustained a skin tear. An incident report dated 09/19/17 at 6:32 a.m., indicated Resident #3 had a fall with injury. Resident #3 was found with blood on her sock and pants and with a skin tear to her left knee approximately 2 cm X 1.8 cm X 0.1 cm with a moderate amount of bleeding. Resident #3 also was bleeding from an open area on the left side of her forehead. This incident report indicated Resident #3 said she fell . The report noted Resident #3 was .forgetful, had a lack of safety awareness, impulsive with confusion and impaired memory . The notes section indicated Resident #3 would be monitored. A nursing progress note dated 10/30/17 at 1:15 p.m. indicated Resident #3 was found with bruising of unknown origin to the lower left extremity and would continue to be monitored. An incident report dated 11/02/17 at 9:05 a.m. indicated Resident #3 had an unwitnessed fall with injury and was transferred to the ER for evaluation and treatment. Resident #3 was found on the floor in her bedroom bleeding from the front of her head. This report indicated Resident #3 sustained a laceration 4 cm X 2 cm when she fell and hit her head on the foot board. This report indicated Resident #3 complained of pain under her sternum, 911 was called and she was transferred to the ER. This report indicated Resident #3 was confused with impaired memory. According to this report, Resident #3 has been educated and reminded innumerable times regarding the importance of summoning assistance . A nursing progress note dated 11/02/17 at 9:40 a.m., indicated Resident #3 fell in her room and hit her head on the edge of the foot board and sustained a laceration. The note indicated Resident #3 complained of pain and was transferred to the ER per family request. A hospital discharge instruction sheet dated 11/02/17 indicated Resident #3 was to have sutures removed in 5-7 days and given a tetanus shot due to the laceration. A Fall Risk assessment dated [DATE] indicated Resident #3 was disoriented at all times, had not fallen in the past 3 months but the category to indicate the resident's fall risk level was marked NA. During an interview on 11/02/17 at 10:50 a.m., CNA F said she heard Resident #3 yelling for help and found her on the floor in a puddle of blood at the foot of her bed. CNA F said Resident #3 had fallen and was sent to the ER. CNA F said Resident #3 had a history of [REDACTED]. CNA F said most of the time there were 3 staff but not always. She said they do the best they can. CNA F said most of Resident #3's falls were in the dining room or because she was trying to go to the restroom. During an interview on 11/02/17 at 11:49 a.m., RN X said Resident #3 fell on the secured unit this morning and sustained a laceration for her forehead. He said 911 was called and transferred to the ER. RN X said Resident #3 was confused and impulsive with an Alzheimer's diagnosis. He said she had a history of [REDACTED]. RN X said Resident #3 did not have a low bed or fall mat because she was independent with ambulation and able to transfer herself in and out of bed. RN X said there were no fall precautions in place for Resident #3. During an interview on 11/02/17 at 5:39 p.m., RN X said Resident #3 returned from the hospital with sutures but he did not know how many. RN X said the staff used to be alerted to when Resident #3 was in need of help but now they found residents on the floor bleeding because all of the fall alarms were discontinued. RN X said the DON told them alarms had to be removed per State because they were considered restraints and this was a restraint free facility. RN X said all alarms had to be removed by 09/01/17. RN X said that made it more difficult to meet the needs of the residents who wandered or were at risk for falling. During an interview on 11/02/17 at 5:41 p.m., when asked about the facility's interventions in response to the 09/19/17 fall with injury, the DON said We didn't do anything, I mean, she is an ambulatory resident. What do you want me to do with someone like that? The DON said Resident #3 used to have safety alarms but their corporate office told them all alarms had to be removed by 09/01/17 due to a new State regulation considering alarms as restraints. The DON said all residents who had fall alarms as interventions no longer had them. She said the only interventions the facility had to offer as fall prevention were the bed in the lowest position, fall mats and therapy evaluations. She said therapy evaluated after every fall. During an interview on 11/02/17 at 5:41 p.m., when asked what the facility did in response to Resident #3's the 11/02/17 fall with injury, the DON said the efforts to prevent future falls were (1) she had gotten an order for [REDACTED]. A nursing progress note dated 11/02/17 at 6:20 p.m. (after surveyor intervention), indicated the DON called Resident #3's daughter and got consent for physical therapy and for Resident #3 to use a walker. A physicians order dated 11/02/17 at 6:27 p.m., (after surveyor intervention), indicated the DON called the physician for an order for [REDACTED]. 