Every finding on record at Ely Manor

Based on interview and record review the facility failed to ensure the Director of Nursing (DON) of record worked full time defined as 40 hours a week and to fulfill DON duties for 3 weeks (from 5/4/2026 to 5/24/2026) resulting in the potential for unmet care needs for all residents who resided in the building during those weeks. Findings include:Review of DON D's timesheet for May 2026 revealed the following during the Monday through Friday work week with DON D working as a charge nurse and the shifts being anywhere from 7-16 hours long:From 5/4/2026 to 5/8/2026, DON D worked 4 of the 5 days on the floor on day/night shiftFrom 5/11/2026 to 5/15/2026, DON D worked 3 of the 5 days on the floor on day/night shiftFrom 5/18/2026 to 5/22/2026, DON D worked 4 of the 5 days on the floor on day/night shiftDuring an interview on 6/25/2026 at 12:40 PM, Registered Nurse (RN) M stated that DON D had to work as a charge nurse on all different shifts when he was the DON at the facility. RN M stated that they don't have any unit managers anymore since they are working as a floor/charge nurse. RN M said that the interim DON was the MDS (Minimum Data Set) nurse (DON) B and she had been pulled to the floor too but not as much as DON D was. During an interview on 6/25/2026 at 1:09 PM, Certified Nursing Assistant (CNA) E stated that DON D worked as a charge nurse a lot on different shifts and wasn't available as a DON. During an interview on 6/25/2026 at 2:12 PM, previous Social Worker (SW) O stated that DON D worked the floor as a charge nurse on different shifts including the night shift because if he didn't work them no one would. SW O said that the only consistent nurse during the day was the MDS nurse who was now covering as interim DON (DON B). SW O reported that DON D could not fulfill DON duties when working all different shifts on the floor. During an interview on 6/26/2026 at 8:18 AM, CNA F stated that DON D worked nights as a charge nurse for at least 1 month. CNA F reported there is no way he could work the floor as a charge nurse and ensure he could do still complete his DON duties.During an interview on 6/26/2026 at 10:57 AM, previous Nursing Home Administrator (NHA) C stated that it was hard to do the residents and staff justice when DON D worked the floor as a charge nurse and he couldn't do his normal DON duties when he was working 8-12-hour shifts. NHA C reported DON D was working the floor as a nurse consistently which included the night shift. During an interview on 6/26/2026 at 1:24 PM, DON B stated that she was the MDS nurse and was working as the interim DON for a few weeks until the new DON started. DON B reported since she didn't have DON experience and was the MDS nurse, corporate staff had been helping her out. DON B said she had to work the cart that afternoon for a few hours and was trying to get a nurse to take over the cart. During an interview on 6/26/2026 at 1:38 PM, RN DD stated that DON D had to cover many empty shifts in the last month before he left the facility and it was tough for him to fulfill his DON duties. During an interview on 6/26/2026 at 2:50 PM, RN L stated that DON D had to cover many shifts on the floor as a nurse and she had to cover shifts too which was why she ended up resigning. During an interview on 6/30/2026 at 7:05 AM, Licensed Practical Nurse (LPN) I stated that DON D worked the night shift as a charge nurse and there was no way he could fully work days or nights as he did for several weeks as a charge nurse and then complete his DON duties. During an interview on 6/30/2026 at 10:21 AM, DON D reported that having enough nurses was challenging so he had to work any open shift whether it was day shift or night shift. When discussing his DON duties, DON D stated he wasn't necessarily able to do much as a DON and couldn't complete risk management duties since he was often working the floor. Review of the DON Job Description signed by DON D on 2/18/2026 revealed .Position Summary: The Director of Nursing plans, coordinates and manages the nursing department. Responsible for overall direction, coordination and evaluation of nursing care and services provided to the residents.For additional information, see F684.

This citation pertains to Intakes #3036506 and #3042881. Based on interview and record review, the facility failed to report within 24 hours to the State Agency 1) an incident of neglect, residents' unadministered medications found in a pharmacy bag with trash in it at the nurses' station on approximately 5/25/26 and 2). Timely report a second incident of neglect of residents' medications not being administered and found unadministered in a dumpster. Findings include:Review of the MI FRI (Michigan Facility Reported Incident) revealed . On June 7, 2026, the administrator {Nursing Home Administrator (NHA) C}received a call from the day shift nurse, {Licensed Practical Nurse (LPN) R}, stating that a pharmacy bag of medications was retrieved from the dumpster and she had concern that {Director of Nursing (DON) D}threw them out. The Administrator immediately went to the facility to begin an investigation. LPN R states that before leaving her shift (on June 6th), she brought to (DON D's) attention that he still had medications left in the cart to pass however his medications were already charted off in the electronic medical record. (DON D) admitted that he had charted the medications; however, had not yet administered the medications. (LPN R) reports that the next day (June 7th) she arrived at work and noted the medications were still in the cart when she completed the hand off report. After hand off report was received, (LPN R) also noted (DON D) to be carrying a pharmacy bag that appeared to be full. (LPN R) was at the nurse's station when she overheard (DON B) ask the unit manager, (LPN I) if she had any duplicate medications, (LPN R) states that (DON D) took a couple of medications that needed to be removed from the cart.then walked down the hall toward the back door, with his personal items and pharmacy bag in hand and said goodbye to the staff. The medication bag was retrieved from the dumpster by housekeeper (H) G . Review of the MI FRI system revealed that the allegation was discovered on 6/7/2026 at 10 AM and it was reported to the State Agency on 6/9/2026 at 12:07 PM. Of note, the incident was reported 2 days after it was discovered. During an interview on 6/26/2026 at 3:35 PM, LPN Q she suspected that DON D didn't pass resident medications multiple times and she along with other staff told NHA C that they thought this was going on for a while, but NHA C stated that she needed proof. LPN Q stated before the incident on the morning of 6/7/2026, there was another incident a few weeks before (wasn't sure of the date) when DON D worked overnight and he put trash in with medications and left it by trash can in a pharmacy bag at the nurses' station and said he was going home. LPN R found the bag of medications, and she wasn't sure if he was hiding unpassed medications or throwing them away. LPN R called the manager LPN I' at the time and LPN I called NHA C. LPN Q stated that NHA C was told about the incident before 6/7/2026 and she acted like no one reported the previous incident to her. LPN Q said she was very upset and the other nurses were too since NHA C didn't do anything about it before so she told NHA C that something had to be done and DON D's license had to be reported and if she didn't do anything about it she would. During an interview on 6/26/2026 at 4:18 PM, LPN R stated that DON D admitted that he didn't give lots of people their medications and then said he probably made mistakes before like some other nurses. LPN R stated there was another incident a few weeks before the incident on 6/7/2026 (couldn't remember the date) where DON D had trash on top of medications by the trash can and this was reported to LPN I who notified NHA C. LPN R stated that she was told by NHA C that there was no proof that he was going to throw them away and these medications could be duplicates. During an interview on 6/30/2026 at 7:05 AM, LPN I stated there was another incident a few weeks before the incident on 6/7/2026 that was brought to her attention where DON D had medications in a pharmacy bag with trash on top and she reported this to NHA C and NHA C stated those were duplicates because she talked to him. NHA C said she would keep an eye on DON D. During an interview on 6/30/2026 at 8:37 AM, LPN J was asked about any other incidents with DON D besides the one that was reported on 6/7/2026 and she stated Yes, on 5/25/2026. Memorial Day. LPN J reported that the same thing as 6/7/2026 occurred where there was a pharmacy bag with medications and trash on top at the nurses' station by the trash can. LPN J stated that NHA C mentioned before that she needed proof that DON D wasn't passing medications and this was the first time they had proof. It was reported to LPN I who then reported it to NHA C. LPN J stated that she didn't know what NHA C did about it. LPN J also reported that residents complained of not getting medications on nights before that when DON D worked, but NHA C said again that she needed proof this was occurring. On 6/30/2026 at 9:27 AM, a text communication was received from NHA C .There were no other incidents of the DON throwing out medication that I am aware of.During an interview on 6/30/2025 at 9:45 AM, RNC AA stated that there was another incident related to DON D not passing medications and LPN I told NHA C about it. RNC AA reported that the medications were locked in LPN I's office until they could review them. RNC AA stated that NHA C and her talked with DON D and he said those medications were duplicates and there weren't any narcotics. RNC AA said she then contacted Pharmacist (P) EE who said she would look at the medications. During a follow up interview on 6/30/2026 at 10:00 AM, RNC AA stated that the conversation she had with NHA C and DON D wasn't documented and the date was 5/22/2026. During an interview on 6/30/2026 at 12:31 PM, P EE stated that DON D did not call her about duplicate resident medications on 5/22/2026, 5/25/2026 or 6/6/2026 but she spoke to him when she was there for the monthly QAPI (Quality Assurance and Performance Improvement) meeting on 5/12/2026 before both incidents and DON D expressed concerns about duplicate medications and asked her to talk to the floor nurses. P EE reported that in June, RNC AA reached out to her regarding looking at duplicate resident medications and she couldn't find any evidence of duplicate medications besides an antibiotic medication since the nurse and doctor both wrote orders. During an interview on 6/30/2026 at 2:03 PM, RNC AA stated that she was told by P EE that there were duplicate medications when she did a review of the resident medications on 6/10/2026. Review of the Abuse Prohibition Policy with a revision date of 9/9/2022 revealed .Misappropriation of guest/resident property means that deliberate misplacement, exploitation, or wrongful, temporary or permanent use of guest's/resident's belongings or money without the guest's/resident's consent. G. Reporting abuse and facility response to the allegation: 1. The staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown source to the Administrator and DON immediately. 2. The Administrator or designee will notify the guest's/resident's representative. Also, any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury; all others not later than 24 hours). At the conclusion of the investigation, and no later than 5 working days of the incident, the facility must report the results of the investigation and if the alleged violation is verified, take corrective action.4. In cases of abuse, neglect, misappropriation of guest/resident property, and exploitation, the Quality Assurance Performance Improvement Committee will review the circumstances to determine if changes in policies and procedures are necessary to provide further preventative measures. All cases will be reviewed at the QAPI meetings.

This citation pertains to intake numbers 3036506 and 3042881. Based on interview and record review, the facility failed to maintain the highest practicable resident well-being by ensuring facility staff administered resident medications as ordered by the physician in 11 of 18 residents (Resident #8, #11, #6, #12, #13, #10, #16, #17, #18, #14, and #15) reviewed for medication administration, resulting in unmet medical needs and the potential for medical complication for affected residents. Findings include:Review of the MI FRI (Michigan Facility Reported Incident) revealed . On June 7, 2026, the administrator {Nursing Home Administrator (NHA) C}received a call from the day shift nurse, {Licensed Practical Nurse (LPN) R}, stating that a pharmacy bag of medications was retrieved from the dumpster and she had concern that {Director of Nursing (DON) D}threw them out. The Administrator immediately went to the facility to begin an investigation. LPN R states that before leaving her shift (on June 6th), she brought to (DON D's) attention that he still had medications left in the cart to pass however his medications were already charted off in the electronic medical record. (DON D) admitted that he had charted the medications; however, had not yet administered the medications. (LPN R) reports that the next day (June 7th) she arrived at work and noted the medications were still in the cart when she completed the hand off report. After hand off report was received, (LPN R) also noted (DON D) to be carrying a pharmacy bag that appeared to be full. (LPN R) was at the nurse's station when she overheard (DON B) ask the unit manager, (LPN I) if she had any duplicate medications, (LPN R) states that (DON D) took a couple of medications that needed to be removed from the cart.then walked down the hall toward the back door, with his personal items and pharmacy bag in hand and said goodbye to the staff. The medication bag was retrieved from the dumpster by housekeeper (H) G . According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.Health care provider- initiated interventions are dependent nursing interventions, or actions that require an order from a health care provider. The interventions are based on the health care provider's response to treating or managing a medical diagnosis .As a nurse you intervene by carrying out the health care provider's written and/or verbal orders. Administering a medication. Accessed from: Kindle Locations 16678-16684). Elsevier Health Sciences. Kindle Edition During an interview on 6/26/2026 at 8:18 AM, Certified Nursing Assistant (CNA) F stated that she worked the morning of 6/7/2026 and she heard the nurses talking with each other and they put things together that DON D did not administer medications overnight. When asked if there were complaints from residents or if she noted any changes in residents that morning, CNA F reported that some residents had behaviors/hallucinations from not getting medications or were in pain and some residents complained of not receiving medications, so she told her nurse (Agency LPN P). CNA F stated that Resident #8 was hallucinating from not receiving his medications he saw spiders that were trying to eat him and he was screaming. CNA F said Resident #8 was taken out of his room since he was bed bound. CNA F stated that residents eventually got their medications later on 6/7/2026 and they started to calm down but it took 2 to 3 days to get back to normal. CNA F mentioned that there was a list of resident complaints from that night due to them not getting their medications but she didn't know what happened to it. During an interview on 6/26/2026 at 8:48 AM, LPN P stated on the morning of 6/7/2026, she was told that residents didn't get their night medications so one of the nurses (LPN) R reported it to NHA C. LPN P stated that Resident #10 stated she was in pain that morning since she didn't receive her pain medication overnight, so she was given it and was okay. During an interview on 6/26/2026 at 8:55 AM, Regional Director of Operations (RDO) S stated that NHA C called her on 6/7/2026 at 9:22 AM and reported that there was an issue with resident medications and they were retrieved from the dumpster. RDO S stated that NHA C came into the building to start the investigation and then suspended and terminated DON D. She said the interim DON (DON) B who was currently the MDS (Minimum Data Set) nurse was filling in until the new DON started. During an interview on 6/26/2026 at 10:57 AM, NHA C stated on 6/7/2026, LPN R reported to her that medications were not passed by DON D the night before and he threw them in the dumpster. So, NHA C came in that day to start an investigation. NHA C stated that this was the first time she heard of DON D not passing medications and throwing them out. NHA C reported that no residents had negative effects from the missing medications since she went over the medications prescribed, determined what was not given and didn't think anything else needed to be done since the residents were monitored by the nurses on the floor. NHA C said she called Medical Director (MD) BB, and she said she wasn't concerned about missing 1 medication and had no new orders to give. When asked what medications were not given, NHA C stated some vitamins, Tylenol, blood thinners, behavioral and pain medications but she didn't think residents had negative outcomes from it. During an interview on 6/26/2026 at 12:27 PM, Nurse Practitioner (NP) CC reported that she heard about the incident overnight on 6/6/2026 but she wasn't involved with it since MD BB was called about it. NP CC stated she didn't know the names of residents and the medications that were not given. During an interview on 6/26/2026 at 3:35 PM, LPN Q stated that she worked on the morning of 6/7/2026 when the medications were found to not be passed by DON D and he threw them in the dumpster. LPN Q said that she suspected that DON D didn't pass resident medications multiple times and she along with other staff told NHA C that they thought this was going on for a while, but NHA C stated that she needed proof. LPN Q stated before the incident on the morning of 6/7/2026, there was another incident a few weeks before (wasn't sure of the date) when DON D worked overnight and he put trash in with medications and left it by trash can in a pharmacy bag at the nurses' station and said he was going home. LPN R found the bag of medications, and she wasn't sure if he was hiding unpassed medications or throwing them away. LPN R called the manager LPN I' at the time and LPN I called NHA C. The 2nd time this happened on 6/7/2026 in the morning, LPN Q told H G to get the medications out of the dumpster that DON D threw out, and LPN R called NHA C to report what happened. LPN Q reported that DON D clicked that medications were given in the computer when they were not. LPN Q stated that NHA C was told about the other incident before 6/7/2026 and she acted like no one reported the previous incident to her. LPN Q said she was very upset and the other nurses were too since NHA C didn't do anything about it before so she told NHA C that something had to be done and DON D's license had to be reported and if she didn't do anything about it she would. During an interview on 6/26/2026 at 3:54 PM, H G stated on 6/7/2026 in the morning DON D left with a pharmacy bag and said he would see everyone later since he was working 3rd shift that night. H G reported that LPN Q asked him to get the pharmacy bag out of the dumpster. H G stated that the bag was placed in the back of dumpster and it was open and upside down, so he had to get something to get it out of the dumpster. Then, he took the bag to LPN Q and LPN R and he saw several packages of unopened resident medications since there were some names on them, and it was dated 6/6/2026. Then, H G said NHA C came to the facility to investigate. During an interview on 6/26/2026 at 4:18 PM, LPN R stated that she worked until 10pm on 6/6/2026 and DON D came in at 6pm and they shared a cart until 10pm. Before LPN R left at 10pm, she counted medications with DON D and noted that DON D still had all the medications on A hall to pass since they were still sitting in the cart and she reminded him to pass them and he said he would do it. Then, when she came in the next morning on 6/7/2026, LPN R spoke with LPN I and mentioned that she thought he didn't go back and pass the medications to the residents on A hall. LPN I told LPN R that sometimes DON D got ahead of himself and clicked the medications before they were given. Then, LPN R observed DON D walk over with a pharmacy bag and put it by the trash. DON D then asked LPN I if she had duplicate medications and she handed him some and he put it in the bag and said he would show NHA C that he didn't throw any medications away. LPN R reported that DON D admitted that he didn't give lots of people their medications and then said he probably made mistakes before like some other nurses then walked away with the pharmacy bag, went out to the dumpster and that was when H G retrieved the pharmacy bag from the dumpster. Then, LPN R called to report this to NHA C and she said she would come in. LPN R stated there was another incident a few weeks before (couldn't remember the date) where DON D had trash on top of medications by the trashcan and this was reported to LPN I who notified NHA C. LPN R stated that she was told by NHA C that there was no proof that he was going to throw them away and that these medications could have been duplicates. During an interview on 6/26/2026 at 5:00 PM, Regional Nurse Consultant (RNC) AA stated that she thought there was a list of residents who didn't get their medications overnight on 6/6/2026 and what the medications were but she couldn't find it and then said maybe she was thinking about another building. During an interview on 6/29/2026 at 8:50 AM, MD BB stated that NHA C called her on 6/7/2026 and told her that DON D worked the previous night and ended up not giving medications and signed out that he gave them and put them in the trash. MD BB asked if this surveyor spoke with NP CC' about the details of this incident because she might have more information and this surveyor stated that NP CC told her that she only knew about the incident but wasn't involved with it. MD BB reported that she sent an email on 6/8/2026 when she was on vacation to all the NPs about the missed medications and said most likely nothing needs to be done but to get a list of all the residents and the medications. MD BB stated that she also asked NHA C to provide a list of the residents and the medications that were missed and she didn't hear anything more after that, and when she came back from vacation there were management changes. During an interview on 6/30/2026 at 7:05 AM, LPN I stated that she worked many night shifts and on opposite halls as DON D when he worked nights and she didn't see anything that night. On 6/7/2026 in the morning, the day shift nurses reported to her that DON D took resident medications, put them in the trash, and then LPN R reported this to the NHA. LPN I stated there was another incident a few weeks before that was brought to her attention where DON D had medications in a pharmacy bag with trash on top and she reported this to NHA C, and NHA C stated those were duplicates because she talked to him. NHA C said she would keep an eye on DON D. During an interview on 6/30/2026 at 8:30 AM, RNC AA showed this surveyor a 1-page list of resident names and a comment about their missed medications on 6/6/2026. This was completed on 6/29/2026 by RNC AA. RNC AA said she couldn't find the list of residents and the medications that were missed that NHA C had and she knew there was a list. During an interview on 6/30/2026 at 8:37 AM, LPN J was asked about any other incidents with DON D besides the one that was reported on 6/7/2026 and she stated Yes, on 5/25/2026. Memorial Day. LPN J reported that the same thing as 6/7/2026 occurred where there was a pharmacy bag with medications and trash on top at the nurses' station by the trash can. LPN J stated that NHA C mentioned before that she needed proof that DON D wasn't passing medications and this was the first time they had proof. It was reported to LPN I who then reported it to NHA C. LPN J stated that she didn't know what NHA C did about it. LPN J also reported that residents complained of not getting medications on nights before that when DON D worked, but NHA C said again that she needed proof this was occurring. On 6/30/2026 at 9:27 AM, a text communication was received from NHA C that revealed .I printed the MARs (Medication Administration Record) and reviewed and compared it with each medication that was found. They were in my office. I gave the Medical Director (MD CC) an overview of the medications verbally over the phone. There were no other incidents of the DON throwing out medication that I am aware of. During an interview on 6/30/2025 at 9:45 AM, RNC AA stated that there was another incident related to DON D not passing medications and LPN I told NHA C about it. RNC AA reported that the medications were locked in LPN I's office until they could review them. RNC AA stated that NHA C and her talked with DON D and he said the medications were duplicates and there weren't any narcotics. RNC AA said she then contacted Pharmacist (P) EE who said she would look at the medications. During a follow up interview on 6/30/2026 at 10:00 AM, RNC AA stated that the conversation she had with NHA C and DON D wasn't documented and the date was 5/22/2026. During an interview on 6/30/2026 at 10:21 AM, DON D stated that he worked the night shift from 6/6/2026 to 6/7/2026 and left in the morning and then NHA C called him and said he didn't give medications to residents overnight. DON D reported that he gave all the residents their medications and I have a problem with the nurse (LPN Q) that went to her (NHA C). DON B stated that he did everything by the book that night, passed meds and signed out everything in the MAR. DON D said that he signed out medications before giving it to the residents but ended up giving it to them before he left at the end of his shift. DON D stated that Resident #10 was the only resident with a complaint that she didn't receive her medications yet and he ended up giving them to her. When further queried about medications, DON D reported that the pharmacy sent duplicate medications many times, so he saved them to return to the pharmacy, and he called to let the pharmacy know (he wasn't sure of the date he called them). DON D said he left the duplicate medications in NHA C's office and they were supposed to start a log of duplicate medications, but they didn't. When asked about the medications found in the dumpster on 6/7/2026 in the morning, DON D stated that he did not put it there and I don't recall putting it in there. When queried about Resident #8's medications including behavioral medications that were not administered and the medications were sealed in a package, DON D stated that he did administer them and not sure why the medications were sealed. When further discussion occurred regarding 20 medication packs that were dated 6/6/2026 and were sealed and not administered, DON D stated that he wasn't sure why they were sealed and said, I gave them all. When discussing again that the night medications were to be given to the residents under his watch and 20 packs of medications were sealed and not given and whether it was fair to say those medications weren't administered, DON D said Yes. During an interview on 6/30/2026 at 12:31 PM, P EE stated that DON D did not call her about duplicate resident medications on 5/22/2026, 5/25/2026 or 6/6/2026 but she spoke to him when she was there for the monthly QAPI (Quality Assurance and Performance Improvement) meeting on 5/12/2026 before both incidents occurred and DON D expressed concerns about duplicate medications and asked her to talk to the floor nurses. P EE reported that in June RNC AA reached out to her regarding looking at duplicate resident medications and she couldn't find any evidence of duplicate medications besides an antibiotic medication since the nurse and doctor both wrote orders. During an interview on 6/30/2026 at 2:03 PM, RNC AA stated that she was told by P EE that there were duplicate medications when she did a review of the resident medications on 6/10/2026. Resident #10 Review of the June 2026 Medication Administration Record (MAR) revealed Resident #10 was scheduled to receive Percocet 5/325mg on 6/6/26 at 8:00pm. The medication was documented as administered by Previous Director of Nursing (DON) D. Review of the Controlled Drug Disposition form, June 2026 revealed Resident #10's Percocet was not signed out by DON D as administered and the document had accurate medication counts, indicating it was never administered on 6/6/26 at 8:00pm. Resident #16 Review of the June 2026 MAR revealed Resident #16 was scheduled to receive Morphine Oral Concentrate 20mg/ml, 15mg every 4 hours for pain on 6/6/26 at 9:00pm and documented as administered by DON D. Review of the Controlled Drug Disposition form, June 2026 revealed Resident #16's Morphine was not signed out by DON D as administered and the document had accurate medication counts, indicating it was never administered on 6/6/26. Resident #17 Review of the June 2026 MAR revealed Resident #17 was scheduled to receive Lacosamide 100mg (anticonvulsant) at bedtime on 6/6/26 and was documented as administered by DON D. Review of the Controlled Drug Disposition form, June 2026 revealed Resident #17's Lacosamide was not signed out by DON D as administered and the document had accurate medication counts, indicating it was never administered on 6/6/26. Resident #18 Review of the June 2026 MAR revealed Resident #18 was scheduled to receive Ativan 0.5mg (for anxiety) on 6/6/26 at 8:00pm and was documented as administered by DON D. Review of the Controlled Drug Disposition form, June 2026 revealed Resident #18's Ativan was not signed out by DON D as administered and the document had accurate medication counts, indicating it was never administered on 6/6/26. Resident #14 Review of the June 2026 MAR revealed Resident #14 was scheduled to receive Clonazepam 0.5mg (for anxiety) on 6/6/26 at bedtime and was documented as administered by DON D. Review of the Controlled Drug Disposition form, June 2026 revealed Resident #14's Clonazepam was not signed out by DON D as administered and the document had accurate medication counts, indicating it was never administered on 6/6/26. Resident #15 Review of the June 2026 MAR revealed Resident #15 was scheduled to receive Tramadol HCI 50mg (for pain) on 6/6/26 at 8:00pm and was documented as administered by DON D. Review of the Controlled Drug Disposition form, June 2026 revealed Resident #15's Tramadol was not signed out by DON D as administered and the document had accurate medication counts, indicating it was never administered on 6/6/26. Resident #13 – controlled medication Review of the June 2026 MAR revealed Resident #13 was scheduled to receive Ativan 0.5mg (for anxiety) on 6/6/26 at 8:00pm, documented as administered by DON D on 6/6/26 at 9:16pm. Review of the Controlled Drug Disposition form, June 2026 revealed Resident #13's Ativan was not signed out by DON D as administered and the document had accurate medication counts, indicating it was never administered on 6/6/26. Review of an email correspondence from Previous Nursing Home Administrator (NHA) C revealed DON D had documented in PCC (Electronic Medication Administration Record) (the administration of the scheduled medications) however NEVER PULLED the narcotic. All medications documented below were located in a bag in the dumpster by facility staff and were sealed in plastic bags labeled with the residents' names and were unopened and unadministered by DON D. Resident #13 Review of the Face Sheet revealed Resident #13 was admitted with diagnosis that included peripheral vascular disease, history of a heart attack, transischemic attacks (brief blood blockage to brain causing stroke-like symptoms) and stroke. Resident #13's Blood Pressure Graph indicated her average blood pressure was 120/70mm/Hg. Review of the June 2026 MAR revealed Resident #13 was scheduled to receive Ticagrelor 90mg (antiplatelet medication used to prevent clots after heart stent placement) and Metoprolol Tartrate 25mg (blood pressure medication) on 6/6/26 at 8:00pm, documented as administered by DON D on 6/6/26 at 9:16pm. Review of the Blood Pressure Summary dated June 2026 revealed Resident #13's blood pressure was 127/71mm/Hg on 6/6/26 at 9:58am, on 6/7/26 at 10:22am and 10:23am, it was 163/87mm/Hg (elevated). Resident #8 Review of the Face Sheet revealed Resident #8 was admitted to the facility with diagnosis that included bipolar disorder, dementia, schizophrenia, benign prostate hyperplasia (enlarged prostate), depression, high blood pressure, and post traumatic stress disorder (PTSD). Review of the June 2026 MAR revealed Resident #8 was scheduled to receive Divalproex Sodium 500mg (for bipolar disease), Flomax 0.4mg (for enlarged prostate) and Amitiza 24mcg (for constipation) on 6/6/26 at 7:00pm, documented as administered on 6/6/26 at 9:11pm. Seroquel 400mg (antipsychotic mood stabilizer), Jardiance 10 mg (diabetic medication) on 6/6/26 at 8:00pm, documented as administered on 6/6/26 at 9:11pm. Metformin MCI 500mg (diabetic medication) Ezetimibe 10mg (cholesterol medication) and Paliperidone ER 3mg (treats schizophrenia) on 6/6/26 at 9:00pm, documented as administered on 6/6/26 at 9:11pm. Review of the Laboratory report dated 12/10/25 revealed Resident #8's Depakote level was low at 32.5 ug/ml (normal 50-100 ug/ml). There were no other laboratory documents for Depakote levels in the resident's medical record. Resident #11 Review of the June 2026 MAR revealed Resident #11 was scheduled to receive Levetiracetam 500mg (seizure medication) on 6/6/26 at 7:00pm. Carbamazepine 200mg (seizure medication), Aricept 10mg (for dementia), Mirtazapine 15mg (appetite stimulant) and Bupropion HCI 100mg (for depression) on 6/6/26 at 8:00pm. All medications were documented as administered by DON D on 6/7/26 at 1:37am except Carbamazepine 200mg which was documented as administered by DON D at 9:14pm on 6/6/26. There was no indication why the other 8:00pm medications were not administered at the same time. Review of the Laboratory report dated 4/8/26 revealed Resident #11's Carbamazepine level was 10.1ug/ml (normal range 4.0-12.0 ug/ml). There were no other documents to indicate whether Resident #11's medication levels were rechecked after 6/6/26. Resident #6 Review of the Face Sheet revealed Resident #6 was admitted to the facility with diagnoses that included history of a stroke, long term use of anticoagulants, venous thrombosis (blood clot), diabetes with polyneuropathy (nerve pain), and breast cancer. Review of the June 2026 MAR revealed Resident #6 was scheduled to received Gabapentin 600mg (for nerve pain), Apixaban 5 mg (anticoagulant), and Clopidogrel Bisulfate 75mg (anticoagulant – resident history of venous thrombosis) on 6/6/26 at 8:00pm. The medications were documented as administered on 6/6/26 at 9:04pm by DON D. Resident #12 Review of the Face Sheet revealed Resident #12 was admitted with diagnoses that included [NAME] syndrome (endocrine medical condition causes high blood pressure), and heart failure. Resident #12's Blood Pressure Graph indicated her average blood pressure was 140/75mm/Hg. Review of the June 2026 MAR revealed Resident #12 was scheduled to receive Hydralazine HCI 100mg (blood pressure medication) and Metoprolol Succinate 25mg (blood pressure medication) on 6/6/26 at 9:00pm, documented as administered by DON D on 6/6/26 at 9:17pm and 10:38 pm respectively. Review of the Blood Pressure Summary dated June 2026 revealed Resident #12's blood pressure was elevated at 169/73mm/Hg on 6/7/26 at 8:24 am, checked twice by facility staff for accuracy. It was documented on 6/6/26 as 133/76mm/Hg at 10:12am. There was no documentation in the Progress Notes or any other location in the medical record to indicate that any residents who did not receive their scheduled medications were thoroughly monitored by facility staff or a medical practitioner after the failure to administer medication occurred on 6/6/26 to ensure medical complications did not occur. Review of the Medication Management Policy with a revision date of 9/22/2023 revealed Medications are stored, dispensed and destroyed in a manner to ensure safety and conformance with state federal laws. 5. Medications discontinued are maintained in a secured area until returned to pharmacy or destroyed.8. Non- controlled medications prepared, but not administered, are disposed of according to state law/guidelines. Controlled medications prepared, but not administered must be witnessed and countersigned by a licensed nurse on the controlled drug inventory sheet. 11. Medications will be dated and discarded per manufactures guidelines.

This citation pertains to intake #2988597.Based on interview and record review, the facility issued an against medical advice (AMA) form when transferring a resident to the hospital and failed to permit 1 resident (Resident #3) of 3 residents reviewed for discharges to return to the facility resulting in the guardian having to find placement elsewhere.Findings include: Resident #3 (R3)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R3 was a [AGE] year-old man who had an initial admission date of 3/4/2026 with pertinent diagnoses including dementia (a group of symptoms including memory loss, confusion, and impaired reasoning that interferes with daily life), anxiety, depression and right BKA (below knee amputation). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R3 was cognitively intact. During an interview on 6/25/2026 at 9:01 AM, Hospital Social Worker (HSW) U stated on 5/11/2026 R3 went to the hospital from the facility, and he signed himself out when he wasn't his own decision maker. HSW U reported that the facility refused to take him (R3) back which is against the rules since he isn't his own decision maker and needed the guardian to sign off on it.Review of R3's chart revealed that Family Member (FM) GG was his court appointed guardian as of 5/19/2025.Review of R3's chart revealed that he was in and out of the hospital during his stay at the facility with his last transfer to the hospital on 5/11/2026. Review of R3's Discharge AMA form dated 5/11/2026 revealed .The resident/Legal Representative understands the following with regard to this decision: 1) The resident's physician and the IDT (Interdisciplinary Team) DO NOT RECOMMEND THIS COURSE OF ACTION. 2) The physician and IDT believe that there is a HIGH RISK that the resident may suffer a SERIOUS NEGATIVE HEALTH OUTCOME without the recommended care and services. 3) Such serious negative health outcomes may include, but are not limited to: [Describe below the specific risks related to the resident's diagnosis - e.g., the resident requires assistance to transfer and has a high risk of falls, etc.]. 4) The resident and/or the Resident's Legal Representative has had the opportunity to meet with representatives of the Facility. The Facility has explained the reasons why it advises against the resident discharging the community AMA, and the resident/Legal Representative has had the opportunity to ask questions about the consequences of the decision that he/she is making. The resident/Legal Representative has had all of his/her questions answered to his/her satisfaction. 5) Discharge Planning: Discharge planning was attempted, and the resident was provided with a copy, or Discharge planning was attempted, and the resident refused to participate and/or take a copy. The form was not filled out besides R3's name and signature, a written statement (FM GG) guardian aware of decision and Registered Nurse (RN) DD signature.Review of R3's transfer to the hospital paperwork dated 5/11/2026 included a Bed Hold Authorization form that R3 signed upon transfer to the hospital, and it was signed by RN N. The daily rate for the bed hold was blank and there was no notation that the guardian was notified of the bed hold.Review of R3's progress noted dated 5/11/2026 documented by RN DD revealed Resident (R3) yelling at staff stating I'm f******calling 911.I don't feel good and the hospital I was just at didn't do anything for me.I'm leaving and no one is stopping me. This writer attempted to assess resident and he continued to yell. VS (vital signs) were taken as resident allowed, they are stable. Phone call to guardian, (FM GG) to discuss. Explained situation and explained resident states he is going to the hospital AMA. Guardian states he will call his dad to discuss but his dad might not listen and guardian states it is his decision if he wants to go. This writer explained if resident goes AMA, he will have to find another placement. Resident called 911 for ambulance. Resident signed AMA form, guardian aware of AMA status and need to find new placement.on call manager and administrator aware.Review of R3's Care Plan revealed .Focus: (R3) has an actual behavior problem AEB (as evidenced by) yelling/screaming at staff, making inappropriate comments, refusing care r/t (related to) dx (diagnosis) dementia with agitation.During an interview on 6/25/2026 at 12:16 PM, FM GG stated on 5/11/2026 the facility called him and said R3 was unhappy and didn't feel good, so he called 911. FM GG reported that the nurse (RN DD) said since R3 was going to the hospital and they didn't think he needed to go, it was going to be AMA. FM GG reported that he thought R3 signed a bed hold form even though he was the guardian, but he didn't think he was called about it. FM GG said he didn't know why the bed hold form was given when the facility didn't take him back. FM GG stated that he wasn't sure why the facility didn't take him back and he wanted R3 to go back to the facility since it was close for him to visit instead of any other facility. During an interview on 6/25/2026 at 2:12 PM, previous Social Worker (SW) O stated on 5/11/2026, R3 was having behavior difficulties and demanded to go to hospital and came back and then wanted to go again to another hospital. SW O reported that the previous Nursing Home Administrator (NHA) C stated that R3 could go to the hospital, but it would be AMA and they wouldn't take him back. SW O stated that she wasn't sure why NHA C said R3 couldn't come back from the hospital, but she thought it was because of his behaviors. When discussing R3's need for FM GG to be his guardian, SW O stated R3's couldn't make good decisions due to his behaviors and mental illness. SW O reported that she couldn't find a pattern with what made R3 unhappy and he needed a lot of attention so that could have been hard for the staff. SW O mentioned that the AMA policy and form should not be used when a resident goes to the hospital, but when they go home AMA. During an interview on 6/26/2026 at 10:57 AM, NHA C stated that R3 had behaviors and was noncompliant and didn't want to follow the rules when he was at the facility. NHA C reported that on 5/11/2026 she thought R3 signed AMA paperwork by his choice and that he didn't want to come back. NHA C said there was no one in admissions at that time and the facility would consider not taking a resident back if they were in and out of the hospital a lot. NHA C thought that they allowed R3 to come back to the facility. During an interview on 6/26/2026 at 12:27 PM, Nurse Practitioner (NP) CC stated that R3 was in and out of the hospital a few times since admission and requested to go sometimes. She stated that R3 had a left BKA recently and it was being treated with antibiotics due to an infection. NP CC reported on 5/11/2026 R3 was upset so he called 911 to be taken to the hospital, When discussing R3 and the AMA papers, NP CC stated that AMA paperwork wasn't typically filled out when a resident went to the hospital. NP CC said she was told that R3 went to the hospital AMA and wasn't really involved with it. During an interview on 6/26/2026 at 1:38 PM, RN DD stated that R3 had behaviors and would cuss and yell at staff and wanted things a certain way. RN DD reported on 5/11/2026, R3 said he wanted to go to hospital so she talked to management (couldn't remember who it was and if it was on the phone or in person) and she was told to fill out AMA paperwork and to tell FM GG that they couldn't take him back without another referral. During an interview on 6/26/2026 at 2:05 PM, Regional Director of Operations (RDO) S stated that AMA paperwork was done when it wasn't safe for a resident to leave the facility. RDO S reported that R3 wanted to go to the hospital, but the facility should have accepted him back. During an interview on 6/29/2026 at 8:50 AM, Medical Director (MD) BB stated that she didn't think an AMA form should be completed when a resident went to the hospital and she wasn't aware of the situation with R3. During an interview on 6/30/2026 at 7:05 AM, Licensed Practical Nurse (LPN) I stated that R3 wanted to go to the hospital on 5/11/2026 and as far she knew he was allowed to come back to the facility. When discussing AMA paperwork for R3, LPN I said AMA paperwork should be filled out when they went home and if it wasn't safe for them, not when they go to the hospital.During an interview on 6/30/2026 at 9:58 AM, RN N stated that she couldn't remember what happened on 5/11/2026 with R3 and she didn't remember doing the bed hold form with R3. RN N reported that RN DD was the charge nurse that day. During an interview on 6/30/2026 at 10:21 AM, previous Director of Nursing (DON) D stated that he thought the decision from NHA C was to not take R3 back from the hospital. Review of the Resident Leave of Absence Policy with a review date of 11/16/2022 revealed .V. Possible Discharge. 1. A Resident's Leave of Absence, including a Leave of Absence Against Medical Advice, shall not be considered a discharge from the Facility unless the Resident him/herself provides a verbal or written notice of his/her intention to leave the Facility permanently. If a Resident and/or a Resident's Responsible Party desires to Discharge Against Medical Advice, and the Resident has the capacity to make healthcare decisions, the Resident shall be educated regarding the reasons why the discharge is not recommended and the potential risks involved, and be given the opportunity to ask questions regarding the consequences of his/her decision. The Resident and/or Resident's Responsible Party shall also be asked to sign the Discharge Against Medical Advice form.

Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: On 9/22/25 at 9:05 AM, Observation of the walk-in cooler found an open container of sour cream with a best by date of 8/25/25.On 9/22/25 at 9:10 AM, Observation of the three door True cooler found an open box of nutritional juices, mighty shakes, and reduced sugar mighty shakes, containing dozens of cartons intermingled. When asked how many days the items are good for, Certified Dietary Manager (CDM) T stated, I think they are good for 30 days. A review of the manufacturer's directions for use found that the items are only good 14 days from thaw. When asked how they track how long the items have been in the fridge, CDM T stated that normally the box gets dated, but the only date found on the box was the receive by date of 7/11. When asked if she knew when this box was pulled from the freezer, CDM T was unsure. On 9/22/25 at 9:52 AM, Observation of the Memory Care Unit (MCU) pantry fridge found two open containers of Vanilla Med Pass 2.0 with no date to indicate discard of the items. A review of the manufacturers' directions for use found that the item should be consumed within 4 days under refrigeration.On 9/22/25 at 10:00 AM, Observation of the A-side pantry found a carton of milk with the best by date of 9/14/25. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .On 9/22/25 at 9:18 AM, An interview with CDM T found that clean pots and pans are stored on an open wire rack in the corner of the kitchen. A review of this area found two 1/2 pans stacked and stored wet.On 9/22/25 at 3:49 PM, A follow up tour of the kitchen found two 1/4 pans and one 1/2 pan stacked and stored wet. According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD.On 9/22/25 at 9:22 AM, Observation of the steam table found it had a container catching water as it dripped from the corner of the steam table onto the floor. An interview with CDM T found that one of the wells of the steam table had a small pinhole, so staff have to refill the well a few times throughout the day. When asked how long the leak had been going on, CDM T stated it's been going on since she started a couple months ago. On 9/22/25 at 9:38 AM, Observation of the hot water line under the dish machine found that it was leaking a steady stream onto the floor and into a nearby floor drain.According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.On 9/22/25 at 9:33 AM, Observation of the clean utensil drawers found two drawers containing mechanical scoops and serving spoons with an accumulation of crumb debris in the floor and back of the drawers. An interview with CDM T found that staff should be cleaning these out daily. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 9/22/25 at 9:54 AM, Observation of the MCU pantry found an ice chest used for hydration pass. An interview with CDM T found that with the ice machine being down right now, staff have to fill up the coolers with bags of ice and stick them in the pantry to be used for resident hydration pass. When asked whose responsibility it is to take care of the ice coolers, CDM T stated that kitchen staff are responsible for filling them, cleaning the coolers/scoops, and stocking them with ice. At this time, the bottom of the cooler had roughly an inch of water in the bottom with a layer of ice floating on top of the water and no way to self-drain or allow the separation of the water and ice. According to the 2022 FDA Food Code section 3-303.12 Storage or Display of Food in Contact with Water or Ice.(B) Except as specified in (C) and (D) of this section, unPACKAGED FOOD may not be stored in direct contact with undrained ice. On 9/22/25 at 9:36 AM, Observation of the dish machine found that it did not hit the required minimum temperatures for the hot water sanitizing rinse. Running the unit three times found contact temperatures ranging between 153F-158F, while requiring a contact of 160F or higher. A record review of the document entitled, Dish Machine High Temperature Log, dated September 2025, found that the Rinse Temp: Minimum 180F (for hot water before it enters the dish machine). A review of the log, listing wash and rinse temperatures for breakfast, lunch, and dinner, found that 41 logged sanitizing rinse temperatures were below the minimum requirement of 180F. According to the 2022 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F), or less than:.(2) For all other machines, 82C (180F).On 9/22/25 at 9:48 AM, observation of the dry storage room found boxes of food items stored on the floor near storage racks. When asked about the food items stored on the floor, CDM T stated that the delivery had come in on Friday (9/19) and she wasn't here over the weekend to put stock away. According to the 2022 FDA Food Code section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.

Based on interview and record review, the facility failed to ensure the Medical Director fulfilled their responsibility of implementing Medication Regimen Review (MRR) policies/procedures to include coordination of care between the facility and the consulting pharmacist/pharmacy for 2 (Resident #3 and Resident #51) of 5 residents reviewed for medications. This deficient practice has the potential to affect all residents that reside at the facility. Findings include: Resident #3Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety disorder. Review of Resident #3's Medication Regimen Review (MRR) dated 6/11/25 revealed, (Resident #3) is receiving Seroquel (antipsychotic medication). Epidemiological studies suggest an increased risk of hyperglycemia (high blood sugar levels)-related adverse effects during atypical antipsychotic use .Recommendation: Please consider obtaining a fasting lipid panel on the next convenient lab day and then periodically thereafter. Physician/provider response: Agree. Order repeat labs to see trend. This was signed by the Medical Doctor (MD) UU on 9/17/25. Review of Resident #3's MRR dated 7/9/25 revealed, (Resident #3) has received Seroquel (antipsychotic medication) for over one year with the current dose of 75 mg (milligrams) at bedtime. Recommendation: Please consider a gradual dose reduction, perhaps decreasing to Seroquel 50 mg at bedtime while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. If therapy is to continue at current dose, please provide rationale describing why a dose reduction is clinically contraindicated . Physician/provider response: Disagree. Care collaboration with Psych; GDR contraindicated at this time. (MD UU) reviewed via phone. This was signed by Director of Nursing (DON) B. It was noted that there was not a date noted on when this review was completed via phone by MD UU. In an interview in 9/24/2025 at 10:01 AM, DON B reported that she had discovered that the facility had not been receiving resident medication regimen reviews in August 2025. DON B reported that the consulting pharmacist had been sending the reviews to the previous Director of Nursing, and the facility was unaware, so all residents in the facility had not had medication reviews completed for several months. DON B reported that she did not know many months of reviews the facility had missed. When this writer queried about Resident #51's June medication review, DON B confirmed that the facility provider had not reviewed this recommendation from June 2025 until September 2025, so there was a delay of Resident #3 getting the recommended lab order completed. When this writer queried DON B about Resident #3's July 2025 lab order, DON B reported that she could not recall when she had reviewed the July 2025 recommendation with MD UU because she did not note the date on the review. DON B confirmed that this review had not been placed in Resident #3's electronic medical record (EMR) and was not made available until this writer requested it. DON B reported that she should have dated the MRR, and it also should have been signed by MD UU. DON B confirmed that she could not verify that Resident #3's July 2025 recommendation was reviewed timely. Resident #51 Review of an admission Record revealed Resident #51 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease and major depressive disorder. Review of Resident #51's MRR dated 5/27/25 revealed, (Resident #51) is noted to be experiencing new onset or worsening of falls as indicated on medication regimen review request. Patient (Resident #51) is receiving Seroquel (antipsychotic) 75 mg in the morning- 50 mg at noon and 75 mg in the evening. Patient's recent lipid panel indicates severe hypertriglyceridemia (too many triglycerides (fats) in your blood) which may be attributable to long term atypical antipsychotic use. Patient has been receiving the same dose for over two years. Patient has continued episodes of delusions. Patient may have symptoms of orthostatic hypotension (a condition where blood pressure drops significantly upon standing up from a sitting or lying position) with recent recorded value of 143/76 while sitting which dropped to 117/61 upon standing. Recommendations: Please evaluate current Seroquel dose, perhaps decreasing to 50 mg twice daily and 75 mg in the evening as contributing to this change in status . Physician/provider response: The provider did not respond or sign this form. Review of Resident #51's MRR dated 8/8/25 revealed, (Resident #51) receives Glucophage (Metformin) (oral medication used to treat diabetes) and does not have a serum B-12 level found in the resident medical record . Recommendation: Please consider obtaining a serum B-12 level on the next convenient lab day. Physician/Provider response: Agree. Ok order. This was signed by MD UU on 9/17/25. In an interview in 9/24/2025 at 10:01 AM, DON B reported that she did not know if any provider had reviewed Resident #51's MRR on 5/27/25 as the facility did not have verification of a provider response. DON B confirmed that Resident #51's MRR dated 8/8/25 was not reviewed by a provider in the facility until 9/17/25. DON B reported that the facility was still working through completing medication reviews for residents from the last 3 months for all residents in the facility. DON B reported that MD UU had been completing the medication reviews for all residents. DON B confirmed that MD TT was the facility Medical Director, but he had not been involved in completing the medication reviews for the residents at the facility, and he had not been aware that the facility had not been receiving the medical regimen reviews for all residents at the facility for months. In an interview on 9/24/2025 at 12:46 PM, MD UU reported that he had reviewed multiple outstanding medication reviews for the facility on 9/17/25. MD UU reported that he was not aware of the facility process for completing medication reviews, but that he was helping the facility catch up on the late reviews in the facility. MD UU confirmed that MD TT was the facility Medical Director, so he would be responsible for overseeing the monthly medication reviews for the facility. In an interview on 9/24/2025 at 2:27 PM, Nursing Home Administrator (NHA) A reported that the facility had discovered in August 2025 that the facility had not been reviewing resident medication regimen reviews. NHA A reported that she did not know how long the facility had missed the reviews, but that the facility was currently reviewing the last 3 months of reviews for all residents. NHA A confirmed that MD TT was the Medical Director of the facility, and that he was responsible for overseeing the monthly medication reviews for the facility, and that he had missed that the facility had not been completing the medication regimen reviews for all residents at the facility for several months. This writer attempted to reach MD TT on 9/24/2025 at 1:14 PM. MD TT did not return this writer's phone call by the time of survey exit. Review of the facility's Timeliness of Medication Regimen Review Reports fated 9/7/23 revealed, Policy: The pharmacist will review and report and medication irregularities at least once a month. 1. With new admissions, the consultant pharmacist will complete a MRR and provide a report via secure email within 72 hours to the Director of Nursing/designee. 2. Clinically significant medication issues, identified by the consultant pharmacist during the admission medication regimen review, must be communicated to the prescriber or the designee and resolved by 11:59 P.M. the following day. 3. The consultant will provide monthly MRR reports addressed to the Medical Director, Director of Nursing, and Attending Physician within 3-5 days of completion via secure email or hard copy. 4. The attending physician is expected to review the resident's individual MRR and document and sign that he/she has reviewed the pharmacist's identified recommendations within 14 days of receipt. 5. If the attending Physician does not respond to the resident's MRR report within 14 days, the Director of Nursing will notify the physician of the pending MRR reports. 6. If by the 21st day, the attending physician has not yet responded to the resident's individual MRR report, the Director of Nursing will notify the Medical Director to review and respond to the pending MRR reports. 7. If the Medical Director is also the attending physician, the Director of Nursing will escalate the issue to the facility Administrator. 8. When the consultant pharmacist identifies a recommendation that requires immediate or urgent action, the pharmacist will notify the Director of Nursing and the assigned nurse at the time the recommendation is identified. For further information related to medication concerns, please see F756.