4. An admission record dated 11/02/17 indicated Resident #4 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. Repeated falls was added as a [DIAGNOSES REDACTED]. A care plan initiated 06/26/17 with the revision date of 06/26/17 indicated Resident #4 had an actual fall with no injury due to poor balance. The goal was to resume usual activities without further incident through the review date of 09/23/17. Interventions listed were as follows: .Check range of motion every shift (initiated 06/26/17 and revised 06/26/17) For no apparent acute injury, determine and address causative factors of the fall (dated initiated 06/26/17) Skilled OT eval and treat 5 x week x 4 weeks for therex, theract, neuro, self cares and WC management as of 6-26-17 s/p falls (date initiated 06/27/17 and revised 06/27/17) . There were no new or revised interventions to prevent falls. A care plan dated 06/26/17 addressed Resident #4's impaired cognitive functioning and confusional episode due to dementia. Listed interventions included .check urine every 2 hours during incontinent care for volume, color and odor and ensure toileting routine was enforced to encourage appropriate emptying of bowel and bladder . A nursing progress note dated 08/03/17 at 9:30 a.m., indicated Resident #4 frequently attempt to toilet herself without assistance. There was not a care plan to address a toileting program for Resident #4. A nursing progress notes dated 08/04/17 at 9:33 a.m., indicated Resident #4 frequently attempt to toilet herself without assistance. There was not a care plan to address a toileting program for Resident #4. The nursing progress notes for Resident #4 indicated the following falls: 08/12/17 and had to be sent to the ER due to complaining of left hip pain. There were no new or revised interventions to prevent falls reflected in the care plans. 08/14/07 - found in her room on the floor, her left hand had bruising at 6 cm X 2 cm and a scratch to the right knee. There were no new or revised interventions to prevent falls reflected in the care plans. 08/27/17 - found sitting on the floor outside of the exit door to the secured unit. 08/28/17 indicated bruising was noted to bilateral hands, left wrist and right buttocks. There were no new or revised interventions to prevent falls reflected in the care plans. The most recent MDS dated [DATE] indicated Resident #4 had clear speech, adequate vision, made herself understood and was usually understood by others. Resident #4 had severely impaired cognition and demonstrated wandering behavior. According to this MDS, Resident #4 required extensive assistance of one staff person with bed mobility, transfers, dressing and toilet use. Resident #4 was frequently incontinent of bowel and bladder and was not participating in a toileting program and was noted to have repeated falls. The nursing progress notes for Resident #4 indicated the following falls: 10/13/17 at 7:33 a.m. - staff witnessed resident fall in her room attempting to transfer without assistance and landed on her right hip. First aide was provided. There were no new or revised interventions to prevent falls reflected in the care plans. 10/16/17 at 1:20 p.m. , the resident complained of pain to her right hip. There was swelling and bruising noted after a fall and orders received for x-ray which showed [MEDICAL CONDITION]. The incident reports for Resident #4 indicated: 10/10/17 at 7:28 a.m. - fell in her room attempting to transfer without assistance and landed on her right hip. There were no noted injuries. Resident #4 was unable to state what happened due to impaired memory and forgetfulness. 10/11/17 -documentation by the DON in the notes section of this report instructed staff to encourage Resident #4 to call for assistance when transferring self. There were no new interventions to prevent falls. 10/14/17 at 7:40 p.m. - found on the floor in her room and sustained multiple skin tears and had a .hard raised area noted to left superior head . According to this note, Resident #4 said she did not know why she fell due to lack of safety awareness, forgetfulness, confusion and impaired memory. 10/15/17- documentation by the DON in the notes section of this report instructed staff to monitor skin tears for signs or symptoms of infection. There were no new or revised interventions to prevent falls. 