This citation contains two deficient practice statements, A & B.Deficient Practice Statement (DPS) A Based on observation, interview, and record review, the facility failed to establish and maintain a system for surveillance of employee infections and effectively implement infection control measures related to Enhanced Barrier Precautions (EBP), Transmission-Based Precautions (TBP), catheter care, and cleanliness of resident equipment in 5 of 18 residents (Resident #1, #37, #69, #5, & #73) reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population. DPS B Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: DPS A In an interview on 9/24/25 at 10:46 AM, Director of Nursing (DON) B reported she was currently responsible for the Infection Preventionist (IP) role at the facility, but Assistant Director of Nursing (ADON) S was in training to take over that position. DON B reported there is a place within the electronic medical record system to track staff illnesses. DON B reported at this time, only four staff have been entered into the electronic medical record staff illness tracking system, with the most recent entry from May of 2025. DON B reported the facility experienced a COVID-19 outbreak in July of 2025 with only a few staff members affected. Noted the staff COVID-19 cases were not entered into the electronic medical record system to track staff illnesses. DON B reported a new system was being implemented to track staff call-ins and signs/symptoms. DON B reported the call-in sheets were given ADON S to determine if there were any trends/patterns identified. DON B reported at this time, there was no current/updated list of staff illnesses identifying start dates and signs/symptoms of infection to assist with infection surveillance. In an interview on 9/24/25 at 2:51 PM, ADON S reported the Human Resources Department handles the staff call-ins and keeps the copies of the call-in sheets indicating signs/symptoms. ADON S reported DON B handles the tracking/surveillance of staff illnesses. Review of the policy/procedure Infection Prevention Program Overview, dated 2/28/25, revealed .The infection prevention and control program (IPCP) must include, at a minimum, the following elements .The facility establishes a program under which it .Investigates, identifies, prevents, reports and controls infections and communicable diseases for all residents, staff, contractors, consultants, volunteers, visitors and others who provided care and services to the residents on behalf of the facility .The major activities of the program are .Surveillance of infections with implementation of control measures and prevention of infections .There is on-going monitoring to identify possible communicable diseases or infections among residents and staff and subsequent documentation of infections that occur .REPORTING MECHANISMS FOR INFECTION PREVENTION .Employee infections are reported by the employee to his/her supervisor, then to the IP (Infection Preventionist). The IP enters the employee infection data into PCC (electronic medical record system) . Resident #37 Review of an admission Record revealed Resident # 37 was originally admitted to the facility on [DATE] with pertinent diagnoses which included personal history of traumatic brain injury and neuromuscular dysfunction of the bladder (a condition where the nerves and muscles that control bladder function are impaired). Review of Resident #37's Orders revealed, Enhanced Barrier Precautions while performing high contact care activities. Start date: 9/22/25. In an observation on 9/22/2025 at 9:06 AM, Resident #37 was lying in his bed. It was noted that his catheter bag was sitting directly on the floor of his room, surrounded by pieces of food. The floor was also noted to be sticky and soiled. In an observation on 9/23/2025 at 10:23 AM, Two Certified Nursing Assistants (CNA's) were noted to be assisting Resident #37 with morning care in the resident's room. CNA HH brushed Resident #37's hair and assisted Resident #37 to put on his socks. It was noted that CNA HH was not wearing gloves or a gown when she was assisting Resident #37. Resident #1 Review of an admission Record revealed Resident #1 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic kidney disease and legal blindness. Review of Resident #1's Orders revealed, Contact and droplet precautions start date: 9/22/25. In an observation on 9/23/2025 at 4:12 PM, Activity Aide (AA) BBB entered Resident #1's room to assist him with his television. It was noted that AA BBB did not don (put on) gloves and a gown before entering Resident #1's room, and she did not sanitize her hands after she left Resident #1's room. During an observation on 9/23/2025 at 2:33 PM, it was noted that R1 had a sign displayed outside his door STOP! Please see nurse before entering. Contact and droplet precautions. The sign showed the PPE (Personal Protective Equipment) that had to be worn when entering the room which included a gown, gloves, N95 mask and eye protection. There was a cart outside his room with PPE. Review of R1's care plan revealed that there wasn't a care plan regarding the contact and droplet precautions. During an observation on 9/23/2025 at 2:43 PM, R1 was sitting in his wheelchair next to his bed. R1 yelled out for this surveyor to help him move closer to his bed and needed help changing the channel on his tv. Licensed Practical Nurse (LPN) W was observed walking into R1's room without putting any PPE on. LPN W moved R1's wheelchair so he could be closer to his bed and grabbed the tv remote and helped him find a channel he liked. During an interview on 9/23/2025 at 2:53 PM, LPN W stated that she thought R1 was coming off of contact and droplet precautions and said LPN KK would know more since R1 was her resident. When asked if she need to wear PPE when going into a contact and droplet precautions room, LPN W said Yes, but he is coming off of it and stated she would have to check to find off if he should be off contact and droplet precautions. During an interview on 9/23/2025 at 2:48 PM, LPN KK stated that R1 and his roommate were both tested for COVID that morning and they were waiting for the results of the respiratory panel. LPN KK stated that even though they are waiting for the respiratory panel results, R1's room was still under full droplet precautions and anyone going into the room had to wear PPE. During an interview on 9/23/2025 at 4:11 PM, Director of Nursing (DON) B stated that when a resident is under contact and droplet precautions, a physician order is put in, a sign is placed on the door, a cart with PPE is placed outside of the door and a care plan is developed. DON B said for contact and droplet precautions a gown, gloves, N95 mask and eye protection needs to be worn before entering the room. DON B said there is a sign on the door that directs anyone on what PPE to wear when entering the room. When discussing R1, DON B' stated that R1 was under contact and droplet precautions because of his roommate. DON B verified there was no care plan for R1 and stated that they were waiting for the respiratory panel to come back and then would determine if a care plan for contact precautions needed to be completed. Review of the facility's Enhanced Barrier Policy last revised 3/5/25 revealed, Policy: It is the intent of the facility to use Enhanced Barrier Precautions (EBP) in addition to Standard Precautions for preventing the transmission of the CDC targeted multidrug-resistant organisms (MDROs). Enhanced Barrier Precautions are indicated for residents with any of the following: 1) infection or colonization with a CDC targeted MDRO when contact precautions do not otherwise apply or 2) a wound or indwelling medical device, even if the resident is not known to be infected or colonized with an MDRO and should remain in place for the duration of a resident's stay or until the resolution of the wound or discontinuation of the indwelling medical device that place them at higher risk . Gloves, gowns, and hand hygiene. A. Health care personnel caring for residents on Enhanced Precautions should wear gloves and gowns during high-contact resident care. Examples of high contact resident care activities requiring gown and glove use: Dressing, Bathing/showering, Transferring, providing hygiene (focused on am and pm care), Changing linens, Changing briefs or assisting with toileting, Device care or use; central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: Chronic wounds . Review of the facility's Multi Route Transmission Based Precautions policy last revised 11/22/22 revealed, Policy: Transmisson based precautions are the second tier of basic infection control are to be used in addition to standard precautions for residents who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission . Contact Precautions: use contact precautions for residents with known or suspected infections that represent an increased risk for contact transmission Use PPE (Personal Protective Equipment) appropriately, including gloves and gowns for all interactions that may involve contact with the resident or the resident's environment. Donning PPE prior to entering the room and doffing (removing) and properly discarding before exiting the room . Droplet precautions: Use droplet precautions for residents with known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a resident who is coughing, sneezing, or talking . Use PPE appropriately, [NAME] mask upon entry into resident's room . R69 According to R69's Minimum Data Set (MDS) dated [DATE], the resident was independent performing her ADLs (activities of daily living). The resident's BIMS (Brief Interview Mental Status) had not been completed however, in conversations with the resident, she was able to recall long and short-term memories and hold an intellectual conversation. Review of R69's Diagnoses List included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and emphysema. Review of R69's Order Summary dated 2/21/25, indicated the resident could use oxygen via nasal cannula (NC) at 2 lpm (liters per minute) to oxygen saturation greater than 88% every shift for the diagnoses of COPD. Observed R69's oxygen concentrator (device that concentrates the oxygen from a gas supply (typically ambient air) by selectively removing nitrogen to supply an oxygen-enriched product gas stream) to have dust, lint, and debris covering the top and vents of the machine on -9/22/25 at 10:00 AM -9/23/25 at 9:22 AM -9/23/25 at 1:55 PM -9/24/25 at 8:55 AM R5 According to the MDS dated [DATE], R5's BIMS (Brief Interview Mental Status) score of 6/15 indicated she was cognitively impaired, and her diagnoses included stroke. Observed on 9/22/25 at 9:40 AM, R5's oxygen concentrator at bedside to have buildup of dust, lint, and food crumbs on the top of it in the vent in the back of it. R73 According to the MDS dated [DATE], R73's BIMS score of 15 /15 indicated she was cognitively intact. Her diagnoses included cancer. During an observation and interview on 9/22/25 at 11:14 AM, R73 reported she had lung cancer, and her oxygen concentrator should be running at 3 lpm. Observed the resident wearing oxygen via NC with tubing connected to a concentrator. There was no bubbler/humidifier. The top and back vent of the concentrator has a buildup of dust, lint, and debris. DPS B On 9/22/25 at 2:01 PM, An interview with Plant and Maintenance (PM) U found that the Maintenance Director is on vacation and not onsite this week. When asked if he knew much about if the facility did regular flushing or sampling of the water supply in regard to the Water Management Plan (WMP), PM U stated that he was unaware of aspects of the WMP and, to his knowledge, didn't carry out any responsibilities associated with it. On 9/22/25 at 2:30 PM, Observation of the Memory Care Unit (MCU) Soiled Linen room, with Housekeeping Manager (HM) JJ, found that the hopper had been removed, but water lines were still in place. When asked if she knew if this area was flushed or had the water shut off, HM JJ was unsure. When asked if there was any regular flushing schedule the facility uses for minimal use or unused water fixtures, HM JJ was unsure. On 9/22/25 at 2:35 PM, Observation of the MCU janitors closet found that the mop sink faucet was connected to a chemical pre-dispense system and was only hooked up to the cold-water supply. The hot water supply did not have a handle for staff to use. When asked about flushing this line, HM JJ was unsure, indicating a stagnant water line in need of regular flushing. On 9/22/25 at 2:39 PM, Observation of the Rehab tub room found dust and debris in the bottom of the spa tub. When asked if the tub gets used often, HM JJ stated that its not used, indicating a stagnant water line in need of regular flushing. On 9/22/25 at 2:43 PM, Observation of the Biohazard room near the Front Nurses station, found plumbing connections where a hopper used to be. When asked if the water to the hopper was disconnected and capped off or regularly flushed, HM JJ was usure. On 9/22/25 at 2:47 PM, Observation of the Front Nurses station janitors closet found a set up that did not use the hot water of the mop sink faucet, and the handle of the faucet was taken off. Upon turning the mount where a handle would go, brown and discolored water ran out of the faucet before slowly turning clear over a 10 second period. On 9/22/25 at 3:16 PM, An interview with NHA A found that there should be a book or binder of the water management plan in the Maintenance Directors office. On 9/22/25 at 3:20 PM, The surveyor and Nurse Consultant PP were unable to find a binder or book for the facilities WMP. Surveyor was unable to review any policies or procedures of the plan, find documentation of a completed risk assessment of the facility, ensure a Water Management Team was in place to carry out the plan, or ensure proper control measures were being followed to reduce the risk of Legionella or other opportunistic pathogens of premises plumbing. No further documentation was received by the end of survey exit.

Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive resident-specific treatment plan for five (R43, R31, R4, R11, and R71) of 18 residents reviewed for care planning, resulting in the potential for unmet medical, physical, mental, and psychosocial needs.Findings include: R43 According to R43's admission Record, diagnoses included COPD (chronic obstructive pulmonary disease) and chronic respiratory failure with hypoxia. Review of R43's Order Summary indicated the resident had 1-PRN (as needed) Albuterol inhaler dated 11/16/24. Further review of R43's Order Summary indicated the resident could keep an inhaler at bedside per hospice as of 9/16/25. It was noted hospice services were ordered for the resident on 9/15/25. Review of R43's Care Plan indicated the resident preferred to keep her inhaler within reach but was not implemented until 9/23/25, 7-days after the physician's order was written and 1-day after the facility's recertification survey had started. R31 According to R31's Minimum Data Set (MDS) dated [DATE], indicated the resident was cognitively intact with a score of 15/15 on his BIMS (Brief Interview Mental Status) and was independent with eating and dressing himself that indicated he had mobility in his arms and hands. His active diagnoses included cardiorespiratory conditions. Review of R31's Self-Administration of Medication Evaluation was dated 8/15/2023, indicating the resident was able to self-administer his medications. It was noted the report Evaluation History Self-Administration of Medication Assessment presented by Nursing Home Administrator (NHA) A, identified R31's evaluation to have been completed on 3/11/2025. Review of R31's Care Plan indicated there was no resident-specific treatment plan for self-administering medications. Review of facility policy, Medication Administration revised 10/17/2023, revealed, Self-administration of medication will be reflected in the resident care plan along with any special considerations. Resident #4 Review of an admission Record revealed Resident #4 was a female, with pertinent diagnoses which included stroke, dementia, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 7/31/25, revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total score of 15, indicating severe cognitive impairment. Further review of this assessment for Resident #4 revealed Section I - Active Diagnoses had a check next to bipolar disorder, and Section N - Medications indicated Resident #4 took antipsychotic medications on a routine basis. Review of an Order Summary Report for Resident #4 revealed the physician order .QUEtiapine Fumarate (an antipsychotic medication) Oral Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet via G-Tube (gastrostomy tube) two times a day for Bipolar disorder . with a start date of 7/25/25 and a status of discontinued. Further review revealed the physician order .QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 25 mg via G-Tube two times a day for mood disorder . with a start date of 7/29/25 and a status of discontinued. Lastly, the active physician order .QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 25 mg via G-Tube two times a day for Bipolar disorder . was noted for Resident #4 with a start date of 9/11/25. Review of the Care Area Assessment (CAA) for Psychotropic Drug Use for Resident #4, contained within the 7/31/25 MDS assessment, revealed .Triggering Conditions .High-Risk Drug (Is Taking): Antipsychotic .Checked (Yes) .(Resident #4) is taking Seroquel-antipsychotic medication to (manage) mood and behavior r/t (related to) Bipolar disorder. (She) is referred for psych services to (manage) behavior and (for) medication adjustment. (She) was noted with (an) episode of agitation, stripping (her) clothes and pulling (her) G-tube, (relieved) after taking scheduled medications .Care Plan Considerations .Will Psychotropic Drug Use be addressed in the care plan? Yes .Will proceed to care plan to manage mood and behavior and monitor potential adverse (effects) of medication that may impact quality of life . Review of a Care Plan Report for Resident #4 revealed no focus/goal/interventions related to her diagnosis of bipolar disorder, mood/behavior concerns, and routine use of antipsychotic medications. In an interview on 9/23/25 at 2:44 PM, Social Service Director (SSD) FF reported care plans are created for residents based on the information in the medical record, information from residents/family members, social service assessments, MDS assessments and CAAs. SSD FF reported when completing a CAA during the MDS process, a decision is made whether to proceed to the care plan when specific items/areas are triggered. SSD FF reviewed Resident #4's Care Plan and acknowledged there was no focus/goal or interventions related to Resident #4's diagnosis of bipolar disorder, mood/behavior concerns, and routine use of antipsychotic medications. Resident #11 (R11) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R11's initial admission date to the facility was on 5/31/2024 with pertinent diagnoses including dementia (decline in mental abilities such as memory, thinking and reasoning that is severe enough to interfere with daily life), tremors, anxiety and depression. Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which indicated R11 was severely cognitively impaired (00 to 07 is severe cognitive impairment). During an interview and observation on 9/22/2025 at 12:11 PM, R11 was lying in bed and was confused and stated she couldn't remember if she had fallen at the facility. Review of R11's fall report dated 7/16/2025 revealed .Resident was found sitting with her back at the bed facing the bedroom door. Resident states that she slid off her bed.Intervention: Nonskid tape applied to the floor in front of the bed. Review of R11's functional status care plan revealed . (R11) requires supervision assistance with transfers and ambulation. Interventions.provide safety devices as ordered.bed against wall. Review of R11's fall care plan revealed (R11) is at risk for fall related injury and falls r/t (related to) impaired cognition d/t (due to) dementia, history of falls, incontinence of bladder . interventions.7/16/25 non-skid tape to be applied in front of bed. Date initiated 7/16/2025. On 9/24/2025 at 11:50 AM, it was observed that R11 did not have non-skid tape on the floor and her bed was not against the wall. During an interview on 9/24/2025 at 11:56 AM, Certified Nursing Assistant (CNA) J stated that R11 had times of confusion but communicates well and had fallen a few times since R11 thinks she can do things herself which she can, but she needs stand by staff assistance. CNA J verified that there wasn't non-skid tape in front or around her bed and that the bed wasn't against the wall. During an interview on 9/24/2025 at 12:17 PM, Director of Nursing (DON) B stated that after every fall a new intervention was put into place and IDT (interdisciplinary team) discusses whether the interventions are effective and if changes need to be made and it is put on the care plan. When discussing that R11's bed was not against the wall and non-skid tape was not in front of bed per her care plan, DON B said We will get that fixed. Resident #71 Review of an admission Record revealed Resident #71 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression (persistent sad mood that impacts daily life), and chronic respiratory failure with hypoxia (chronic condition in which the lungs cannot adequately provide oxygen to the body over an extended period, leading to low oxygen levels in the blood). Review of a Minimum Data Set (MDS) assessment for Resident #71 with a reference date of 9/9/25, revealed the resident refused to complete a Brief Interview for Mental Status (BIMS) assessment. Resident # 71's short-term memory was not assessed. Review of section D revealed Resident # 71 was not assessed for feelings of depression or thoughts of being better off dead/hurting self. Review of a Care Plan for Resident # 71 revealed there were no goals or interventions to address Resident 71's safety issues related to smoking/hiding of smoking paraphernalia, or his suspected history of smoking in his room while unsupervised. In an interview on 9/22/25, at 2:01pm, Resident #71 reported he had a lighter and cigarettes in his room until a few days ago when a police officer came and confiscated them. Resident #71 reported staff allowed him to go outside and smoke and to keep his smoking materials in his possession. When further queried, Resident #71 reported he had a little paranoia, felt his phoneline was tapped and felt the need to hide his smoking materials. In an interview on 9/23/25 at 10:34am, Registered Nurse (RN) X reported on 9/20/25 at approximately 5:00pm a staff member came to her and told her she suspected Resident #71 had been smoking in his room. RN X reported upon investigating she found Resident #71's room appeared smoky and smelled of cigarette smoke. RN X reported she had cared for Resident #71 and did not know he was a smoker until that day. RN X reported she felt Resident #71's care plan should reflect that he smoked, was noncompliant with relinquishing his smoking paraphernalia, and had an incident of smoking in his room. In an interview on 9/24/25 at 1:55pm, Nursing Home Administrator (NHA) A confirmed the facility had not developed a care plan to address Resident #71's preference to smoke cigarettes, his noncompliance with the facility's smoking policy, or his safety needs related to the incident in which he likely smoked a cigarette in his room. NHA A reported although Resident #71 did not get visitors, he had the potential to acquire smoking paraphernalia from other facility visitors and/or other residents.

Based on observation, interview, and record review the facility failed to ensure 1.) 2 residents (R43 and R69) of 3 residents reviewed for self-administration of medications was assessed to determine if self-administration of medication was clinically appropriate, and 2.) orders were written for 2 residents (R69 and R31) of 3 residents reviewed to be able to self-administer medications, resulting in unsupervised administration of medications (R43 and R69) and the potential for mismanagement of medication and potential for adverse side effects.Findings include: Review of the facility list of residents that had the Evaluation History Self-Administration of Medication Assessment received 9/23/2025, revealed two residents had been evaluated for self-administrating medications. The residents were R43 on 9/23/25 and R31 on 3/11/25. R43According to R43's admission Record, diagnoses included COPD (chronic obstructive pulmonary disease) and chronic respiratory failure with hypoxia.Review of R43's Order Summary indicated the resident had 1-PRN (as needed) inhaler. Further review of R43's Order Summary indicated the resident could keep an inhaler at bedside per hospice as of 9/16/25.Review of R43's Care Plan indicated the resident preferred to keep her inhaler within reach but was not implemented until 9/23/25, 7-days after the physician's order was written and 1-day after the facility's recertification survey had started. Review of R43's Self-Administration of Medication Assessment was documented as being completed on 9/23/25 which was after the resident began using the medication at bedside on 9/16/25 and further noted to have been done after a list of residents who self-administer medications at bedside was request from the facility's Administrator on 9/23/25. During an interview on 9/24/2025 at 1:53 PM, R43 stated her inhaler had stayed at her bedside since it was ordered for her and she used it every day. This morning, a nurse took it to clean it and did not bring it back. The conversation with R43 revealed the resident was able to recall short- and long-term memories and hold an intellectual conversation.R69According to R69's Minimum Data Set (MDS) dated [DATE], the resident was independent performing her ADLs (activities of daily living). The resident's BIMS had not been completed however, in conversations with the resident, she was able to recall long and short memories and hold an intellectual conversation. Review of R69's Diagnoses List included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and emphysema. Review of R69's Order Summary, dated 2/25/25, revealed, Saline Nasal Solution 0.65 % (Saline) 1 spray in each nostril every 1 hour as needed for dry nose. Further review of R69's Order Summary indicated there was no order stating the resident could self-administer any medication including Saline spray. Review of R69's Care Plan indicated there was no resident-specific treatment plan for self-administering medications. Observation and interview on 9/22/25 at 10:00 AM, revealed R69 was sitting in her room in a recliner next to a bedside table. On the bedside table was a bottle of Normal Saline nasal spray with the resident's name and dated 2/25/25. R69 stated, Staff left this bottle of nose spray for me to use because my nose gets dry and has little sores in it from the oxygen I wear. Observed on 9/23/5 at 9:22 AM, R69 sitting in her room in a recliner next to a bedside table. On the bedside table was a bottle of Normal Saline nasal spray with the resident's name and dated 2/25/25. Observed on 9/23/25 at 1:55 PM, on R69's bedside table was a bottle of Normal Saline nasal spray with the resident's name and dated 2/25/25. On 9/23/25 at 3:43 PM, email request sent to Nursing Home Administrator (NHA) A for a list of residents that were evaluated to self-administer medications. During an observation and interview on 9/24/25 at 8:55 AM, R69 was awake in her recliner. There was no saline nasal spray visible. R69 stated, The nurse came yesterday (9/23/25) and took my spray away. During an interview on 9/24/25 at 9:10 AM, Director of Nursing (DON) B reported a resident required a self-administer medication evaluation before they could take their medications by themselves. She also stated she did not know if any residents in the facility had had one and was self-administering their medications. She did know that R69 did not have an evaluation. R31According to R31's MDS dated [DATE], indicated the resident was cognitively intact with a score of 15/15 on his BIMS (Brief Interview Mental Status) and was independent with eating and dressing himself that indicated he had mobility in his arms and hands. His active diagnoses included cardiorespiratory conditions.Review of R31's Order Summary did not have an order independently or connected to any medication(s) to self-administer.Review of R31's Care Plan indicated there was no resident-specific treatment plan for self-administering medications. Review of R31's Self-Administration of Medication Evaluation was dated 8/15/2023, indicating the resident was able to self-administer his medications. It was noted the report Evaluation History Self-Administration of Medication Assessment presented by NHA A, identified R31's evaluation to have been completed on 3/11/2025. Review of facility policy, Medication Administration revised 10/17/2023, revealed, .Self-Administration - residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guideline for self-administration of medication. A self-administration evaluation will be completed prior to the resident starting the self-administering process.

Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse by a resident in 2 (Resident #49 and Resident #51) of 2 residents reviewed for abuse resulting in Resident #49 being physically assaulted by Resident #51 and the potential for a decline in physical, mental, and psychosocial well-being. Findings include: Resident #49Review of an admission Record revealed Resident #49 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease and cognitive communication disease. Review of Resident #49's Progress Notes dated 9/11/25 and documented by Physician Assistant (PA) AAA revealed, RN (Registered Nurse) called and notified me resident (Resident #49) was in an altercation with another resident (Resident #51). Resident (Resident #49) was struck in the face with a book by another resident (Resident #51) Resident #51Review of an admission Record revealed Resident #51 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease and major depressive disorder. Review of Resident #51's Care Plan revealed, (Resident #51) has the potential to demonstrate physical and verbal aggression R/T (related to): hitting, kicking, resistive to care, biting, slapping, repetitive movements, yelling, screaming and abusive language r/t dementia, delusional thinking, depression and anxiety. Start date: 1/8/25. Goal: Will not harm self or others through the review date. Date Initiated: 01/08/2025. Interventions: Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, need for sleep, pain etc. as needed. Date Initiated: 01/08/2025. Assess resident's understanding of the situation. Allow time for the resident toexpress self and feelings towards the situation, including antecedents, effective calming strategies etc . Date Initiated: 01/08/2025. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Date Initiated: 01/08/2025. Notify nurse/social worker when behaviors occur. Date Initiated: 01/08/2025. Observe key times, places, circumstances, triggers, and what de-escalates behavior. Adjust plan of care to reduce incidents of aggression where possible. Date Initiated: 01/08/2025 . Review of Resident #51's Incident Report dated 9/11/25 and documented by Registered Nurse (RN) G revealed, The author writing this note heard the resident (Resident #51) raising her voice. This author observed (Resident #51) holding onto another resident (Resident #49) walker and yelling at other resident (Resident #49). This author removed (Resident #51) from the day room . In an interview on 9/22/2025 at 12:01 PM, Family Member (FM) NN reported that he had recently been contacted by the facility and informed that Resident #51 had been in a physical altercation with another resident, and that Resident #51 had hit Resident #49 in the face with a book. FM NN reported that Resident #51 had a history of aggressive behavior towards other residents. In an interview on 9/23/2025 at 11:23 AM, RN NN reported that he was the nurse caring for Resident #51 on 9/11/25 when she got into a physical altercation with Resident #49. RN NN reported that he had heard yelling in the day room and when he entered the day room, he saw Activity Aide (AA) D in between Resident #49 and Resident #51. RN NN reported that he did not observe the physical altercation between the two residents because it had been broken up by AA D before he got there. RN NN reported that he assisted Resident #51 out of the day room and back to her room. RN NN reported that Resident #51 had a history of being aggressive with other residents, and that she had been in multiple physical altercations with other residents at the facility. In an interview on 9/23/2025 at 11:53 AM, AA D reported that on 9/11/25 she was assisting a resident to walk down the hall when she noticed that Resident #49 and Resident #51 were sitting next to each other in the day room with Resident #49's walker in between them. AA D reported that she saw Resident #51 trying to move Resident #49's walker and she began screaming at Resident #49 and then grabbed a book and smacked Resident #49 across the face with the book. AA D reported that Resident #49 grabbed Resident's arm in an attempt to block her from hitting her again, but Resident #51 slapped Resident #49 across the face with her other hand. AA D reported that she was able to safely move the resident she was assisting in the hallway, and then she got in between Resident #49 and Resident #51 to stop the physical altercation. AA DD confirmed that Resident #51 did make full on contact with Resident #49 when she hit her with the book and slapped her, and that when Resident #51 slapped Resident #49, she had fallen back in the chair she was in. In an interview on 9/23/2025 at 12:39 PM, Nursing Home Administrator (NHA) A reported that she was aware of the physical altercation on 9/11/25 between Resident #49 and Resident #51. NHA A reported that she was not sure if the incident was considered abuse because the facility was unable to determine the intent of residents. NHA A reported that she was aware that Resident #51 had struck Resident #49 in the face with a book and then slapped Resident #49 across the face. Review of the facility's Abuse policy last revised 9/9/22 revealed, Policy: Each guest/resident shall be free from abuse . Abuse shall include free from verbal, mental, sexual, physical abuse . To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents . Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Physical abuse includes hitting, slapping, pinching, and kicking .

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 (Resident #49 and Resident #51) of 2 residents reviewed for abuse resulting in an allegation of physical abuse not being thoroughly investigated and the potential for ongoing resident to resident physical abuse to occur. Findings include: Resident #49 Review of Resident #49's Progress Notes dated 9/11/25 and documented by Physician Assistant (PA) AAA revealed, RN (Registered Nurse) called and notified me resident (Resident #49) was in an altercation with another resident (Resident #51). Resident (Resident #49) was struck in the face with a book by another resident (Resident #51) Resident #51 Review of Resident #51's Incident Report dated 9/11/25 and documented by Registered Nurse (RN) G revealed, The author writing this note heard the resident (Resident #51) raising her voice. This author observed (Resident #51) holding onto another resident (Resident #49) walker and yelling at other resident (Resident #49). This author removed (Resident #51) from the day room . In an interview on 9/22/2025 at 12:01 PM, Family Member (FM) NN reported that he had recently been contacted by the facility and informed that Resident #51 had been in a physical altercation with another resident, and that Resident #51 had hit Resident #49 in the face with a book. FM NN reported that Resident #51 had a history of aggressive behavior towards other residents. In an interview on 9/23/2025 at 11:23 AM, RN NN reported that he was the nurse caring for Resident #51 on 9/11/25 when she got into a physical altercation with Resident #49. RN NN reported that he had heard yelling in the day room and when he entered the day room, he saw Activity Aide (AA) D in between Resident #49 and Resident #51. RN NN reported that he did not observe the physical altercation between the two residents because it had been broken up by AA D before he got there. RN NN reported that he assisted Resident #51 out of the day room and back to her room. RN NN reported that Resident #51 had a history of being aggressive with other residents, and that she had been in multiple physical altercations with other residents at the facility. RN NN reported that he had reported the incident immediately after it happened to Nursing Home Administrator (NHA) A, who was the facility's designated abuse coordinator. In an interview on 9/23/2025 at 11:53 AM, AA D reported that on 9/11/25 she was assisting a resident to walk down the hall when she noticed that Resident #49 and Resident #51 were sitting next to each other in the day room with Resident #49's walker in between them. AA D reported that she saw Resident #51 trying to move Resident #49's walker and she began screaming at Resident #49 and then grabbed a book and smacked Resident #49 across the face with the book. AA D reported that Resident #49 grabbed Resident's arm in an attempt to block her from hitting her again, but Resident #51 slapped Resident #49 across the face with her other hand. AA D reported that she was able to safely move the resident she was assisting in the hallway, and then she got in between Resident #49 and Resident #51 to stop the physical altercation. AA DD confirmed that Resident #51 did make full on contact with Resident #49 when she hit her with the book and slapped her, and that when Resident #51 slapped Resident #49, she had fallen back in the chair she was in. AA DD reported that they had reported the incident to NHA A right after the incident occurred. In an interview on 9/23/2025 at 12:39 PM, Nursing Home Administrator (NHA) A reported that she was aware of the physical altercation on 9/11/25 between Resident #49 and Resident #51. NHA A reported that she was aware that Resident #51 had struck Resident #49 in the face with a book and then slapped Resident #49 across the face. NHA A confirmed that she did not report the incident to the State Agency. NHA A reported that she usually would report this type of incident. Review of the facility's Abuse policy last revised 9/9/22 revealed, Policy: Each guest/resident shall be free from abuse . Abuse shall include free from verbal, mental, sexual, physical abuse . To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents . Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Physical abuse includes hitting, slapping, pinching, and kicking . G. Reporting abuse and the facility response to the allegation: 1. The staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown source to the Administrator and DON (Director of Nursing) immediately. 2.The Administrator or designee will notify the guest's/resident's representative. Also, any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury; all others not later than 24 hours). At the conclusion of the investigation, and no later than 5 working days of the incident, the facility must report the results of the investigation and if the alleged violation is verified, take corrective action .

Based on interview and record review, the facility failed to thoroughly investigate an allegation of resident-to-resident abuse and protect residents from further abuse for 2 residents (Resident #49 & #51) of 2 residents reviewed for abuse, resulting in the potential for ongoing abuse due to an incomplete investigation of abuse. Findings include: Resident #49 Review of Resident #49's Progress Notes dated 9/11/25 and documented by Physician Assistant (PA) AAA revealed, RN (Registered Nurse) called and notified me resident (Resident #49) was in an altercation with another resident (Resident #51). Resident (Resident #49) was struck in the face with a book by another resident (Resident #51) Resident #51 Review of Resident #51's Incident Report dated 9/11/25 and documented by Registered Nurse (RN) G revealed, The author writing this note heard the resident (Resident #51) raising her voice. This author observed (Resident #51) holding onto another resident (Resident #49) walker and yelling at other resident (Resident #49). This author removed (Resident #51) from the day room . In an interview on 9/23/2025 at 11:23 AM, RN NN reported that he was the nurse caring for Resident #51 on 9/11/25 when she got into a physical altercation with Resident #49. RN NN reported that he had heard yelling in the day room and when he entered the day room, he saw Activity Aide (AA) D in between Resident #49 and Resident #51. RN NN reported that he did not observe the physical altercation between the two residents because it had been broken up by AA D before he got there. RN NN reported that he assisted Resident #51 out of the day room and back to her room. RN NN reported that Resident #51 had a history of being aggressive with other residents, and that she had been in multiple physical altercations with other residents at the facility. RN NN reported that he had reported the incident immediately after it happened to Nursing Home Administrator (NHA) A, who was the facility's designated abuse coordinator. In an interview on 9/23/2025 at 11:53 AM, AA D reported that on 9/11/25 she was assisting a resident to walk down the hall when she noticed that Resident #49 and Resident #51 were sitting next to each other in the day room with Resident #49's walker in between them. AA D reported that she saw Resident #51 trying to move Resident #49's walker and she began screaming at Resident #49 and then grabbed a book and smacked Resident #49 across the face with the book. AA D reported that Resident #49 grabbed Resident's arm in an attempt to block her from hitting her again, but Resident #51 slapped Resident #49 across the face with her other hand. AA D reported that she was able to safely move the resident she was assisting in the hallway, and then she got in between Resident #49 and Resident #51 to stop the physical altercation. AA DD confirmed that Resident #51 did make full on contact with Resident #49 when she hit her with the book and slapped her, and that when Resident #51 slapped Resident #49, she had fallen back in the chair she was in. AA DD reported that they had reported the incident to NHA A right after the incident occurred. AA D reported that she had not been asked to complete a written witness statement of the investigation. In an interview on 9/23/2025 at 12:39 PM, Nursing Home Administrator (NHA) A reported that she was aware of the physical altercation on 9/11/25 between Resident #49 and Resident #51. NHA A reported that she was aware that Resident #51 had struck Resident #49 in the face with a book and then slapped Resident #49 across the face. NHA A reported that she was working on an investigation for the incident, and she would submit it shortly. When this writer queried as to what NHA A had for the investigation, NHA A showed this writer a one-page document with a list of staff names that were working during the incident. NHA A was unable to provide further documentation for this writer to review during this interview. NHA A was unable to report what actions she had taken for the investigation during the interview with this writer. In a follow up interview on 9/24/2025 at 2:37 PM, this writer asked NHA A for the investigation report that she had reported she would submit the day before and NHA A reported she was still working on uploading the report. On 9/24/25 at 3:07 PM, NHA A uploaded the Investigation Report. Review of the Investigation Report revealed a two-page typed document which revealed, Allegation Statement: On September 11, 2025, the ADON (Assistant Director of Nursing) and Activities Aide (AA D) reported to the administrator that they walked by the common day room and witnessed an altercation between (Resident #49 and Resident #51). (The document then provided a brief medical summary of Resident #49 and Resident #51) . Action taken: Assessments Completed, Informed Responsible Parties, Guardians, Administrator, Director of Nursing, Provider and Police, Staff and Resident interviews completed, Social Worker Visits initiated, Care Plans reviewed and updated as needed, Abuse Policy Reviewed, (local mental health provider) visit planned. Immediate Intervention: Residents were immediately separated and assessed for injury, none observed. Interviews/Investigation: During interviews and investigation it was determined that just prior to the incident, both residents participated in consuming lunch in the dining room. After lunch the residents were residing in the common day room. Interviews/Investigations: (Name Redacted- AA D) - states she was pushing another resident in their wheelchair down the hallway, she passed the day room and noted (Resident #51) and (Resident #49) appeared to be fighting over (Resident #49's) walker, she explained that both resident's had their hands on the walker and were pulling the walker to them. AA D began to enter the day room to assist the residents when she watched (Resident #51) pick up a magazine that was on the table and hit (Resident #49) in the arm with it. (Resident #51) then dropped the magazine and open handed slapped (Resident #49) across the face before she could get to the two residents to intervene. AA D was assisted by the ADON and reported the incident to the primary nurse, assisting (Resident #51) out to the hallway. AA D then reported the incident to the administrator . (Name Redacted- RN NN) states he was completing his medication pass in the hallway when he overheard (Resident #51) raising her voice. RN NN entered the day room and assisted with the separation; it was reported to him by (AA D) that she observed (Resident #51) hitting (Resident #49). (Resident #51) was unable to recall the incident within 10 minutes of the altercation. The administrator attempted to interview (Resident #51), she was laying in her bed, pleasant and calm. She stated she was doing ok today, just going to lay down for a nap. (Resident #49) was unable to recall the incident within 15 minutes of the altercation. The administrator attempted to interview (Resident #49) she was still in the common day room, sitting at the table, walker within reach and appeared to be reading a book. (Resident #49) smiled at the administrator however did not answer any questions. She appeared to be pleasant and calm, no distress noted. Intervention: The residents were separated after the incident. (local mental health provider) contacted for a visit to assist with management of (Resident #51's) behaviors. Conclusion: After investigation and interview it was determined that no intent could be indicated for abuse as both residents have a low BIMs indicating significant cognitive impairment, no witnesses to explain the begin/reasoning for the altercation and neither resident could recall the incident directly after it occurred. No injuries. All appropriate parties notified. It was noted that the Investigation Report did not include assessments that were reported to have been completed, or evidence to verify that the police had been contacted, copies of witness statements, verification that resident care plans were reviewed and updated, or verification of the scheduled mental health provider visits that were reported to have been planned. It was also noted that the description of the interview with AA D did not reflect the statement that AAD had provided to this writer, as AA D had reported to this writer that Resident #51 had hit Resident #49 in the face with a book, and not her arm. The investigation report did not describe any additional outcomes to Resident #49 and Resident #51 such as physical or mental harm, the date and time the incident was reported to responsible parties, provider and the police. The investigation report did not include summary information from the investigation related to the incident from the resident's clinical record, such as relevant portions of the RAI, the resident's care plan, nurses' notes, social services note, lab reports, physician or other practitioner reports or reports from other disciplines that are related to the incident or any relevant details that may have caused Resident #51's behavior, such as habits, routines, medications, diagnosis. The report did not include the plan for oversight of implementation of corrective action, interventions planned and implemented to assist Resident #49 and Resident #51. Review of the Facility's Abuse Prohibition Policy last revised 9/9/22 revealed, Review of the facility's Abuse policy last revised 9/9/22 revealed, Policy: Each guest/resident shall be free from abuse . Abuse shall include free from verbal, mental, sexual, physical abuse . To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents . Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Physical abuse includes hitting, slapping, pinching, and kicking . E. Investigation: 1. Allegations by anyone who becomes aware od verbal, physical, mental, sexual or abuse or mistreatment, neglect, exploitation, involuntary seclusion or misappropriation of property must immediately report it to his/her Administrator. 2. The Director of Nursing or designee will complete an assessment of guests/residents and document findings in the record 3. An incident Report (and/or grievance forms per state specific requirements) will be completed . 5. A preliminary, on-site investigation will be initiated within twenty-four hours of any report. 6. The Administrator or Director of Nursing/designee shall initiate the Incident and Accident Investigation Form (or other grievance forms per state specific guidelines) and take the following actions to ensure that the investigation is conducted effectively. a.If the incident has resulted in an injury (requiring acute intervention) or was a sexual assault, the guest/resident will be transferred to a hospital emergency room. The physician and family will be notified of the transfer . e. The Administrator or Director of Nursing shall call local police when assault, sexual abuse, homicide, forgery or neglect are suspected or have occurred or per state law .

Based on interview and record review, the facility failed to ensure 1(Resident #4) of 1 resident reviewed for Pre-admission Screening and Resident Review (PASARR) was referred for a comprehensive level II PASARR evaluation, resulting in the potential for the resident to not receive the appropriate mental health treatment and services. Findings include:Resident #4Review of an admission Record revealed Resident #4 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).Review of a Minimum Data Set (MDS) assessment for Resident #4 with a reference date of 7/31/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 0/15, which indicated the resident was severely cognitively impaired.Review of a PASARR Level I screening form for Resident #4 with a reference date of 7/22/25, section II revealed the resident 1.has a current diagnosis of mental illness, 2.has received treatment for mental illness, .3. routinely received one or more prescribed antipsychotic medications in the last 14 days, 4. There is presenting evidence of mental illness.including significant disturbances in thought, conduct, emotions, or judgement.In an interview on 09/24/2025 at 12:02pm, Social Services Director (SSD) FF reported Resident #4 triggered the need for a level II PASARR screening due to her history of mental illness. SSD FF reported a referral for a level II PASARR screening should have been made to a community mental health agency at the time of her admission, but it had not been done.Review of a facility Pre-admission Screening and Resident Review policy with a reference date of 11/12/21 revealed Policy: The PASRR process was established.to ensure that needs are met to assist the individual in reaching their highest potential. All persons .who are seriously mentally ill.are required to be evaluated to determine if a nursing facility is the appropriate place to receive services.7. For those who screen positively for a mental illness.the facility submits the Level I screen to the local community mental health program for comprehensive screening (Level II) .9. If a comprehensive Level II screening is performed, the recommendations are to be included in the plan of care.

Based on interview and record review, the facility failed to review and revise a comprehensive, individualized plan of care for 1 of 18 residents (Resident #51) reviewed for care plans, resulting in further occurrences of resident-to-resident physical aggression and the potential for unmet care needs and impaired physical, mental, and psychosocial well-being. Findings include: Resident #51 Review of an admission Record revealed Resident #51 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease and major depressive disorder. Review of Resident #51's Care Plan revealed, (Resident #51) has the potential to demonstrate physical and verbal aggression R/T (related to): hitting, kicking, resistive to care, biting, slapping, repetitive movements, yelling, screaming and abusive language r/t dementia, delusional thinking, depression and anxiety. Start date: 1/8/25. Goal: Will not harm self or others through the review date. Date Initiated: 01/08/2025. Interventions: Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, need for sleep, pain etc. as needed. Date Initiated: 01/08/2025. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation, including antecedents, effective calming strategies etc . Date Initiated: 01/08/2025. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Date Initiated: 01/08/2025. Notify nurse/social worker when behaviors occur. Date Initiated: 01/08/2025. Observe key times, places, circumstances, triggers, and what de-escalates behavior. Adjust plan of care to reduce incidents of aggression where possible. Date Initiated: 01/08/2025 . It was noted that Resident #51's physical and verbal aggression care plan had not been updated since 1/8/25. Review of Resident #51's Progress Note dated 8/24/25 revealed, During this evening meal in the room dining room, the resident (Resident #51) was reported by Certified Nursing Assistant (CNA) (Name redacted) to have initiated physical aggression towards another resident. Review of Resident #51's Incident Report dated 9/11/25 and documented by Registered Nurse (RN) G revealed, The author writing this note heard the resident (Resident #51) raising her voice. This author observed (Resident #51) holding onto another resident (Resident #49) walker and yelling at other resident (Resident #49). This author removed (Resident #51) from the day room . In an interview on 9/22/2025 at 12:01 PM, Family Member (FM) NN reported that he had recently been contacted by the facility and informed that Resident #51 had been in a physical altercation with another resident, and that Resident #51 had hit Resident #49 in the face with a book. FM NN reported that Resident #51 had a history of aggressive behavior towards other residents and had been in multiple other altercations at the facility with residents. In an interview on 9/23/2025 at 11:23 AM, RN NN reported that he was the nurse caring for Resident #51 on 9/11/25 when she got into a physical altercation with Resident #49. RN NN reported that he had heard yelling in the day room and when he entered the day room, he saw Activity Aide (AA) D in between Resident #49 and Resident #51. RN NN reported that he did not observe the physical altercation between the two residents because it had been broken up by AA D before he got there. RN NN reported that he assisted Resident #51 out of the day room and back to her room. RN NN reported that Resident #51 had a history of being aggressive with other residents, and that she had been in multiple physical altercations with other residents at the facility. RN NN reported that he did not know what interventions were in place to assist Resident #51 when she would get aggressive towards other residents. RN NN reported that the facility had moved Resident #51 to other rooms, but that did not seem to help her. RN NN was not aware of any new interventions that the facility had implemented after the incident on 9/11/25. In an interview on 9/23/2025 at 11:53 AM, AA D reported that on 9/11/25 she was assisting a resident to walk down the hall when she noticed that Resident #49 and Resident #51 were sitting next to each other in the day room with Resident #49's walker in between them. AA D reported that she saw Resident #51 trying to move Resident #49's walker and she (Resident #51) began screaming at Resident #49 and then grabbed a book and smacked Resident #49 across the face with the book. AA D reported that Resident #49 grabbed Resident's arm in an attempt to block her from hitting her again, but Resident #51 slapped Resident #49 across the face with her other hand. AA D reported that she was able to safely move the resident she was assisting in the hallway, and then she got in between Resident #49 and Resident #51 to stop the physical altercation. AA DD confirmed that Resident #51 did make full on contact with Resident #49 when she hit her with the book and slapped her, and that when Resident #51 slapped Resident #49, she had fallen back in the chair she was in. AA DD was not aware of any new interventions that the facility had implemented after this incident to prevent further incidences from occurring. In an interview on 9/24/2025 at 8:47 AM, Social Services Director (SSD) FF reported that she was aware of the recent aggressive incidents that Resident #51 had with other residents in August and September 2025. SSD FF reviewed Resident #51's Care Plan with this writer and confirmed that the facility had not reviewed and revised Resident #51's Care Plan to reduce the likelihood of another resident-to-resident incidents from happening again. SSD FF was unable to report any new interventions that the facility had implemented after the August 2025 or September 2025 resident to resident incidents with Resident #51. In an interview on 9/24/2025 at 10:01 AM, Director of Nursing (DON) B reported that she was aware of the resident-to-resident incidents that Resident #51 was involved in during August 2025 and September 2025. DON B reported that Resident #51 did have a history of physical aggression towards others. DON B reported that the facility had considered moving Resident #51 to another room, but they had not moved Resident #51 yet. DON B confirmed that the facility had not reviewed and revised Resident #51's Care Plan to reduce the likelihood of another resident-to-resident incidents from happening again, and that the facility had not implemented any new interventions to address Resident #51's aggression since the August and September 2025 incidents.

Based on observation, interview, and record review, the facility failed to implement interventions to reduce hazards and risks for 2 residents (Resident #71 and Resident #24) of 6 residents reviewed for accidents, resulting in: 1. Resident #71 maintaining possession of smoking paraphernalia while unsupervised. This deficient practice has the potential to impact all 80 residents of the facility due to the increased risk of a potential fire. 2. Resident #24 being transported in a wheelchair without foot pedals in place, resulting in the potential for an avoidable injury.Findings include:Resident #71Review of an admission Record revealed Resident #71 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression (persistent sad mood that impacts daily life).Review of a Care Plan for Resident # 71 with a reference date of 3/12/25, revealed there was no care plan related to Resident 71's noncompliance with the facility smoking policy, hiding smoking paraphernalia, and smoking in his room.Review of a Nurses Note for Resident #71, with a reference date of 9/16/25 at 11:52pm, revealed declined all evening medications.proceeded to go outside for approximately two hours to smoke.Review of a Nurses Note for Resident #71, with a reference date of 9/20/25 at 5:39pm revealed Resident was found awake in his room with oxygen concentrator in use after staff detected the smell of smoke in the hallway. Upon assessment resident (sic) denied smoking in the room, however, odor of smoke was noticeable.Resident was observed to be verbally hostile toward the nurse.Review of a Nurses Note for Resident #71, with a reference date of 9/20/25 at 7:04pm revealed Deputy (Deputy's name) came to facility to address non-smoking facility violations. He was able to confiscate the resident's lighter from his room.Review of a Leave of Absence Sign Out form for Resident #71 revealed 6 occurrences in which Resident #71 signed himself out of the facility between 8/28-9/16/25. Outside smoke was listed as the destination for each occurrence. No staff signatures were present to indicate the resident returned indoors and relinquished his smoking paraphernalia.In an interview on 9/22/25, at 2:01pm, Resident #71 reported he had a lighter and cigarettes in his room until a few days ago when a police officer came and confiscated them. Resident #71 reported staff allowed him to go outside and smoke and to keep his smoking materials in his possession. When further queried, Resident #71 reported he had a little paranoia, felt his phoneline was tapped and felt the need to hide his smoking materials.In an interview on 9/23/25 at 11:50am, Licensed Practical Nurse (LPN) KK reported it was the expectation that staff maintain Resident #71's smoking materials in a cupboard in the locked medication room on his hall. LPN KK reported the floor nurse was expected to regain possession of Resident #71's smoking materials each time he returned from going outside to smoke and then sign the Leave of Absence form.During an observation on 9/23/25 at 11:55am, no smoking materials for Resident #71 were present in the cupboard in the locked medication room of his hall.In an interview on 9/23/25 at 11:02am, Certified Nursing Assistant (CNA) F reported on the evening of 9/20/25 at approximately 5:00pm, she smelled smoke in the hallway near Resident #71's room. CNA F reported the smell intensified as she approached Resident #71's room and when she entered, a smokey haze was present in the room. CNA F reported Resident #71 was sitting in his bed, his oxygen concentrator was running, but the resident did not have his oxygen cannula in his nostrils. CNA F reported she did not see Resident #71 actively smoking when she entered the room. However, CNA F reported based on the smell and the smoke in the room, she was certain Resident #71 had been smoking in his room, and she reported her concern to Registered Nurse (RN) X.In an interview on 9/23/25 at 10:34am, RN X reported she was in another resident's room on 9/20/25 around 5:00pm, when CNA F came to her and reported smoke coming from Resident #71's room. RN X reported she immediately went to investigate, found the resident's door and windows open, and noticed a haze of smoke in Resident #71's room. Resident #71 sat on his bed, with his oxygen concentrator running nearby. His oxygen cannula was on the floor near his bed. RN X reported she began searching the resident's room for his cigarettes and lighter, because she was sure the resident had been smoking, but Resident #71 demanded she get out of his room. RN X reported she was told by management to contact the police for assistance. RN X reported she had never seen Resident #71's smoking materials locked up where other resident's smoking materials were kept. RN X reported after she called the police, a deputy came to the facility, met with Resident #71 and removed a working lighter from the resident's possession. RN X reported she locked the lighter in the medication cart. When further queried, RN X reported she tested the lighter and found it was in working condition.Review of a Sheriff's Office Summary with a reference date of 9/20/25 at 5:21pm, revealed I was called to (facility name omitted) to assist staff with a resident who was not following the rules. Staff advised me (Resident #71) was not obeying the rules. Staff advised me that he (Resident #71) was smoking inside, and they were requesting that I collect his lighter and cigarettes. I made contact with (Resident #71) who denied smoking inside but handed over his lighter.In an interview on 9/23/25 at 11:16am, CNA DD reported she had seen Resident #71 smoking just outside the front door of the facility at times despite being told he had to leave the property to smoke. CNA DD reported Resident #71 was supposed to turn in his smoking materials to the nurse as soon as he returned indoors but she did not think the resident did so because he went outside multiple times each night. CNA DD reported the facility was aware of other incidences in which Resident #71 was found with smoking materials in his possession and there was suspicion that the resident hid his supplies somewhere on the facility grounds. CNA DD reported one time she was assigned to go outdoors with the resident while he led her to find his smoking materials. CNA DD reported the resident led her all over the property but never divulged where his smoking materials were hidden.In an interview on 9/24/25 at 1:55pm, Nursing Home Administrator (NHA) A reported the facility was aware Resident #71 had a history of maintaining possession of his smoking materials in his room and it was suspected the resident also hid smoking materials outdoors. NHA A reported at times Resident #71 refused to give his smoking materials to the staff when he returned from smoking outdoors and refused to allow staff to search his room. When further queried, NHA A confirmed although Resident #71 had the right to privacy, the facility was responsible to maintain a safe environment for every resident, which outweighed his right. NHA A reported no further interventions had been put in place to mitigate the risks involved with Resident #71 possessing a lighter in his room because she assumed the resident was no longer interested in smoking due to his physical decline.Resident #24Review of an admission Record revealed Resident #24 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: restlessness and agitation and severe intellectual disability.Review of a Minimum Data Set (MDS) assessment for Resident #24with a reference date of 6/23/25, revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #24 was-severely cognitively impaired.Review of a Care Plan for Resident #24 with a reference date of 2/23/25, revealed a focus/goal/interventions of: (Resident #24) is at risk for fall related injury and falls R/T (related to): weakness, impaired mobility, severe intellectual disability, seizures.Goal: Will be free from injury related to falls.Interventions: I need dycem (therapeutic material that creates friction between two surfaces) to my wheelchair cushion to help reduce my risk of falls.anticipate needs and meet.During an observation on 9/24/25 at 10:58am, Resident #24 quickly emerged from the dining room into the 300 hall, as an unknown staff member pushed Resident #24's wheelchair. Resident #24 had no footrests on her wheelchair and the staff member walked briskly as she pushed the resident. Resident #24's legs were extended in front of her and hovered above the floor 3-4. Uncoordinated up and down movements were noted in Resident #24's legs as she was pushed >75', down the entire 300 hall, until both she and the staff member disappeared around the far corner.In an interview on 9/24/25 at 1:39pm, Registered Nurse (RN) P reported residents should never be pushed in a wheelchair unless footrests are in place to support the resident's feet. RN P reported footrests are necessary to prevent the resident from dropping their feet down onto the floor while in motion which could then cause them to fall forward out of the wheelchair. RN P also reported that pushing a resident in a wheelchair without using footrests left the resident at higher risk for sustaining foot injuries because their feet could get caught in the wheels or bump against obstacles.Review of a Nurses Note for Resident #71, with a reference date of 9/12/25 at 9:43pm revealed .This nurse asked if she could check his (Resident #71) oxygen level.the level was 64%. It was noted that he was not wearing his supplemental oxygen. When this nurse brought this to (Resident #71's) attention he stated that he did not need it and then asked(sic) do you want to know why?. He then stated he didn't want to live anymore. This nurse explained that not wearing his oxygen was not a way to die. He then stated he would just smoke a cigaretteIn an interview on 9/24/25 at 1:55pm, NHA A confirmed it was the expectation that staff members place footrests on a resident's wheelchair before assisting them with wheelchair mobility.

Based on observation, interview, and record review, the facility failed to identify the need of a bubbler/humidifier to aid in oxygen therapy for 1 of 1 resident (R69) reviewed for oxygen therapy, resulting in the resident experiencing dryness and sores in her nose resulting in psychosocial and physical distress. Findings include: R69According to R69's Minimum Data Set (MDS) dated [DATE], the resident was independent performing her ADLs (activities of daily living). The resident's BIMS (Brief Interview Mental Status) had not been completed however, in conversations with the resident, she was able to recall long and short-term memories and hold an intellectual conversation. Review of R69's Diagnoses List included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and emphysema.Review of R69's Order Summary, dated 2/21/25, revealed, Oxygen at 2 L/min (deliver liters per minute) via nasal cannula (NC) to maintain saturation greater than 88% every shift for COPD.Review of R69's Care Plan revised 9/2/25, indicated a focus a potential for difficulty breathing and being at risk for respiratory complications related to COPD, emphysema, asthma, and requiring the use of oxygen. The goal was for R69 to display an optimal breathing pattern daily with no labored breathing using interventions that included administering medication and treatment per orders and monitoring for adverse reactions.Observation and interview on 9/22/25 at 10:00 AM, R69 was sitting in her room in a recliner wearing oxygen set at 2 lpm stating, My nose gets dry and has sores in it from the oxygen I wear. I had a bubbler/humidifier (device to provide moistened oxygen that can be very dry and uncomfortable when inhaled directly) at home before I came here and that helped with the dryness.During an observation and interview on 9/24/25 at 8:55 AM, R69 was awake in her recliner wearing oxygen via NC stating, Oxygen dries out my nose and causes sores and scabs. I had a bubbler at home, and it helped a lot. I've told nurses I'd like one but still have not gotten one.During an observation and interview on 9/24/25 at 9:05 AM, Director of Nursing (DON) B in R69's room observed there was no bubbler/humidifier on the resident's oxygen concentrator. R69 stated she had a bubbler at home that helped keep her nose from drying out and causing sores and scabs on the inside of her nose. R69 also explained to the DON she has told the nurses she would like one and that the saline spray she was ordered does not help her like a bubbler does. The DON stated she was unaware of the resident's need and want of a bubbler.

Based on interview and record review the facility failed to ensure that residents pain medications as ordered in 1 resident (Resident #7) of 6 residents reviewed for medications, resulting in Resident #7 receiving prescribed opioid (pain reliever) medication at a lower dose than the physician had ordered potentially causing Resident #7 to be at risk for breakthrough pain.Findings include:Resident #7(R7)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R7 admitted to the facility on [DATE] with pertinent diagnoses including hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction (stroke), dementia (decline in mental abilities such as memory, thinking and reasoning that is severe enough to interfere with daily life), aphasia (impaired speech and language that can limit ability to communicate) and depression. Brief Interview for Mental Status (BIMS) could not be completed due to R7's cognitive impairment. She was under Hospice care due to her terminal diagnosis. On 9/22/2025 at 10:36 AM, R7 was observed in her gerichair in the common room up front at the facility. She was resting with her eyes closed. Review of R7's progress note dated 8/25/2025 and documented by Assistant Director of Nursing (ADON) S revealed This writer noticed resident was receiving 2.5mg of methadone in error instead of her 5mg order. Family was notified, provider was contacted with no new orders, hospice was notified. Resident is not showing any S/S (sign/symptoms) of increased pain, this writer administered 5mg methadone as order reads.Review of Medical Record Coordination Notes Report dated 8/25/2025 and documented by Hospice Registered Nurse (RN) revealed RN returned call to (ADON S) who wanted to confirm (methadone) medication order. She states that staff had only been giving 2.5 mg when the order is for 5 mg's. (ADON S says she wanted to make sure it wasn't changed and she was not aware. RN confirmed with medication list that the order is 5MG three times daily. Review of R7's Medication Error Report dated 8/25/2025 revealed .Description of Error: Methadone dose change from 2.5 mg to 5 mg on 8/20/25. Current form reads methadone 5 mg, but in smaller lettering indicates they are 2.5 mg because of 1/2 tablets. Outcome to resident and care provided: no noted increase in pain. Physician instructions: Destruction of 2.5 mg tablets. 25, 5 mg tablets received to prevent repeat error. Summary of Error: wrong dose. Misread error. Corrective action taken: med (medication) destruction of 2.5 mg tablets. Person making error: multiple (nurses). Person Correcting Error: (ADON S).Review of R7's physician order history for methadone with a start date of 1/7/2025 and end date of 8/20/2025 revealed Give 2.5 mg (milligrams) by mouth every 8 hours for pain. The order was changed on 8/20/2025 to Give 5 mg by mouth every 8 hours for pain.During an interview on 9/23/2025 at 2:11 PM, ADON S stated that she worked the nurse's cart on 8/25/2025 and noted the methadone order increased to 5 mg on 8/20/2025 and she had 2.5 mg tablets on the cart and that's when she realized the nurses were giving one 2.5 mg of methadone to R7 instead of two 2.5 mg tablets. Review of the August MAR revealed that there were 14 opportunities of administering 5 mg of methadone and there were 14 errors of where 2.5 mg of methadone was given instead. There were 5 different nurses involved with administering these medication errors. During a phone interview on 9/24/2025 at 9:03 AM, Registered Nurse (RN) EE stated she didn't know about a medication error with R7's methadone.During a phone interview on 9/24/2025 at 9:56 AM, RN DDD stated she didn't know about a medication error with R7's methadone.During a phone interview on 9/24/2025 at 1:10 PM, RN CCC stated she didn't know about a medication error with R7's methadone. During an interview on 9/23/2025 at 4:01 PM, LPN W stated she didn't know anything about a medication error with R7's methadone. During an interview on 9/23/2025 at 4:08 PM, Director of Nursing (DON) B stated that ADON S found the medication error while working the cart and the nurses working previously didn't question the order change. DON 'B said she didn't do any education with nurses about the medication error or any 1:1 education with the nurses involved. She was going to discuss it at the monthly nurse's meeting that was scheduled for next week. Review of the Medication Administration Policy with a revision date of 10/17/2023 revealed .Procedure: 2. Verify the medication label against the medication administration record for resident name, time, drug, dose and route. A. The nurse is responsible to read it and follow precautionary instructions and prescription labels. B. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the doses or directions, the physician orders are checked for the correct dosage schedule. C. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved.

Based on observation, interview and record review, the facility failed to provide medically related social services to attain and maintain the mental and psychosocial health for 3 (Resident #71, Resident #13 and Resident # 4) of 18 residents reviewed for social services resulting in: 1. lack of evaluation of psychosocial needs for Resident #71, 2. expired resident guardianship paperwork for Resident #13, and 3. lack of care planning for Resident #4's psychiatric diagnosis with mood/behavior concerns and the use of psychotropic medication.Findings include: Resident #71 Review of an admission Record revealed Resident #71 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alcohol abuse, depression (persistent sad mood that impacts daily life) and chronic respiratory failure with hypoxia (a condition in which the lungs cannot adequately provide oxygen to the body, leading to low oxygen levels). Review of a Minimum Data Set (MDS) assessment for Resident #71 with a reference date of [DATE], revealed the resident refused to complete a Brief Interview for Mental Status (BIMS) assessment. Section E of the MDS revealed Resident #71 exhibited rejection of care daily. Review of a Care Plan for Resident # 71 with a reference date of [DATE], revealed a focus/goal/interventions of: (Resident #71) has the potential for mood difficulties r/t (related to) history of drug use, homeless status, paranoid thoughts related to staff.Goal: Mood will have minimal effects on daily life.Interventions.approach in calm, quiet manner. Maintain appropriate body language during interactions.observe and report to SW (social worker) .changes in mood or behavior. During an observation and interview on [DATE], at 1:33pm, Resident #71 reported he experienced feelings of anger and paranoia. Resident #71 pointed to his room phone and stated, You see that phone there, it's tapped. Resident #71 reported he frequently felt anxious and struggled to talk about his situation because doing so caused him increased anxiety. At that point, Resident #71 began taking rapid, shallow breaths, waved his left hand over his chest and looked away. After 30 seconds, Resident #71's breath rate lowered, he turned back toward the surveyor and stated, I know I'm going to die. Review of a Nurses Note for Resident #71, with a reference date of [DATE] at 9:43pm revealed .This nurse asked if she could check his (Resident #71's) oxygen level.the level was 64%. It was noted that he was not wearing his supplemental oxygen. When this nurse brought this to (Resident #71's) attention he stated that he did not need it and then asked(sic) do you want to know why?. He then stated he didn't want to live anymore. This nurse explained that not wearing his oxygen was not a way to die. He then stated he would just smoke a cigarette. Review of a Patient Health Questionnaire 2 (PHQ 2-9) for Resident #71 with a reference date of [DATE], revealed a score of 5 which indicated he experienced depression. Review of a Social Services Re-evaluation with a reference date of [DATE] revealed (Resident #71.is alert and oriented.with demonstration of illogical flow of thoughts and distracted thinking with changes in severity. Review of a Standard Evaluations list for Resident #71 revealed the following overdue evaluations: PHQ 2-9 Evaluation due date [DATE], Social Service Re-evaluation due date [DATE]). In an interview on [DATE] at 12:02pm, Social Services Director (SSD) FF reported she had no documented interactions with Resident #71 in the past 3 months. SSD FF confirmed the last documented social services interaction with the resident was on [DATE], approximately 15 weeks prior to [DATE]. SSD FF reported the resident should have had a Social Services Re-evaluation done a few weeks ago but stated she must have missed it. SSD FF reported the areas she would assess during a Social Services Re-evaluation included: changes in mood and behavior and changes in mental or cognitive status. When further queried about behavioral health services offered to Resident #17, SSD FF confirmed services had not been offered to Resident #71 in last 12 months. Review of a Social Service Program policy with a reference date of [DATE] revealed Policy.The facility will provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.The social service department will assist with.ongoing assessment and comprehensive care planning,.making referrals and obtaining needed services.Situations in which the facility should provide social services include lack of.legal representative. Resident #13 Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia and cognitive communication deficit. Review of Resident #13's Letter of Co-Guardianship dated [DATE] revealed, In the matter of (Resident #13), a legally incapacitated individual . it is ordered the guardianship is continued without modification. The guardian(s) shall continue to file annual reports. The court shall conduct the next review on [DATE] . In an interview on [DATE] at 8:35 AM, Social Services Director (SSD) FF reported that Social Work was responsible for ensuring that all residents with a legal guardian had current guardianship paperwork in their electronic medical record (EMR). SSD F was not able to report how often the facility was reviewing resident guardianship paperwork was not expired. SSD F reviewed Resident #13's Letter of Co-Guardianship with this writer and confirmed that the legal document was expired and could not be used as verification that Resident #13's had an active guardian in place. SSD F was unable to report if Resident #13 still had an active legal guardian. SSD F confirmed that the facility should have identified that Resident #13's guardianship paperwork was expired, and that this was missed. Resident #4 Review of an admission Record revealed Resident #4 was a female, with pertinent diagnoses which included stroke, dementia, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total score of 15, indicating severe cognitive impairment. Further review of this assessment for Resident #4 revealed Section I - Active Diagnoses had a check next to bipolar disorder, and Section N - Medications indicated Resident #4 took antipsychotic medications on a routine basis. Review of an Order Summary Report for Resident #4 revealed the physician order .QUEtiapine Fumarate (an antipsychotic medication) Oral Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet via G-Tube (gastrostomy tube) two times a day for Bipolar disorder . with a start date of [DATE] and a status of discontinued. Further review revealed the physician order .QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 25 mg via G-Tube two times a day for mood disorder . with a start date of [DATE] and a status of discontinued. Lastly, the active physician order .QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 25 mg via G-Tube two times a day for Bipolar disorder . was noted for Resident #4 with a start date of [DATE]. Review of the Care Area Assessment (CAA) for Psychotropic Drug Use for Resident #4, contained within the [DATE] MDS assessment, revealed .Triggering Conditions .High-Risk Drug (Is Taking): Antipsychotic .Checked (Yes) .(Resident #4) is taking Seroquel-antipsychotic medication to (manage) mood and behavior r/t (related to) Bipolar disorder. (She) is referred for psych services to (manage) behavior and (for) medication adjustment. (She) was noted with (an) episode of agitation, stripping (her) clothes and pulling (her) G-tube, (relieved) after taking scheduled medications .Care Plan Considerations .Will Psychotropic Drug Use be addressed in the care plan? Yes .Will proceed to care plan to manage mood and behavior and monitor potential adverse (effects) of medication that may impact quality of life . Review of a Care Plan Report for Resident #4 revealed no focus/goal/interventions related to her diagnosis of bipolar disorder, mood/behavior concerns, and routine use of antipsychotic medications. In an interview on [DATE] at 2:44 PM, Social Service Director (SSD) FF reported care plans are created for residents based on the information in the medical record, information from residents/family members, social service assessments, MDS assessments and CAAs. SSD FF reported when completing a CAA during the MDS process, a decision is made whether to proceed to the care plan when specific items/areas are triggered. SSD FF reviewed Resident #4's Care Plan and acknowledged there was no focus/goal or interventions related to Resident #4's diagnosis of bipolar disorder, mood/behavior concerns, and routine use of antipsychotic medications.

Based on interview and record review, the facility failed to ensure timely follow up with pharmacy recommendations occurred for 2 residents (Resident #3 and Resident# 51) of 5 residents reviewed for medications resulting in the potential for medication side effects and/or unnecessary medications for residents. Findings include: Resident #3Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety disorder. Review of Resident #3's Medication Regimen Review (MRR) dated 6/11/25 revealed, (Resident #3) is receiving Seroquel (antipsychotic medication). Epidemiological studies suggest an increased risk of hyperglycemia (high blood sugar levels)-related adverse effects during atypical antipsychotic use. These agents have been associated with extreme case of hyperglycemia, ketoacidosis (complication of diabetes where the body cannot produce enough insulin), hyperosmolar coma (serious complication of diabetes that happens when blood sugar levels are very high for a long period of time), and death. In post-marketing trials, elevations of total cholesterol (primarily LDL- low-density lipoprotein) have been observed. It is advisable to monitor cholesterol and triglyceride levels periodically in patients receiving antipsychotics, particular those with pre-existing hypercholesterolemia (disorder known for an excess of low-density lipoprotein (LDL) in your blood) or hypertriglyceridemia (Hypertriglyceridemia means you have too many triglycerides (fats) in your blood. This raises your risk of atherosclerosis and related heart diseases.). Recommendation: Please consider obtaining a fasting lipid panel on the next convenient lab day and then periodically thereafter. Physician/provider response: Agree. Order repeat labs to see trend. This was signed by the Medical Doctor (MD) UU on 9/17/25. Review of Resident #3's MRR dated 7/9/25 revealed, (Resident #3) has received Seroquel for over one year with the current dose of 75 mg (milligrams) at bedtime. Recommendation: Please consider a gradual dose reduction, perhaps decreasing to Seroquel 50 mg at bedtime while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. If therapy is to continue at current dose, please provide rationale describing why a dose reduction is clinically contraindicated . Physician/provider response: Disagree. Care collaboration with Psych; GDR contraindicated at this time. (MD UU) reviewed via phone. This was signed by Director of Nursing (DON) B. It was noted that there was not a date noted on when this review was completed via phone by MD UU. In an interview on 9/24/2025 at 10:01 AM, DON B reported that she had discovered that the facility had not been receiving resident medication regimen reviews in August 2025. DON B reported that the consulting pharmacist had been sending the reviews to the previous Director of Nursing, and the facility was unaware, so all residents in the facility had not had medication reviews completed for several months. DON B reported that she did not know how many months of reviews the facility had missed. When this writer queried about Resident #51's June medication review, DON B confirmed that the facility provider had not reviewed this recommendation from June 2025 until September 2025, so there was a delay of Resident #3 getting the recommended lab order completed. When this writer queried DON B about Resident #3's July 2025 lab order, DON B reported that she could not recall when she had reviewed the July 2025 recommendation with MD UU because she did not note the date on the review. DON B confirmed that this review had not been placed in Resident #3's electronic medical record (EMR) and was not made available until this writer requested it. DON B reported that she should have dated the MRR, and it also should have been signed by MD UU. DON B confirmed that she could not verify that Resident #3's July 2025 recommendation was reviewed timely. Resident #51 Review of an admission Record revealed Resident #51 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease and major depressive disorder. Review of Resident #51's MRR dated 5/27/25 revealed, (Resident #51) is noted to be experiencing new onset or worsening of falls as indicated on medication regimen review request. Patient (Resident #51) is receiving Seroquel 75 mg in the morning- 50 mg at noon and 75 mg in the evening. Patient's recent lipid panel indicates severe hypertriglyceridemia (too many triglycerides (fats) in your blood) which may be attributable to long term atypical antipsychotic use. Patient has been receiving the same dose for over two years. Patient has continued episodes of delusions. Patient may have symptoms of orthostatic hypotension (a condition where blood pressure drops significantly upon standing up from a sitting or lying position) with recent recorded value of 143/76 while sitting which dropped to 117/61 upon standing. Recommendations: Please evaluate current Seroquel dose, perhaps decreasing to 50 mg twice daily and 75 mg in the evening as contributing to this change in status . Physician/provider response: The provider did not respond or sign this form. Review of Resident #51's MRR dated 8/8/25 revealed, (Resident #51) receives Glucophage (Metformin) (oral medication used to treat diabetes) and does not have a serum B-12 level found in the resident medical record. Certain individuals (those with inadequate vitamin B-12, folic acid, or calcium intake or absorption) appears to be predisposed to developing subnormal vitamin B-12 levels. In these patients, routine serum vitamin B-12 measurements at 2-3-year intervals may be useful. Recommendation: Please consider obtaining a serum B-12 level on the next convenient lab day. Physician/Provider response: Agree. Ok order. This was signed by MD UU on 9/17/25. In an interview on 9/24/2025 at 10:01 AM, DON B reported that she did not know if any provider had reviewed Resident #51's MRR on 5/27/25 as the facility did not have verification of a provider response. DON B confirmed that Resident #51's MRR dated 8/8/25 was not reviewed by a provider in the facility until 9/17/25. DON B reported that the facility was still working through completing medication reviews for residents from the last 3 months for all residents in the facility. DON B reported that MD UU had been completing the medication reviews for all residents. In an interview on 9/24/2025 at 12:46 PM, MD UU reported that he had reviewed multiple outstanding medication reviews for the facility on 9/17/25. MD UU reported that he was not aware of the facility process for completing medication reviews, but that he was helping the facility catch up on the late reviews in the facility. In an interview on 9/24/2025 at 2:27 PM, Nursing Home Administrator (NHA) A reported that the facility had discovered in August 2025 that the facility had not been reviewing resident medication regimen reviews. NHA A reported that she did not know how long the facility had missed the reviews, but that the facility was currently reviewing the last 3 months of reviews for all residents. Review of the facility's Timeliness of Medication Regimen Review Reports fated 9/7/23 revealed, Policy: The pharmacist will review and report and medication irregularities at least once a month. 1. With new admissions, the consultant pharmacist will complete a MRR and provide a report via secure email within 72 hours to the Director of Nursing/designee. 2. Clinically significant medication issues, identified by the consultant pharmacist during the admission medication regimen review, must be communicated to the prescriber or the designee and resolved by 11:59 P.M. the following day. 3. The consultant will provide monthly MRR reports addressed to the Medical Director, Director of Nursing, and Attending Physician within 3-5 days of completion via secure email or hard copy. 4. The attending physician is expected to review the resident's individual MRR and document and sign that he/she has reviewed the pharmacist's identified recommendations within 14 days of receipt. 5. If the attending Physician does not respond to the resident's MRR report within 14 days, the Director of Nursing will notify the physician of the pending MRR reports. 6. If by the 21st day, the attending physician has not yet responded to the resident's individual MRR report, the Director of Nursing will notify the Medical Director to review and respond to the pending MRR reports. 7. If the Medical Director is also the attending physician, the Director of Nursing will escalate the issue to the facility Administrator. 8. When the consultant pharmacist identifies a recommendation that requires immediate or urgent action, the pharmacist will notify the Director of Nursing and the assigned nurse at the time the recommendation is identified.