10/19/17 at 5:00 p.m. - was found on the bathroom floor with her head against the former of the wall and the wheelchair outside of the door. Resident #4 was not able to state what happened. Per this report, the nurse explained the significance of requesting help before ambulating without assistance. This report indicated the resident was confused with impaired memory. 10/20/17-documentation by the DON in the notes section of this report instructed to continue therapy and monitor for injuries the next 72 hours. There were no new or revised interventions to prevent falls. During an interview on 11/02/17 at 5:49 p.m., the DON said Resident #4 fell on [DATE] and 10/14/17 with fall intervention the same for both, which were to encourage her to ask for assistance and continue therapy initiated 08/30/17 as the result of a fall. The DON said no additional interventions were implemented because Resident #4 was to continue therapy and nursing would comply with any recommendations from that department once they were made. A fall risk assessment dated [DATE] indicated Resident #4 was categorized as a high risk for falls. This assessment indicated Resident #4 had 3 or more falls in the past 3 months. During an interview on 11/02/17 at 10:47 a.m., CNA T said Resident #4 has a lot of falls. She said the only fall intervention was to monitor her every 15 minutes but that could not always be done because they have so many other residents to take care of. CNA T said she did not know if Resident #4 was on a toileting program or not. She said they check on all of the residents every 2 hours. During an interview on 11/02/17 at 12:25 p.m., CNA F said Resident #4 constantly got out of her wheelchair or bed, especially at night. CNA F said she had a low bed and fall mat but no other interventions. CNA F said Resident #4 would use the restroom if staff reminded her, but denied she was on a toileting program. CNA F said it is almost impossible to keep up with Resident #4's location and needs one on one attention because she does not understand she can get hurt, she's confused. During an observation on 11/02/17 at 1:08 p.m., Resident #4 was laying in her bed, the bed was in the highest position, and the fall mat was partially on the floor while the other half was draped across the seat of the wheelchair. Resident #4's call light was not within reach. During an interview on 11/02/17 at 6:12 p.m., the DON said Resident #4 was placed on toileting program as an intervention to the 10/19/17 fall but did not know the date the program started. The DON said most of her falls were her attempting to toilet unassisted. She said Resident #4 was to be toileted every 2 hours, but if the staff would take (Resident #4) to the restroom she may not have as many falls. During an interview on 11/02/17 at 6:12 p.m., the MDS Coordinator asked the DON if she printed the correct care plans and the DON said she was rushing and did had not printed the updated care plans. They said Resident #4's care plans were updated with new interventions but the DON printed the old care plans. During an interview on 11/02/17 at 6:38 p.m., the DON and MDS Coordinator returned and said they printed the most recent care plans that showed the facility's fall interventions. A care plan initiated 06/26/17 with the revision date of 11/02/17 indicated Resident #4 had an actual fall with no injury due to poor balance. The goal was to resume usual activities without further incident through the review date of 09/23/17. Interventions listed were as follows: .Assess for injury, determine and address causative factors of the fall; (initiated 10/09/17 and revised 11/02/17) Check range of motion every shift; (initiated 06/26/17 and revised 06/26/17) PT recertification clarification orders. PT to treat 5 times per week for 4 weeks to meet P[NAME] requirements; (initiated 10/09/17) PT to treat and evaluate (initiated 10/14/17) . The care plan did not address Resident #4's [MEDICAL CONDITION] or toileting program. During an interview on 11/02/17 at 6:41 p.m., the DON said therapy was the fall intervention for Resident #4's fall on 10/14/17. When asked for therapy's evaluation, the DON said therapy was gone for the day and she needed a key to get their records. The ADON and MDS Coordinator said the records were on the computer and could be printed. During an exit interview on 11/02/17 at 7:00 p.m., the BOM, DON and MDS Coordinator were offered the opportunity to scan or fax Resident #4's 10/14/17 therapy notes to be submitted as evidence of addressing the fall. Those records were not received. An abuse prevention program policy revised June, 2005 defined neglect .as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . An undated resident rights policy included . not following the resident's care plan as an example of abuse. The CMS 672 dated 11/02/17 indicated there were 45 residents diagnosed with [REDACTED].