Based on observation and interview the facility failed to provide food at a palatable texture for 2 residents (R69 and R73) of 18 residents reviewed for palatable foods and 3 of 14 residents in attendance of a confidential meeting, resulting in the potential for decreased food consumption and the potential for nutritional decline.Findings include:R69 According to R69's Minimum Data Set (MDS) dated [DATE], the resident was independent performing her ADLs (activities of daily living). The resident's BIMS had not been completed however, in conversations with the resident, she was able to recall long and short memories and hold an intellectual conversation. Review of R69's Diagnoses List included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and emphysema. During an interview on 9/22/25 at 10:00 AM, R69 complained of cooked vegetables being too soft. R73 According to the MDS dated [DATE], R73's BIMS score of 15 /15 indicated she was cognitively intact. Her diagnoses included cancer. During an interview on 9/22/25 at 11:14 AM, R73 complained she does not like the cooked vegetables because they are runny and are like mush. In a confidential meeting on 09/24/2025 at 11:22 AM, 3 of 14 residents in attendance reported they were consistently served vegetables that were overcooked resulting in a mushy texture that made the food unappealing. The residents reported the mushy vegetables oozed moisture that drained into the surrounding foods on their plates, making other foods unappealing as well. 1 resident stated, I can't eat those vegetables, and they make the other food look unappetizing when it gets runny. On 9/22/25 at 12:05 PM a regular lunch meal test tray was plated for the Rehab / A side hall and was the first meal plated among the 18 trays loaded on the hall cart. The meal consisted of chicken fettucine alfredo, broccoli, and a roll on a heated base with an insulated cover. The dessert was an upside-down pineapple cake. On 9/22/25 at 12:15 PM, The meal cart was loaded and on the hall for Rehab / A side. On 9/22/25 at 12:29 PM, All meals from the cart were delivered and the test tray was in the conference room with the following temperatures (taken with a digital rapid read thermometer): Fettucine [NAME] was 123F, and the Broccoli was 125F. Observation and taste of the broccoli found they were overly tender to the point of being mushy.

This citation pertains to intake # 2592873.Based on interview, and record review, the facility failed to provide adequate supervision to prevent elopement and respond appropriately to an alarming exit door to ensure resident safety in 1 of 5 residents (Resident #101) reviewed for elopement/supervision, resulting in an Immediate Jeopardy when on 8/13/25 between 8:30 PM and 8:45 PM, Resident #101, who was an elopement risk with a prior recent history of elopement, exited the facility, unbeknownst to facility staff, and was found by a Certified Nursing Assistant (CNA) approximately 0.3 miles away from the facility, sitting on the front porch of a residential home. This deficient practice placed all residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death.Findings include:The facility failed to provide adequate supervision to prevent elopement for an exit seeking resident, Resident #101, who was an elopement risk with a prior recent history of elopement, and respond appropriately to an alarming exit door to ensure resident safety. Resident #101 was found by a Certified Nursing Assistant (CNA) approximately 0.3 miles away from the facility, down a 35 MPH (miles per hour) road, sitting on the front porch of a residential home on the opposite side of the street.The Immediate Jeopardy began on 8/13/25 when the facility failed to supervise Resident #101 and he eloped from the facility between 8:30 PM-8:45 PM. The Director of Nursing (DON) B and Regional Clinical Coordinator (RCC) V were notified of the Immediate Jeopardy on 8/19/25 at 3:28 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 8/19/25, but noncompliance remains at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance has not been verified by the State Agency.In an observation on 8/19/25 at 9:25 AM, completed a tour of the facility with DON B to review placement/functioning of wander guard devices for current residents identified as At Risk for elopement. Noted one resident within the facility wore a Fitbit style wander guard device on their right wrist.In an observation and interview on 8/19/25 at 9:42 AM, the front door/main entrance wander guard alarm system was tested, accompanied by Environmental Service Director I. Environmental Service Director I reported the door alarm/wander guard system was checked daily for appropriate functioning. Environmental Service Director I reported the front doors are unlocked during the day (between 7:00 AM-7:00 PM), however, if a resident wearing a wander guard were to approach the doors they would automatically lock. Environmental Service Director I reported an alarm would sound if a resident wearing a wander guard device were to attempt to exit the facility through the front doors while the door was ajar, or by pushing on the door for 15-seconds. This surveyor tested the front door wander guard locking system while holding an active Fitbit style wander guard device. Noted the front doors initially locked when approached with the Fitbit style device, however, after 3-4 approaches the automatic lock did not activate and this surveyor was able to open the front door without an alarm sounding. Regional Clinical Coordinator (RCC) V reported the Fitbit style device was an older device, no longer used by the facility. RCC V provided the newer style wander guard device, which appeared much more sensitive during observation and locked down every time when approached.In an observation on 8/19/25 at 10:22 AM, the fire exit door within the main dining room was observed with Environmental Service Director I. Noted the exit door must be pushed for 15-seconds to open which would activate an alarm (no code required to open the door by using the 15 second egress). No wander guard system noted on this exit door. Observed a keypad on the wall to the right of the main dining room fire exit door, with a grey flip-open panel labeled CODE FOR EMERGENCY EXIT. The box was easily opened and at eye level. Noted the code to exit the door posted within the flip-open panel.In an observation and interview on 8/19/25 at 11:26 AM, the fire exit door within the main dining room was observed with Environmental Service Director I. Again, noted the flip-open panel which contained the code to exit the door, posted on the wall to the right of the door at eye level. Environmental Service Director I entered the code and was able to open the door without activating the alarm system. Environmental Service Director I reported there was no wander guard system installed on this exit door, and he was unsure why the exit code was posted.Resident #101Review of an admission Record revealed Resident #101 was a male, with pertinent diagnoses which included cognitive communication deficit (a communication problem resulting from difficulties with cognitive function), dementia, depression, anxiety, arthritis, and insomnia. Further review of the admission Record revealed Resident #101 was not his own responsible party.Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 7/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated severe cognitive impairment. Further review of this assessment revealed Resident #101 had cognitive symptoms which included inattention and disorganized thinking, along with wandering behaviors.Review of a Care Plan for Resident #101 revealed the focus (Resident #101) is at risk for elopement R/T (related to): impaired cognition d/t (due to) advanced dementia, elopement score of 12 . revised 7/21/25, with interventions which included Apply wanderguard per order. Check placement, function and expiration date per facility protocol. Wanderguard to: left ankle . initiated 7/18/25 and revised 7/21/25, .Approach in a slow, calm manner and redirect away from exit doors as needed . initiated 7/21/25, .Distract resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, conversation etc . initiated 7/21/25, .Invite and encourage (Resident #101) to participate in an activity in the day room or a group activity. May needs (sic) assistance to and from activities of interest . initiated 8/7/25, and .Provide structured activities, toileting, walking inside and outside with supervision as needed . initiated 7/18/25.Review of a Risk for Elopement assessment for Resident #101, dated 8/12/25, revealed a score of 13.0 indicating he was At Risk for elopement.Review of an Incident Report for Resident #101, dated 8/13/25 at 8:40 PM, revealed .This writer/RN (Registered Nurse (RN) N) attempted to administer scheduled medication at (8:30 PM). Resident was not in room. Had been previously seen walking in halls and sitting in day room. RN and (CNA T) checked halls to determine resident's location. Unable to locate resident. Code Search called at (8:40 PM). (Administration) and police notified. (Three) staff members .searched outside building including wooded areas and street. Resident not located, (CNA C) used vehicle to search further down street. Resident located by (CNA C), returned to (facility) approximately (9:00 PM). Resident pleasantly confused, assessment normal, denies pain or injury .Police reported to facility after resident located .Resident placed on constant 1:1 observation .Review of a Nurses Note dated 8/13/25 at 9:06 PM, revealed .RN attempted to administer medication, was not able to locate resident. Code search called at (8:40 PM), resident located outside the building by staff. (RN N) called 911 to report, follow up call to update that resident was located. Police reported to facility after resident located .In an interview on 8/19/25 at 11:00 AM, CNA E reported she saw Resident #101 walking throughout the facility the evening of 8/13/25, prior to his elopement. CNA E reported she heard an alarm sound at the front door at approximately 8:40 PM. CNA E reported she responded to the alarm and stated .I didn't go outside but I looked out the window at the doorway. I didn't see anybody there . CNA E reported she was unsure how long the alarm was going off prior to responding, as she had just come out of a resident's room when she heard the alarm. CNA E reported she had recently received education on the elopement policy as Resident #101 had a prior elopement a few weeks before and stated .I was supposed to go outside. I didn't remember that I was supposed to go outside and look to see if anybody was there . CNA E reported when staff realized Resident #101 was missing, another CNA left the facility in a vehicle and found Resident #101 down the road.In an interview on 8/19/25 at 11:08 AM, CNA L reported she was working the evening of Resident #101's elopement, on 8/13/25. CNA L reported she saw Resident #101 about thirty minutes prior to the elopement, in the activity room. CNA L reported she did not hear any alarms, and first became aware that Resident #101 was missing when a nurse called a CODE SEARCH and stated .we started looking for him .In an interview on 8/19/25 at 11:46 AM, CNA H reported she was working on a different unit the evening of Resident #101's elopement on 8/13/25. CNA H reported she observed Resident #101 wandering throughout the facility prior to the elopement. CNA H stated .I noticed he was wandering and wondered why someone wasn't following him or looking after him. When I had him (was assigned to him) I would watch him . CNA H reported when she first arrived, she observed Resident #101 near the front entrance, and as the night progressed she observed Resident #101 wandering up and down the halls and trying to go into other residents' rooms. CNA H reported Resident #101 often made statements about leaving the facility and stated staff had to .talk him out of it . or .make up something to get him to stay inside . CNA H reported sometime after 8:00 PM, a staff member asked if she had recently observed Resident #101. CNA H reported they all acknowledged it .had been a while . since anyone had observed Resident #101 within the facility, so staff began a search, and stated .we couldn't find him anywhere . CNA H reported several staff members left the facility in vehicles to search down the road, and the resident was ultimately located down the street from the facility on the front porch of a residential home.In an interview on 8/19/25 at 2:42 PM, Family Member Y reported she was notified of Resident #101's elopement on 8/13/25. Family Member Y reported she was told a staff member responded to a door alarm and deactivated the alarm, not thinking it was an issue. Family Member Y reported shortly after, staff realized Resident #101 was missing and went looking for him. Family Member Y stated .Thank God, they found him .In an interview on 8/20/25 at 8:27 AM, RN J reported she was in a resident's room the evening of 8/13/25 at approximately 8:20 PM and thought she heard a door alarm sound. RN J reported when she exited the room, she no longer heard the alarm. RN J stated .a CNA came around the corner and said she took care of the alarm, and everything was good . RN J reported she then continued with medication administration. RN J reported a short time later, another staff member came and asked her if she had recently seen Resident #101. RN J reported she recalled the alarm sounding earlier and went to clarify with the CNA what had set off the door alarm. RN J reported the CNA reported there was no one present at the front entrance when she responded to the door alarm, and indicated she had looked out the window, but had not exited the building to look prior to deactivating the front door alarm. RN J reported at that point staff called a CODE SEARCH at approximately 8:40 PM and a head count was initiated, along with a search for Resident #101 both inside and outside of the facility. RN J reported Resident #101 was found approximately fifteen minutes later, down the street from the facility sitting on the porch of a residential home.In an interview on 8/20/25 at 8:40 AM, CNA C reported she arrived at the facility for her shift on 8/13/25 at approximately 8:00 PM. CNA C reported she was not assigned to Resident #101, however, she did observe him walking throughout the halls. CNA C reported she did not hear any door alarms but realized there was an issue when a CODE SEARCH was called and staff began searching for Resident #101. CNA C reported she and RN N immediately went outside and began searching the perimeter. CNA C reported when Resident #101 was not immediately located, she took her car and began a search for the resident down the street. CNA C reported she located Resident #101 sitting on the front porch of a residential home, across the street from the church (approximately 0.3 miles away), on the opposite side of the road from the facility. CNA C reported when she found Resident #101, it was just starting to get dark outside.In an interview on 8/21/25 at 8:38 AM, RN N reported she was Resident #101's assigned nurse the evening of 8/13/25, at the time of his elopement. RN N reported prior to the elopement, she had observed Resident #101 in the activity room and walking throughout the hallways. RN N reported Resident #101 had a scheduled medication, which she prepared for administration at 8:25 PM. RN N reported she checked for Resident #101 in his room and in the hallway and was unable to locate him. RN N reported she asked RN J if she had seen Resident #101, and she had reported he had been in the area not long before. RN N reported she continued on and completed a loop around the facility. RN N reported when she approached RN J a second time without finding Resident #101, they decided to call a CODE SEARCH and complete a head count of the residents/begin a search for Resident #101. RN N reported the CODE SEARCH was called at approximately 8:40 PM on 8/13/25. RN N reported RN J recalled hearing the door alarm earlier in the evening. RN N reported she exited the facility to search for Resident #101 outside. RN N reported Resident #101 was found by CNA C on the porch of a residential home down the street from the facility.In an interview on 8/21/25 at 11:06 AM, DON B reported after Resident #101's first elopement in July 2025, he was placed on 1:1 observation for a period of time until he adjusted to the environment. DON B reported once the 1:1 observation was discontinued, staff were to supervise the resident as necessary and redirect Resident #101 away from the doors when exit-seeking. DON B reported Resident #101 wore a wander guard device due to elopement risk. DON B reported after Resident #101 was located on 8/13/25 after the second elopement, he was immediately placed on 1:1 observation which continued until his discharge from the facility on 8/15/25. DON B reported the CNA who responded to the door alarm on 8/13/25 (CNA E) acknowledged she should have exited the building to check outside when she responded to the door alarm with no one present and called a CODE SEARCH to begin a head count of the residents/ensure all residents were accounted for.Review of the policy/procedure Elopement, dated 4/26/22, revealed It is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility .Alarm Activation .If an employee hears a door alarm, he or she should .Immediately go (to) the site of the alarm .If no guest/resident is found to be exiting the facility, the employee should walk outside; conduct a visual observation of the immediate area to ensure that a guest/resident has not already exited the facility. If no guest/resident is observed, then the staff member will return into the building .In situations where the alarm sounds and a guest/resident is not found to have exited .Notify the licensed nurse immediately, and .Ensure that a head count is completed to ensure that all guests/residents are accounted for .The Immediate Jeopardy that began on 8/13/25 was removed on 8/19/25 when the facility took the following actions to remove the immediacy.1) Resident #101 was returned to the facility at approximately 9:05 PM on 8/13/25. Staff confirmed the wander guard was in place and functioning upon return to the facility. Staff were required to enter the door code in order for the resident to return to the facility. The door and wander guard were checked for functioning when Resident #101 returned on 8/13/25. The POA (Power of Attorney) for Resident #101 and the Physician were notified. Resident #101 was assessed with no injury noted on 8/13/25. An investigation was initiated, and the State Agency was notified.2) Resident #101 was placed on 1:1 supervision immediately upon return to the facility on 8/13/25. Social Services met with Resident #101's POA to discuss safe discharge for the resident. Discharge was planned for 8/15/25. On 8/15/25, Resident #101 discharged home with his wife.3) On 8/13/25, all doors were tested and noted to be in working order by the Licensed Nurses. The licensed nurse re-educated staff immediately on responding to door alarms and the need to exit the facility to observe if any resident is outside the facility that is an elopement risk.4) On 8/14/25, the Maintenance Director tested the front door and service hall door and alarms are sounding and doors lock down appropriately when checked with a wander guard.5) On 8/14/25, DON/designee initiated education with staff related to elopement, specifically the risk and expectation that staff will EXIT the facility when responding to a door alarm. Staff will walk the grounds and perimeter and observe the driveway to ensure no cognitively impaired residents are noted to be outside. Staff will be educated 8/14/25, and any staff member not educated on 8/14/25 will be educated prior to working their next shift. Staff were educated that failure to follow the policy and exit the building when door alarms are going off will result in disciplinary action up to/including termination. The CNA who did not follow policy on 8/13/25 was suspended and ultimately terminated for not following procedure. The charge nurse was given a written discipline for not ensuring the policy was followed.6) On 8/19/25, residents with wander guards were checked for placement and function. The Fitbit style wander guards were removed from the facility. One resident had their Fitbit style band replaced on 8/19/25 with the newer style.7) On 8/14/25, staff were educated to provide 1:1 observation to actively exit-seeking residents and notify the DON/Administrator if staffing needs to be adjusted/additional staff need to be provided.8) On 8/14/25, the DON/designee assessed all new admissions for elopement risk. No new residents were identified as an elopement risk at that time.9) On 8/14/25, Social Services checked the elopement books for accuracy with no concerns noted.10) The receptionist schedule was extended until 10:00 PM on 8/14/25. Doors will still lock at 7 PM, and the receptionist will be available to watch the door/assist families to exit until 10:00 PM. The front entrance door ONLY is unlocked and does not need a code to enter from 7:00 AM-7:00 PM. At 7:00 PM, the doors lock and require a code to be entered by staff in order to unlock the door. The door does have a release when the door is pushed for 15-seconds. When a wander guard is within 6 feet, the doors will lock down at all times of the day and if the resident is attempting to exit and pushing on the door handle, an alarm will sound.11) Beginning 8/14/25, the scheduler is to assign on the daily assignment sheet a staff member responsible for 1:1 observation of Resident #101.12) On 8/19/25, the door code label posted beside the exit door within the main dining room was removed.13) On 8/14/25, an elopement drill was completed.14) (Alarm Company Name) continues to service (Facility Name) regarding service hallway doors. Expectation for service doors to be changed out to new doors within 6-8 weeks from 7/24/25, and enunciators/strobes to be installed. The facility is waiting for a quote and to be put on the service calendar. (Alarm Company Name) is aware of the rush order. The service hall doors are also locked at all times and require a code to be entered to go through the doors. These doors have already been approved by BFS (Bureau of Fire Services).15) The Administrator/DON reviewed the elopement policy and deemed it appropriate on 8/14/25.16) The Administrator/DON initiated education with staff on 8/13/25, which included education on the elopement policy with stress on the expectation that staff WILL exit the facility when responding to a door alarm and observe for any cognitively impaired residents. The staff will walk the perimeter and observe the driveway to ensure no residents have left the facility unattended. Failure to do so will result in disciplinary action up to/including termination. Staff are to observe residents in house and those who are actively wandering/exit-seeking will be placed on 1:1 observation immediately with a call placed to the Administrator/DON. Nurses will ensure proper follow through when door alarms have sounded in facility. Staff were educated by 8/15/25, and any staff member not educated by 8/15/25 will be educated prior to working their next shift. The facility has educated 94/97 staff members, and the outstanding staff have not worked.17) An ad hoc (for a specific purpose) QAPI (Quality Assurance and Performance Improvement) meeting was completed on 8/14/25, with the Medical Director.18) The Maintenance Director/designee will complete elopement drills weekly x 4 on different shifts, including on the weekend for 30 days, then monthly per TELS (a system used to manage preventative maintenance and work orders) schedule. The Administrator/designee will question 5 staff members per week x 30 days and then monthly x 60 days on the elopement policy/procedure. The Administrator will review elopement drill findings in QAPI monthly x 90 days or until substantial compliance is achieved.

This citation pertains to intake 2575758Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement and ensure safety in 1 of 4 residents (Resident #101) reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 7/20/25 between 7:30 p.m. and 7:45 p.m., Resident #101 exited the facility, unbeknownst to facility staff, and was found by an off duty nurse approximately 0.3 miles away after sustaining a fall. This deficient practice placed all residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include:The facility failed to provide adequate supervision to prevent elopement for an exit seeking resident, Resident #101, who was an elopement risk. Resident #101 was found 0.3 miles away from the facility by an off-duty nurse and bystanders. Resident #101 was lying in an embankment holding onto a traffic cone with a bleeding skin tear on his lower right arm. The EMS (emergency medical services) report noted that Resident #101 was observed by bystanders to be walking in the road, weaving in and out of traffic. The road was 35 MPH (miles per hour) with no sidewalks. The Immediate Jeopardy began on 7/20/25 when the facility failed to supervise Resident #101 and he eloped from the facility between 7:30- 7:45 PM. The Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 8/6/25 at 1:30 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 8/6/25, but noncompliance remains at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance has not been verified by the State Agency.Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #101's Nursing admission Evaluation dated 7/18/25 indicated that Resident #101 was ambulatory (able to walk), was noted to wander, had two or more predisposing diseases such as Dementia, OBS (organic brain syndrome- a condition characterized by cognitive and behavioral changes caused by damage to the brain), Alzheimer's, Depression, Mental Illness, or Expressive Language Deficits. Resident #101 was cognitively impaired, took 7 or more medications, was a new admission to the facility, and scored 11 or higher on the elopement risk assessment indicating that Resident #101 was at risk for elopement. Resident #101 had a wander guard placed due to elopement risk.Review of Resident #101's Care Plan revealed, (Resident #101) is at risk for elopement R/T (related to) impaired cognition d/t (due to) advanced dementia, elopement score of 12. Date initiated: 7/18/25. Goal: Will not leave the facility unattended through review date. Date initiated: 7/18/25. Interventions: Apply wander guard per order. Wander guard to the left ankle. Date initiated: 7/18/25. Approach in a slow, calm, manner and redirect away from exit doors as needed. Date initiated: 7/21/25. Distract when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, conversations, etc. Date initiated: 7/21/25. Observe wandering behavior and attempted diversional interventions when wandering into inappropriate locations such as other resident room when not invited, behind nurses' stations, shower rooms, attempts at exiting the facility ect date initiated: 7/18/25. Provide reassurance/redirect as needed when in an area resident should not be in. Use calm approach. Date initiated: 7/18/25. Provide structured activities, toileting, walking inside and outside with supervision as needed. Date initiated: 7/18/25 .Review of Resident #101's Progress Notes dated 7/21/25 at 02:06 AM revealed, (Resident #101) observed by off duty RN (Registered Nurse) walking down the sidewalk. Police notified and transported to (Local Emergency Department) to treat and eval (evaluate). All appropriate parties notified. Resident returned to the facility at 22:10 (10:10 PM) accompanied by wife to room. Resident has an abrasion to right elbow. Wander guard to left ankle. Prior to elopement, resident continued with exit seeking. Observed before 1900 (7:00 PM) by receptionist of removal (sic) of wander guard to right ankle. B hall nurse replaced wander guard to left ankle.19:30 (7:30 PM) this nurse had visual redirection of exit seeking on C hall side door and visual of his wander guard in place. All staff was made aware to keep visuals on resident d/t exit seeking. Remains on continued visuals .Review of Resident #101's Incident Report dated 7/20/25 revealed, Allegation Statement: At approximately 8:00 PM, RN II contacted the Administrator (NHA) A to report that she was with a male on the roadside with a wander guard to his ankle. The male (Resident #101) was pleasantly confused and unable to tell the off-duty nurse with what his name was. NHA A contacted the facility to complete a head count while RN II remained with the male. Resident: (Resident #101). BIMS (Brief Interview for Mental Status) score of 2/15 indicating severe cognitive impairment. (Resident #101) was admitted to the facility on [DATE], after being hospitalized for a urinary tract infection. While at the hospital. (Resident #101's) wife requested placement for rehab with intention to transfer to long term care related to his progressing dementia. (Resident #101) is able to ambulate independently without the use of an assistive devices and requires supervision and cueing for ADL'S (activities of daily living) related to his cognition . Action Taken: Administrator (NHA) A contacted the facility to complete a full head count, (Resident #101) was taken to (local emergency department) by EMS (emergency medical services) for evaluation, facility nurse conducted an audit to ensure all wander guards were in place and functioning, facility nurse verified doors were locked and in working order, upon return to the facility, the primary nurse verified (Resident #101) wander guard was functioning properly, upon return from the facility, (Resident #101) was placed on a 1:1 for supervision . Intervention: After investigation, it was determined that (Resident #101) did exit the facility, he sustained no significant injuries, he was sent to the ER (emergency room) by ambulance for evaluation, he returned to the facility, and it was determined that his wander guard was functioning properly. He was placed on a 1:1 for supervision upon return. Conclusion: Root cause of the elopement was determined to be due to the staff turning the alarm off without walking outside the door and checking the perimeter . Review of Resident #101's EMS Prehospital Care Report Summary dated 7/20/25 revealed, Patient (PT) is a . male whose chief complaint is elopement. Patient is a resident at (Facility name), a local skilled nursing facility. POSITION PT FOUND/INITIAL SCENE FINDINGS: Dispatched priority 1 for a male that was walking in the road, weaving in and out of traffic. Arrived on scene of the side of the road to find patient lying supine (face up on back) in the grass. Bystanders state that patient was walking on the road carrying a traffic cone approximately 4 feet tall, then sat on the ground. Patient knows his name but is unable to answer any other questions appropriately .Patient has a small skin rear on his lower right arm, bleeding controlled. The bystander that found patient observed a monitor on patient's right ankle. Bystander reports that she is a nurse at (facility name) and believes that patient may be a patient at (facility name). Nurse called the facility and confirmed that patient is a resident there and staff was unaware that patient had eloped from the facility. Staff reports that they want patient taken to the hospital to be evaluated .In an interview and observation on 8/5/25 at 1:15 PM, NHA A walked outside of the facility with surveyor to show the location which Resident #101 was found by bystanders. This writer walked to the location where Resident #101 was found and noted the location to be 0.3 miles away from the facility. It was noted that there were no sidewalks, and the speed limit of the road was 35 MPH. Resident #101 had crossed the street of the facility. NHA A reported that she was unable to confirm from her investigation how Resident #101 had left the facility, because he was wearing a wander guard, which should have alarmed as he exited the building. NHA A reported that she could not determine if the facility alarm had gone off and staff turned it off without checking for a resident. NHA A confirmed that the facility alarm was not loud enough for staff to hear throughout the entire building and reported that they were looking at quotes to improve the alarm system. NHA A reported that she had been contacted by RN II on 7/20/25 around 8:00 PM, letting her know that she had found a man on the side of the road that had a wander guard on and might have been from the facility. NHA A reported that she called the facility right away to instruct the staff to complete a head count of all residents to determine if anyone was missing. NHA A confirmed that the facility staff were not aware that Resident #101 was missing until staff conducted a head count. In an interview on 8/6/25 at 8:17 AM, RN II reported that she was driving down the road from the facility with her husband on 7/20/25 when they saw two people standing near the road and pointing across the street at a man lying down on the side of the road near the facility. RN II reported that her husband turned around and went back to where the bystanders and man laying down were to see if they needed help. RN II reported that she observed Resident #101 lying on the ground in an embankment next to the road. RN II reported that she could tell from trying to speak with Resident #101 that he was very confused, and that he had told her his name was a name other than what his actual name was. RN II noticed that his arm was bleeding and reported that the bystanders had told her that they observed Resident #101 pick up a traffic cone and tumbled down twice into the embankment, and that they had called 911. RN II reported that she noticed Resident #101 was wearing a wander guard, so she immediately called NHA A to notify her that the facility might have had a resident elope. RN II confirmed that the facility had two doors that would alarm if a wander guard were to pass by them, which were the front door, and the back service door. RN II reported that the alarms for the wander guards were too low, and very hard to hear throughout most of the building. In an interview on 8/6/25 at 2:10 PM, Family Member (FM) KK reported that Resident #101 lived at home with her prior to admitting to the facility. FM KK reported that Resident #101 did wander a lot at home, especially at night, and that he had gone missing from their home before. FM KK reported that she did not know if the facility was aware of how much Resident #101 wandered, but that they did not ask her about his wandering when he was admitted . FM KK reported that she had requested Resident #101 go to a long-term care facility because she was no longer able to care for Resident #101 at home due to his wandering and increased confusion. FM KK reported that she met Resident #101 at the hospital the night that he eloped, and she was with Resident #101 when he returned to the facility. FM KK reported that when Resident #101 entered the facility, his wander guard did not set off the alarms at the facility. FM KK reported that she stayed with Resident #101 until he fell asleep that night, and she did not observe any staff members come assess Resident #101 or his wander guard while she was there. In an interview on 8/6/25 at 8:31 AM, Receptionist P reported that she had been working on 7/20/25 until 7:00 PM. Receptionist P reported that she had observed Resident #101 wandering throughout the lobby that evening, and between 6-6:30 PM, Resident #101 had sat down and removed his wander guard in front of her. Receptionist P reported that she immediately went and got Licensed Practical Nurse (LPN) DD and informed her that Resident #101 removed his wander guard. Receptionist P confirmed that after she left at 7:00 PM, the front doors to the facility were locked, and that an alarm would sound if a resident with a wander guard attempted to exit the facility. In an interview on 8/6/25 at 1:30 PM, LPN DD reported that she was working on 7/20/25 when Resident #101 eloped from the facility. LPN DD reported that she was not the nurse assigned to Resident #101 that evening, but she had been informed by Receptionist P that he had removed his wander guard, so she found Resident #101 in the facility, replaced his wander guard, redirected Resident #101 to his room, and told the nurse that was assigned to care for Resident #101. LPN DD reported that she recalled that Resident #101 was very highly exit seeking that night, and that she had observed Resident #101 attempting to open many facility doors, entering other resident rooms, and walking up and down the halls. LPN DD reported that the last time she recalled observing Resident #101 before he eloped was around 7:30 PM. LPN DD reported that she was passing medications at that time, and she did not recall hearing the door alarm. LPN DD confirmed that the door alarm was not very loud, and that staff were unable to hear the alarm throughout most of the building. LPN DD reported that she had learned that Resident #101 had eloped around 8:00 PM, when staff were informed that they needed to do a head count for all residents because a man had just been found outside of the facility with a wander guard on. LPN DD reported that they did confirm that Resident #101 was missing. In an interview on 8/5/25 at 5:08 PM, LPN HH reported that she was the nurse assigned to care for Resident #101 on 7/20/25 when he eloped. LPN HH reported that Resident #101 was highly exit seeking that night and was all over the place, and you had to keep your eyes on Resident #101 at all times because he was trying to get out of the front door, the service door, and going into other resident rooms nonstop. LPN HH reported that around 7:30 or so, she needed to begin her medication pass, so she had asked Certified Nursing Assistant (CNA) V to watch Resident #101. LPN HH reported that after she had completed a medication administration, she observed CNA V in the day room, and Resident #101 was not near her. LPN HH reported that she asked where Resident #101 was, and that they both began to look for him. LPN HH reported that just a few minutes later, she received a call from NHA A and was informed that they needed to complete a resident head count, and that is when she discovered that Resident #101 had eloped from the facility. LPN HH reported that she did not know why CNA V did not continue to watch Resident #101 when she had instructed her to do so. LPN HH reported that she believed that CNA V was the staff member assigned to care Resident #101 that day. In a follow up interview on 8/6/25 at 11:18 AM, LPN HH reported that she had told all staff working that night that Resident #101 was a high elopement risk and he needed to be watched closely. LPN HH reported that she did not hear the alarms going off at all that night. LPN HH confirmed that the facility alarms were not loud enough to hear throughout the building, and that she felt that many of the staff were de-sensitized to the alarm on the service door because it alarmed so often that staff were just putting in the code to get it to stop alarming. LPN HH reported that she had reported her concerns about the service door alarm to NHA A. LPN HH reported that the facility was not staffed adequately enough to safely supervise Resident #101 the night that he eloped. LPN HH reported that she did not observe Resident #101's wander guard when he returned to the facility from the hospital later that night, but she had scanned his wander guard, and it was noted to be working per the scanner. In an interview on 8/6/25 at 10:39 AM, CNA V reported that she did think she was assigned to care for Resident #101 the night that he eloped from the facility, but that she had been told by LPN HH to keep an eye on him. CNA V reported that she was not aware that Resident #101 was an elopement risk. CNA V reported that she thought that LPN HH meant that Resident #101 was on 15-minute checks, and she had had last observed Resident #101 around 7:00-7:15 PM when she was collecting dinner trays near his room. CNA V reported that when LPN HH found her without Resident #101 she was told that they needed to do a head count because he might have left the facility. CNA V reported that after the staff completed a head count, she found out that Resident #101 had left the facility. CNA V reported that she thought that Resident #101 might have followed a resident's family member out of the facility, because she never heard an alarm. CNA V confirmed that the alarms in the facility were not very loud, and staff were unable to hear the alarms throughout the entire building. CNA V confirmed that Resident #101 was exit seeking prior to his elopement, and that she had observed him wandering the halls, and trying to open all of the facility doors. CNA V reported that she felt that Resident #101 needed 1:1 supervision, and that she did not feel like the facility was staffed to accommodate his needs the night that he eloped. CNA V reported that she did not think that she was supposed to be providing direct supervision for Resident #101 when LPN HH asked her to keep an eye on him the night that Resident #101 eloped. CNA V reported that she was the staff member that opened the facility door when Resident #101 returned from the hospital after he eloped. CNA V reported that Resident #101's wander guard did not alarm when he entered the facility. CNA V reported that she had informed LPN HH that Resident #101's wander guard did not alarm when he entered the facility. In an interview on 8/5/25 at 12:11 PM, CNA EE reported that she had observed Resident #101 attempting to exit the facility and wandering around the building prior to his elopement on 7/20/25. CNA EE reported that was she was by told by LPN HH told at the beginning of her shift that Resident #101 was exit seeking, and that staff needed to watch him. CNA EE reported that she had last seen Resident #101 in the hallway before she went into another resident room, and when she exited that resident's room around 8:00 PM, she was informed that Resident #101 had left the building and was found down the street. CNA EE reported that she did not hear any alarms going off in the facility but reported that could have been because she was in a resident room, and you could not hear the alarms inside a resident room. CNA EE confirmed that she knew Resident #101 was exit seeking, and that he had tried to remove his wander guard earlier in the night. In an interview in 8/5/25 at 12:22 PM, CNA S reported that he was working the night that Resident #101 eloped, but he was not working directly with Resident #101. CNA S reported that he had been told earlier in the shift that Resident #101 was exit seeking, and he had observed Resident #101 wandering around the facility around 6:30-6:45 PM. CNA S reported that he learned that Resident #101 was missing when the facility called a code to count all residents. CNA S reported that he did not know how often staff were checking on Resident #101 that night, and reported that the facility is often short staffed, and unable to adequately supervise residents. CNA S reported that we do the best we can, but there is only so much we can do. CNA S reported that he did not hear any alarms going off, but he would not have been able to hear the alarms if they were going off, because he was in the back of the building, and you cannot hear the alarms from the back of the building. In an interview on 8/6/25 at 7:47 AM, LPN W reported that she was working on 7/20/25 when Resident #101 eloped. LPN W reported that Resident #101 was highly exit seeking and that she had observed him walking around the facility and trying to open doors and entering resident rooms. LPN W reported that Resident #101 needed constant redirection. LPN W was not able to recall the last time that she had observed Resident #101 prior to his elopement from the facility. LPN W reported that she had heard the service door alarm a few times that night but reported that was common and the door would often beep if not closed all the way. LPN W reported that she did not hear the front door alarm, but that she may not have because it was too low to hear in resident rooms or most of the building. In an interview on 8/6/25 at 12:04 PM, CNA J reported that she had worked the night that Resident #101 had eloped from the facility. CNA J reported that she did observe Resident #101 wandering around the facility prior to his elopement and attempting to leave the facility. CNA J reported that she did hear the front door alarm go off once during the night when she went into the hallway to grab a care item, but she was in the middle of caring for a resident, so she did not respond to the alarm, and returned to the resident's room that she was caring for. CNA J reported that when she left the resident's room that she was caring for, the alarm was off, and shortly after that, the facility began a head count because Resident #101 had been found outside. CNA J reported that the facility is often short staffed on nights, which makes it hard to adequately monitor residents such as Resident #101 that are highly exit seeking.In an interview on 8/6/25 at 3:26 PM, CNA D reported that she had worked the night that Resident #101 had eloped, but she was not assigned to care for him. CNA D reported that she had observed Resident #101 wandering throughout the facility that night and recalled LPN HH telling her that all staff needed to keep eyes on him because he was confused and exit seeking. CNA D reported that the last time she had observed Resident #101 was around 6:00 PM, and then around 8:00 PM she had learned that he was missing when the facility called a code to search for him. CNA D reported that she did not hear any alarms go off that night but reported that staff were not able to hear alarms in resident rooms or most of the building. CNA D reported that there had been several occasions where she felt that the facility was not adequately staffed to safely supervise residents with higher acuity needs, such as Resident #101. CNA D reported that the service door would alarm frequently if not shut all the way, and that staff would often have to put in the code to turn off the alarm because staff did not ensure the door was closed all the way. During an observation and interview on 8/5/25 at 3:25 PM with Maintenance Director (MD) Q toured the facility with surveyor to test the wander guards and alarms. MD Q reported that he was not the staff member that was performing audits to ensure that the alarms for the wander guards on the doors were working, and he was not sure if anyone else was. At 3:35 PM, the front door was tested and noted to automatically lock when a wander guard got close to the door. As the wander guard alarm went off, this writer walked down the hallway and noted that the alarm could not be heard past room [ROOM NUMBER] in the first hallway and room [ROOM NUMBER] in the second hallway. It was noted that the area where the alarm could no longer be heard was about halfway down the hallways of the first two halls in the building. At 3:53 PM, this writer and MD Q went to the service door to test the alarm on that door. It was noted that the door was not closed all the way, and when MD Q brought the wander guard to the door, the door remained open and did not alarm as the wander guard passed through the door. MD Q reported that if staff did not ensure that the door was closed all the way, that this error could happen. In an interview and observation on 8/6/25 at 8:33 AM, Director of Nursing (DON) B checked the service door with a wander guard with this writer. DON B showed this writer that if the service door was not closed all the way, but a code had been entered (a code was required to be entered to open the door) that the door had a six second time lapse where a wander guard could go through the door without the door alarming or locking. DON B reported that she did not know if anyone in the facility was auditing the doors to ensure that the wander guard alarms were in working order. In an interview and observation on 8/6/25 at 9:02 AM, Regional Nurse Consultant (RNC) U and NHA A observed the service door with MD Q and this writer. RNC U and NHA A reported that the service door was working as it was supposed to, and that it would be impossible for a resident to exit through the service door with a wander guard because staff had to be available to enter the code for the door to not alarm.The Immediate Jeopardy that began on 7/20/25 was removed on 8/6/25 when the facility took the following actions to remove the immediacy.1. Resident returned from (local) hospital on 7/20/25 at 10:10pm, the front door locks down and requires keypad code to enter/exit. Staff were required to enter code into the keypad in order for resident to enter facility. The door and the wander guard was checked for function when he returned on 7/20/25. 2. 7/20/25. One-on-one was provided to resident until deemed appropriate. 3. Resident POA was notified 7/20/25, Physician was notified 7/20/2025. 4. 7/21/25 IDT met with POA to discuss potential transfer to appropriate locked dementia unit. POA in agreement and is going to visit facilities.5. All doors were tested by nurses and are latching appropriately on 7/20/25. 6. Maintenance Director tested the front door and service hall door and alarms are sounding/door lock down as appropriate when checked with wander guard on 7/21/25. 7. (Local service provider) has sent a quote for replacing the service hall doors 7/21/25, facility is waiting for approval for Capitol improvement request. Doors will be ordered and replaced. The service hall door is locked at all times and requires key pad code entry. The door has been checked for function and closes and locks as intended. The key pad will be replaced which has an improved enunciator to allow staff to hear if alarms are sounding and educated to check to ensure no residents are following them when going through doors on 7/11/25. 8. Staff were educated to provide one on one with actively seeking residents on 7/21/25. 9. Signs were placed on front door to remind families to check that residents are not following them outside when they exit on 7/21/25.10. DON/designee reassessed all residents for elopement risk 7/21/25, no new residents identified. 11. DON/designee checked Wander guards for working order/expiration date 7/21/25, all wander guards in working order. 12. Social Services checked all elopement books for accuracy 7/21/25, all books accurate. 13. DON/designee reviewed care plans for residents with elopement risk 7/21/25, no concerns noted.14. (Local service company) (fire and security) came to facility and assessed wander guard system 7/21/25, no concerns with door safety, noted alarm is not loud, will provide quote to change out the keypads.15. (Local service company) disabled the door release button at the nursing station and at the receptionist desk 7/21/25. Nurses must release doors by inputting code into the keypad when visitors leave. Will observe to ensure this is disabled. Facility provided documentation that (local service company) came to the facility on 7/21/25. 16. Receptionist is scheduled from 7am-7pm to monitor front doors, doors lock at 7pm and unlock at 7am. Staff member is assigned to monitor doors when receptionist is on break/lunch. 17. DON/designee-initiated education 7/21/25 on elopement policy/response to elopement (100% completed by 7/22/25). 18. (Local service company) to provide quote for new wander guard keypad that will increase the enunciator volume. 19, (Local service company) has provided a quote to replace service hall door (7/21/25). 20. The maintenance director/designee will check wander guard doors for functioning 7 days per week. 21. Education initiated 7/21/25, any staff not educated by 7/21/25 will be educated prior to working next shift, 71/94 employees educated 7/21/25. (100% completed by 7/22/25). Staff were educated on elopement policy, responding to alarms, ensuring resident safety and doing exterior observation when responding to the door alarms, key pad code has been changed and maintenance disabled exit release at nurse's station and front desk so that staff have to let visitors out/in after 7 pm ensuring safety of residents and ensuring residents are not exiting with visitors/staff and staff to provide/initiate one-on-one with actively exit seeking residents. Staff will contact DON and/or NHA if there is a need for one on one to assist with adequate staffing.22. DON/designee reeducated licensed nurses on following physician orders, audit tool shift to shift between nurses to ensure MAR/TAR (medication administration record/treatment administration record) is complete and to retrieve the wander guard checker to complete task prior to leaving shift on 8/6/25. An additional Accutech machine is being ordered on 8/6/25 to allow each side of the facility access to an Accutech machine. An Accutech machine has been available and in working condition. The facility provided education to nursing staff on documentation of wander guards, and the expectation to place the resident on 15-minute checks if unable to test wander guard. 23. NHA/DON reviewed the Elopement Policy and deemed appropriate 7/21/25. Resident #104 Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included personal history of traumatic brain injury.In review of the Incident Report dated 7/11/25 for Resident #104 which revealed, (Resident #104) went through the service doors and was retrieved by staff. He was assisted into the building at the front lobby. Resident stated he was going to the store . Wander guard in place and functioning properly .In a follow up interview on 8/6/25 at 12:19 PM, NHA A confirmed that Resident #104 had a wander guard on and was able to make it through the service doors without staff knowing. NHA A reported that she had completed an investigation into the incident and determined that staff did not close the door all the way and ensure that a resident did not follow them. NHA A was not able to provide evidence of her investigation. Review of the facility's Elopement Policy last revised 4/26/222 revealed, Policy: It is the policy of this facility to prevent to the extent reasonably possible, that elopement of guests/residents from the facility . Procedure: The facility will evaluate guest's/resident's risk for elopement upon admission, weekly x 4, quarterly, and with a significant change. Periodic reviews will be completed as deemed necessary by the interdisciplinary team.2. After the Risk for Elopement is completed, and a guest/resident is deemed at risk for elopement, the licensed nurse will: a. Assure the guest/resident has an identification band with guest/resident's name, and facility phone number. b. If the facility has a wandering system, the wandering device will be checked for functionality prior to placement on the guest/resident according to manufacturer's specifications. c. Verification of the placement of the wandering device will be done on each shift and documented on the MAR (Medication Administration Record) by the licensed nurse. d. The Social Worker/designee will create and maintain a current log for all guests/residents that are at risk for elopement. Minimally, this log will be kept at the nursing station, reception desk and/or additional locations as deemed appropriate by the facility's interdisciplinary team. e. Verification of unit functionality will be tested by the midnight shift licensed nurse using wandering testing device and documented on the [TRUNCATED]

This citation pertains to intake #1234842Based on observation, interview and record review the facility failed to identify signs and symptoms of a stroke for 1 (Resident #112) of 3 residents reviewed for change of condition, resulting in an Immediate Jeopardy when Resident #112 did not receive timely medical intervention for a stroke on 7/15/25 who then suffered significant loss of function of her left upper extremity, developing unilateral spatial neglect (condition where a person has difficulty noticing or responding to stimuli on one side of their body), facial droop, and decreased ability to communicate verbally.Findings include:The facility failed to accurately assess Resident #112 for a change in condition on 7/15/25 at 12:00pm when Physical Therapist (PT) JJ reported to Director of Nursing (DON) B that the resident exhibited new onset of left sided weakness, exceptional fatigue and a significant decline in the ability to self-transfer.The Immediate Jeopardy began on 7/15/25 when the facility failed to assess Resident #112 for a change in neurological status despite multiple reports of stroke like symptoms resulting in Resident #112 suffering significant loss of function of her left upper extremity, developing unilateral spatial neglect (condition where a person has difficulty noticing or responding to stimuli on one side of their body), facial droop, and decreased ability to communicate verbally. The Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 7/17/25 at 12:02pm. The surveyor confirmed by interview, and record review that the Immediate Jeopardy was removed on 7/17/25, but noncompliance remains at a scope of isolated and severity of harm due to sustained compliance has not been verified by the State Agency. Review of Treatment and Intervention for Stroke, www.cdc.gove/stroke/treament/index.html, revealed If you get to the hospital within 3 hours of the first symptoms of an ischemic stroke, you may get a type of medicine called a thrombolytic (a clot-busting drug) to break up blood clots. Tissue plasminogen activator (tPA) is thrombolytic. tPA improves the chances of recovering from a stroke. Studies show that patients with ischemic strokes who receive tPA are more likely to recover fully or have less disability than patients who do not receive the drug.Review of Impact of Time to Treatment on Endovascular Thrombectomy Outcomes in the Early Versus Late Treatment Time Windows, published 2023, https://www.ahajournals.org/doi/10/1161/STROKEAHA.122.040352, revealed The impact of time to treatment on outcomes of endovascular thrombectomy (EVT)(mechanical removal of clot in a blocked blood vessel) especially in patients presenting after 6 hours from symptom onset is not well characterized.increased time from symptom onset to treatment is significantly associated with lower change of independent ambulation and ability to be discharged home.Review of an admission Record revealed Resident #112 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: encounter for surgical aftercare following surgery on the circulatory system, aortic stenosis (narrowing of the valve in the large blood vessel branching off the heart), hyperlipidemia (high cholesterol), history of venous thrombosis (blood clot in a vein) and embolism (blood clot that has broken off and traveled into the blood stream), diabetes mellitus type 2 (condition in which the body cannot use insulin properly to regulate blood sugar levels), and morbid obesity.Review of a Minimum Data Set (MDS) assessment for Resident #112 with a reference date of 7/4/25, revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #112 was mildly cognitively impaired. Section B of the MDS revealed Resident #112 could always make herself understood with verbal expression. Section GG revealed Resident #112 required supervision for rolling side to side in bed.Review of a Care Plan for Resident # 112 with a reference date of 4/2/25, revealed a focus/goal/interventions of: Focus: (Resident #112) is at risk for cardiac complications r/t (related to)multiple cardiovascular diseases: hyperlipidemia, cardiac murmur, recent subaortic membrane resection (open heart surgery), aortic stenosis.Goal: Will be free from s/sx (signs and symptoms) of cardiac complications.Interventions:.observe/document/report to physician PRN (as needed) any s/sx of cardiac distress:.shortness of breath.In an interview on 7/16/25 at 2:31pm, PT JJ reported she conducted a therapy discharge assessment on Resident #112 on 7/15/25. PT JJ reported she had not previously provided therapy to the resident but had reviewed her therapy notes and was told by therapists who knew her well that Resident #112 was nearly independent with most tasks prior to her session on 7/15/25. PT JJ reported she recognized right away that Resident #112 appeared to be struggling with tasks that she had not needed assistance with during her prior therapy session. PT JJ reported Resident #112 did not have functional use of her left arm during the session, appeared exceptionally fatigued and was difficult to understand. PT JJ reported she went to DON B (who was caring for the resident that day) and inquired if Resident #112 had a history of having had a stroke. PT JJ reported she told DON B at that time that the resident appeared to have had a change in condition. PT JJ reported DON B told her to try to reapproach Resident #112 later because she was probably just tired. PT JJ reported she returned to Resident #112 a few hours later and again voiced her concerns to DON B. PT JJ reported during the second therapy session, Resident #112 required maximal assistance of 2 staff to transfer to bed, and she had previously been able to do so with only supervision assistance.In an interview on 7/16/25 at 4:21 DON B reported PT JJ came to her on 7/15/25 and reported Resident #112 had exhibited a change of condition that included left sided weakness during a therapy session that day. DON B reported she didn't notice any changes in the resident but had not cared for her before. DON B confirmed she did not complete a neurological assessment of Resident #112 at that time. DON B DON B reported when she spoke to Resident #112 at approximately 6:15pm on 7/15/25, Resident #112 thought she was having a panic attack and complained of shortness of breath.In an interview on 7/16/25 at 4:00pm, CNA F reported she cared for Resident #112 on 7/15/25 and noticed the resident required assistance of 2 staff to roll her in bed when she had been independent in prior days. CNA F reported Resident #112 also complained of pain but did not voice where the pain was, reported she was having a hard time breathing and she began mumbling and was not able to make herself easily understood. CNA F reported she told RN X that something else was going on, more than just anxiety, with Resident #112. CNA F noted that Resident #112 could not maintain her attention on simple care tasks and had become completely incontinent of urine.In an interview on 7/16/25 at 3:03pm, Registered Nurse (RN) C reported she was orienting to the position of Floor Nurse on 7/15/25 at approximately 5:00pm, when a CNA told her she was concerned about Resident #112 because she did not seem to be herself. RN C reported she did not know what Resident #112's baseline physical abilities were and did not complete a neurological assessment.In an interview on 7/16/25 at 4:41pm, RN X reported he cared for Resident #112 overnight on 7/15/25 into 7/16/25. RN X reported he did not know Resident #112 well and did not assess her during his shift. RN X reported he was told by DON B during a shift change report that Resident #112 was short of breath due to anxiety and had been put on oxygen.In an interview on 7/16/25 at 12:01pm, Registered Nurse (RN) O reported Resident #112 told her she was having the worst headache of her life during the morning medication pass on this date. When further queried, RN O reported Resident #112 said the headache started the previous day.During an observation on 7/16/25 at 9:30 AM, Certified Nursing Assistant (CNA) K assisted Resident #112 with personal cares while the resident was on the toilet. The resident's head was lying to one side onto her shoulder with her left arm limply hanging at her side. CNA K tried several times to have Resident #112 place her hand and arm on the railing next to the toilet while saying, You've got to help me. Put your arm up on the railing. Your head keeps flopping over and your arm is falling off. Pick it up and help me.In an interview on 7/16/25 at 12:21pm, Certified Nursing Assistant (CNA) K reported she provided morning care to Resident #112 early that day, around 9:00am. CNA K reported at that time, she noticed a significant decline in Resident #112's physical abilities in comparison to a previous date that she cared for the resident. CNA K reported during toileting, she noticed Resident #112's left arm was hanging at her side. CNA K reported she placed Resident #112's left hand on the handrail but it just fell off the rail when Resident #112 attempted to use it. CNA K reported Resident #112 appeared pale and lethargic. CNA K she told Licensed Practical Nurse (LPN) Y that something seemed wrong with the resident.In an interview on 7/16/25 at 4:10pm, LPN Y reported she was not the nurse caring for Resident #112 on 7/16/25 but CNA K came to her around lunch time and told her something was wrong with the resident. LPN Y reported she and CNA K could not find RN O, the nurse responsible for providing care to Resident #112 on 7/16/25. LPN Y reported some time around 11:45am, she assessed Resident #112 for possible stroke symptoms and found Resident #112's left arm was flaccid (condition in which the muscles do not contract), and she had no grasp in her left hand. LPN Y got a physician's order to send Resident #112 to the emergency room for further evaluation.Review of a Nurses Note for Resident #112 with a reference date of 7/16/25 at 1:14pm revealed resident assessed and resident stated she had the worst headache she has ever had, some blurry vision, chest pain, looked pale, vitals were all WNL (within normal limits).L (left) sided weakness noted on full left side, resident not able to hold left arm for 10 seconds without dropping, resident has been sent to. ED (emergency department).During an observation on 7/16/25 at 11:57am, an unknown male Emergency Medical Technician (EMT) assessed Resident #112's left sided weakness and stated to Registered Nurse (RN) O She (Resident #112) has had symptoms of a stroke since yesterday. There's nothing the hospital will be able to do for her. Review of Emergency Department History of Present Illness for Resident #112, with a reference date of 7/16/25 at 3:29pm revealed: Patient.presents from (skilled nursing facility name omitted) with concerns for stroke. They noted that patient had some slurred speech left-sided facility drop and left arm weakness.first noticed some left arm weakness yesterday when patient was participating in her physical therapy.Physical Exam: Patient with noted left-sided facial droop some slurring of the speech.does appear to neglect left side.does have weakness involving the left upper extremity.Information Gathering: I did consult (neurologist name omitted).he notes patient is not a candidate for any thrombectomy (removal of clot/blockage within blood vessel), very well outside any TNK (clot-busting medication) window.Final diagnoses: cerebrovascular accident (stroke).Review of a Physical Therapy Treatment Encounter Note for Resident #112 with a reference date of 7/11/25 at 3:21pm revealed Transfer training, toilet transfer at SBA (stand by assistance) .Review of an Occupational Therapy Treatment Encounter Note for Resident #112 with a reference date of 7/14/25 at 12:29pm revealed Patient participates in BUE (bilateral upper extremity) exercise with use of #1 wrist weight, completes 8 reps (repetitions).Review of a Physical Therapy Treatment Encounter Note for Resident #112 with a reference date of 7/15/25 at 12:00pm, revealed transfer training with min (minimal) A (assistance) to mod (moderate) A in bathroom.Comments: Patient is exceptionally fatigued during this session.required more assist than is typical. (DON B) notified of concerns of fatigue, increased assist and questionable decreased use of LUE (left upper extremity) during session.Review of CNA task documentation with a reference date of 7/14-7/15/25 revealed Resident #112 transferred from lying in bed to sitting at the side of the bed with supervision assistance on 7/14/25 at 4:35am. On 7/15/25 at 4:49 PM Resident #112's assistance level increased to needing 2 staff to complete the task. Resident #112 did not require assistance of 2 staff for this transfer any time prior to 7/15/25. Review of CNA task documentation with a reference date of 7/14-7/15/25 revealed Resident #112 transferred from the bed to a wheelchair with set up assistance on 7/14/25 at 4:35am but required assistance of 2 staff for the same transfer on 7/15/25 and 4:50pm and 11:27pm. Resident #112 did not require assistance of 2 staff for this transfer any time prior to 7/15/25.During an observation and interview on 7/17/25 at 8:48am, Resident #112 sat in a wheelchair in her room with her head turned and fixed to the right of midline (imaginary vertical plane that runs from head to toe). Resident #112's left arm and hand were supported on a pillow; her hand was swollen. Resident #112 reported she had a stroke and attempted to raise her left arm to shoulder height. Resident #112 raised her left arm approximately 2 off the pillow in a slow, uncoordinated motion and as she did so, her hand drooped downward and her arm fell back onto the pillow. No functional grip of left hand observed as the resident attempted to make a fist. Resident #112 confirmed she began feeling unwell, weak, and extremely fatigued on 7/15/25. Resident #112 reported she told a few staff members she did not feel well but she was not aware of all the stroke symptoms she was exhibiting at the time. Throughout the interview, Resident #112 spoke with a weak vocal quality and slowed speech. Resident #112 had to repeat herself several times to make herself understood. Resident #112's eye gaze remained fixed to her far right throughout the observation.The Immediate Jeopardy that began on 7/15/25 was removed on 7/17/25 when the facility took the following actions to remove the immediacy. 1. 1. Res #112 was assessed and sent to ER on [DATE] at 1:01pm and returned to the facility at 7/16/25 5:26pm, with a diagnosis of recent acute infarction(stroke). New order for an anticoagulant on readmission. Upon assessment of resident #112 on 7/17/25 with therapy resident is showing improvement.2. 2. DON B/designed completed assessments on all residents for change in condition, with review of progress notes and vital signs.3. 3. Nursing staff were re-educated on resident change of condition and assessing the resident and treatment on 7/17/25. Any licensed nurses will be educated prior to working their next shift.4. 4. CNA's were re-educated on reporting resident symptoms of a potential change of condition on 7/17/25. Any CNA not educated on 7/17/25 will be educated prior to working next shift.5. 5. An Ad Hoc QAPI meeting was held 7/17/25, including the Medical Director regarding review of the facility's process for identifying resident change of condition and documentation.

This citation pertains to intake 2563197. Based on observation, interview, and record review, the facility to ensure safety and prevent a major injury 1 of 3 residents (R108) reviewed for safety, resulting in an Immediate Jeopardy when, on 7/2/25 at 5:04AM, R108 fell from a transferring position onto an exposed metal bracket at the end of her bed impaling her in the soft tissue of her left buttock entering the rectum cutting it and the anal sphincter and also suffering an open fracture of the pubis ramus. The injured tissues required surgical reconstruction and after complications, placement of an ostomy (surgery that creates a new opening in your body for waste to come out).Findings include:The Facility failed to identify environmental hazards and risks of an exposed bed frame bracket. On 7/2/25 at 5:40 AM, R108, who was a fall risk with two or more previous falls, was found impaled on the exposed bracket of her bed. The facility determined at the time of R108's fall on 7/2/25, there were eight additional resident beds that did not have the foot boards installed. An interview with Plant Maintenance (PM) M revealed the 8 beds did not have foot boards installed when they arrived and that only the bottom bracket where it attached was left on the bed. The Nursing Home Administrator (NHA) A reported not knowing how long the beds had been in use with the exposed bracket in place but added they have been in place longer than I've worked here.The Nursing Home Administrator (NHA) A was notified on 7/15/25 at 2:25 PM of the Immediate Jeopardy on 7/2/25 at 5:40 AM when R108 was found impaled on the exposed bracket of her bed after a fall. The surveyors confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 7/2/25 but noncompliance remained at scope of isolated and severity of actual harm due to maintenance not fully trained in bed maintenance and safety and sustained compliance had not been verified by the state agency. According to the Minimum Data Set (MDS) dated [DATE], R108 scored 9/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status). R108 was occasionally incontinent and had diagnoses that included right artificial knee joint, cognitive communication deficit, and a history of falling. Section J-Fall History on Admission/Entry or Reentry, indicated R108 had two or more falls since admission or prior assessment with no injury. Section GG-Functional Abilities and Goals indicated a wheelchair was used for mobility.Review of R108's Emergency Medical Service (EMS) Run-Sheet dated 7/2/25 revealed, .Dispatch Reason.penetrating trauma.impalement.musculoskeletal/skin.back.trauma injury.fall.sacral-midline.puncture/stab wound.patient was attempting to get out of bed despite being wheelchair bound, when she fell on the L-shaped corner piece of her metal bed frame.On EMS arrival patient was laying on her right side, staff members had lifted her off the metal piece and laid her on the floor. There was a large, coagulated pool of blood.the post had held her up off the floor.Review of R108's 5th District EMS Field Notes dated 7/2/25 reported the resident was impaled by metal bed frame approximately 3-4 inches.Review of R108's Trauma/Surgical Critical Care History and Physical dated 7/2/25 revealed, .brought in as a Tier I Trauma.suffering a mechanical ground-level fall with her left buttock landing onto her metallic bed frame.3 to 4 inches of the exposed bed frame had entered the patient's soft tissue of her left buttock.noted to be fair amount of exsanguination and blood loss.some form of injury to her anal canal or rectum.complaining of left gluteal and buttock pain.Physical Assessment.anorectal 4 cm radial laceration outside the anoderm in the left lateral position with extruding subcutaneous fat and blood.there is a comminuted fracture of the left inferior pubic ramus and ischial tuberosity with surrounding subcutaneous gas.soft tissue hematoma in the left buttock/perineal region.warrant further exploration and endoscopy.admit.Operating today for rectal exam under anesthesia, flexible sigmoidoscopy, possible exploratory laparotomy, possible bowel resection.Review of Investigation authored and provided by NHA A on 7/2/25 reported at approximately 5:40 AM, a nurse was in the hallway near the resident's room and heard a noise. Upon entrance to the room, the nurse noticed the resident had a fall at the end of her bed. The resident was sent to the ER for further evaluation. Once evaluated in the ER, the facility learned that (R108) had a fracture to her left inferior pubic ramus. It was noted the Investigation did not mention the penetrating trauma/impalement of a metal bracket to the resident's buttock that caused bleeding.Review of R108's Care Plan revealed:-10/15/2025, focused on Risk for Decline in Cognition and had impaired cognitive function or impaired thought processes related to and including dementia and cognitive communication deficit. The goal for the resident included having her needs met daily using interventions that included anticipate and meet needs as needed and anticipating needs from non-verbal indicators and past preferences as known.-10/3/2024, focused on Risk for Fall related injury and falls related to history of falls, decreased mobility, weakness, potential for shortness of breath due to COPD, osteoarthritis, and impaired cognition. Goals included the resident was to be free from injury related to falls using interventions that included the wheelchair next to the bed (11/16/24), frequent checks (11/10/24), and keep the resident's environment as safe as possible (10/3/24).-10/10/24 focused on Functional Ability Deficit and required assistance with self-care/mobility related to and included impaired balance, impaired mobility, decreased endurance, decreased standing balance, pain, history of falls and incontinent of bowel and bladder. The goal was self-care with improvement or maintain current level of function using interventions that included dependence on helper for ambulation/walking and bed mobility (substantial/maximal assistance) for lying to sitting on side of bed.During an interview on 7/15/25 at 9:42 AM, Registered Nurse (RN) N stated, The bracket from the end of the bed did not have a footboard. The bracket was impaled in (R108's) right side buttock looking like it was going to rip right through the skin. I don't think she was totally all the way on the floor. The bracket was holding her up off the floor. There was blood on the floor about plate size around her leg to buttock. R108 was a fall risk and was not steady on her own. I do believe she had fallen before. I was assigned to the other side of the building and coming towards the front. I was not asked to give a written witness statement. No one from administration talked to me about the incident.During an interview on 7/15/25 at 10:06 AM, Certified Nursing Assistant (CNA) E stated, I was not working the evening (R108) fell. She did not have a lot of falls. She used to fall but not lately.During an interview on 7/15/25 at 10:38 AM, RN Q stated, (R108) is my family and I work at the facility. (R108) had fallen onto the bracket that was supposed to hold the footboard to her bed. The footboard was not there. The bracket was 6 high. I was told the call light was on, she was able to use the call light baseline cognitively. Her wheelchair was at the end of the bed. She likes to have it by her side so she can use the handrail to help her get up. The metal bracket impaled in (R108's) left buttock. It went 3 into her rectum, it cut her sphincter muscle and cut her anus. The bracket went so far into her it fractured her left buttock bone, pubic rami. (R108's) primary nurse on 7/2/25 told me he and a housekeeping aide manhandled the bed to twist it and get it out of her. They lifted the head of the bed to pull the bracket out of her. (R108) was sent to the ER for evaluation and had surgery to stitch the rectum, anus, and sphincter back together. Two openings were left to drain fluids. (R108) also had a fractured a left pubic [NAME]. The drain did not drain well enough, so a wound vac was applied. She was discharged back to the facility on July 11th (2025). On July 14th (2025), (R108) was covered in stool. The wound vac was unable to work with the amount of stool coming out (R108), and it looked like it was sucking in stool and not fluids. From the path the metal bracket made directly to the pubic [NAME], stool followed it and caused an infection in the fractured bone. The stool was constantly flowing because of the injuries. (R108) had to go back to the hospital for surgery and have a permanent colostomy (a surgical procedure that creates an opening (stoma) in the abdomen through which a portion of the colon is brought to the surface, allowing waste to be eliminated into an external pouch) because the infection went into the bone.During an interview on 7/16/25 at 4:45 PM, RN X stated, I was in a resident room one or two door over from (R108) when I heard a crash. I went into (R108's) room and she was on the floor. She was going down on her right side. When I made my assessment there was something sticking up in her bottom, and it dawned on me it was the metal bracket of the bed. It was sticking up and I could see the shape of the bracket through her skin. It was a judgement call to try to get her off the bracket. I didn't want it to go through the skin and make more bleeding. Housekeeping Aide BB and RN N moved the bed to get (R108) off the bracket. The bracket entered between her butt cheeks. The blood was running out. There was something else that was coming out that looked like fat. It was yellow in color. It was adipose tissue. (R108) was supposed to have help to get up because she was unstable on her feet. That bracket was for a foot board. I think this accident would never have happened if the footboard had been on it like it was supposed to be. Why wasn't the footboard on there? The Administrator did not have me make a written witness statement. I showed the Administrator the bracket. There were metal brackets like the one (R108) fell onto on beds being used by other residents.Review of R108's Progress Note revealed:-7/2/25 5:40 AM, revealed, .a crash was heard.(R108) was observed lying on her right side with her left buttocks impaled on a bracket used to mount a footboard on the bed. The bracket had entered her butt checks and was pressing the lateral side of her buttocks out.the bed was moved to the point where she was no longer impaled.transported to (name of hospital) by ambulance.-7/11/25 8:24 PM, revealed, .arrived to the facility at 4:45 PM.full depth tunneling. 1st opening on side of rectum.2nd opening near labia.-7/14/25 00:00 AM, revealed, fall, fracture, buttock wound.hospitalized from 7/2-7/11 with left buttock wound secondary to inserted bed frame from a fall.left inferior pubic rami fracture.washout in operating room with reconstruction of anal sphincter on 7/2.-7/14/25 5:42 PM, revealed, 2:45 PM wound vac changed to coccyx attempted.soft stool surrounding wound site and drain tube area. Noted drain area on right lower buttock to be sealed shut and area swollen, firm, tender, and warm.resident is painful with direct touch to area. EMS to transport (to ER for evaluation).The Immediate Jeopardy began on 7/2/25 and was removed on 7/2/25 when the facility took the following actions to remove the immediacy:1. On 7/2/25, Resident 108 was assessed for injury post fall, and sent to ER via EMS. Family and Physician notified of incident.2. On 7/2/25 at 9:00 AM, the Maintenance director removed brackets off the bed of Resident 108. There were 8 beds identified that did not have footboards, those beds will be replaced. An order was placed for new beds that arrived 7/15/25.3. On 7/3/25, a new bed was delivered for Resident 108 and installed, the old bed removed.4. On 7/2/25, at 9:15 AM, The NHA and Maintenance director completed an assessment on all beds in the facility for any sharp edges and/or brackets. Any beds with brackets in place were immediately removed. No beds presented with safety issues as of 7/2/25.5. On 7/10/25, The RCC completed a 100% audit on all beds to assess for sharp edges/protruding brackets. There were no beds that presented a safety risk.6. On 7/2/25, education was initiated with staff via Onshift and in person to observe equipment for protruding parts/sharp edges and to report to NHA/Maintenance immediately. Staff are to remove equipment immediately from use and put work order into TELS. Any staff not educated by 7/2/25 will be educated on the next working shift. There were 94 staff members educated via Onshift on 7/2/25, 44 of 94 employees have wet signature for in-person training on 7/2/25.7. On 7/2/25, staff were educated to not alter equipment, including beds, to ensure resident safety. There were 94 staff members educated via Onshift on 7/2/25, 44 of 94 employees have wet signature for in-person training on 7/2/25.8. On 7/2/25, an Ad Hoc QAPI was held to review policy and deficient practice, including the Medical Director.9. Beginning 7/2/25, Maintenance/Designee will conduct a monthly assessment of beds per TELS schedule to assess any broken equipment, protruding/sharp edges ongoing. Audit to include missing equipment/broken equipment. The first assessment completed 7/2/25.10. On 7/2/25, the Maintenance Director completed an Entrapment Log assessment on all beds. Beds that had a discrepancy on the Entrapment Log were resolved by Maintenance on 7/2/25. The maintenance director was re-educated on 7/16/25 on the correct manner in which to conduct and document bed audits to ensure resident safety.

This citation pertains to intake 2563197. Based on observation, interview and record review, the facility failed to perform routine inspections and maintenance to ensure safety of resident beds for 1 of 1 resident (R108) reviewed for bed safety, resulting in a life-altering injury for R108 and potential for further injury for 9 additional residents who had foot-board brackets on their beds with no foot board.Findings include: According to the Minimum Data Set (MDS) dated [DATE], R108 had a BIMS (Brief Interview Mental Status) of 9/15, indicating the resident was cognitively impaired. Diagnoses that included cognitive communication deficit and history of falling. Review of R108's Progress Note dated 7/2/25 5:40 AM, revealed, .a crash was heard.(R108) was observed lying on her right side with her left buttocks impaled on a bracket used to mount a footboard on the bed. The bracket had entered her butt checks and was pressing the lateral side of her buttocks out During an interview on 7/14/25 at 9:52 AM, with Nursing Home Administrator (NHA) A and Maintenance Director M, Maintenance M reported there were a total of 9 beds that had two metal brackets, approximately 4 with a pointed top that extended up from a 90-degree bend at the end of the bed to hold a footboard. There were no footboards to place in the brackets with the beds being in use from before he had taken over as Maintenance since May of 2025. NHA A reported she had no idea how long the beds had been in use with the exposed bracket in place but added they (metal brackets) have been in place on the beds with no footboards longer than I've worked here. During an interview on 7/15/25 at 9:42 AM, Registered Nurse (RN) N stated, (R18's) bed had metal brackets at the end of the bed that was sticking up. There was no footboard in them. One bracket had impaled (R108) into her left buttock. During an interview on 7/15/25 at 10:38 AM, RN Q stated, I work at the facility and (R108) is my family member. I saw (R108) on the morning of the incident. There were two metal brackets approximately 6 high at the end of the bed that were supposed to hold a footboard. There was no footboard in the brackets. Review of facility Closed Work Orders, dated 3/1/25-7/14/25 indicated not one of the nine beds with exposed metal brackets had been listed on the work order list.

This citation pertains to intake: #MI00138772. Based on interview and record review, the facility failed to ensure the safety and prevent elopement in 1 (Resident #35) of 4 residents reviewed for accidents/hazards, resulting in an Immediate Jeopardy when Resident #35, who had been assessed as an elopement and fall risk on admission and had a Brief Interview for Mental Status (BIMS) of 9, left the facility unbeknownst to facility staff and was found on [DATE] at 7:25 pm approximately 0.25 miles away at a neighbors residence, across a 35 mph road, after another resident notified the nurse that the wheelchair at the facility exit door belonged to R#35. Findings include: Review of an Admission Record revealed Resident #35 was a male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: acute kidney failure, heart failure, chronic obstructive pulmonary disease (a lung disease that results in difficulty breathing), type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) depression, and other stimulant abuse. Review of a Facility Reported Incident (FRI) report received by the State Agency on [DATE] at 9:08 PM revealed Incident Summary: Resident eloped from facility; full investigation to follow . Review of an Investigation Report received by the State Agency on [DATE] at 10:45 AM revealed, Allegation Statement: On [DATE] at 7:25 pm, a resident, (Resident #35) left the facility unsupervised. The alarm was sounding, his primary nurse, (Registered Nurse (RN) Z) came to the front door to see a wheelchair stuck in the doorway and a group of visitors walking to their car. The nurse stepped outside to check the parking lot; however, she did not see anyone other than the visitors getting into their car. The nurse returned to the facility and asked the nurse in the rehab hallway if the visitors were using a wheelchair. The nurse stated no, at that time a resident came to the nurse to say that (Resident #35) was at the end of the driveway. The nurse and a CNA (Certified Nursing Assistant) went to the end of the drive to assist the resident back to the facility, he refused. The nurse stayed with the resident and was able to redirect the resident back to his wheelchair, then assisted back into the facility. The resident was immediately put on 1:1 (one to one) supervision. Resident: (Resident #35) .BIMS 9 - indicating mild impairment . Review of a Witness Statement Form dated [DATE] and authored by RN Z revealed, Alarm at front door was going off. I went to turn off alarm & (and) empty w/c (wheelchair) @ (at) door. I went out to parking lot. People getting into vehicle. Didn't see anyone else. Came back in & asked (Licensed Practical Nurse (LPN) Y) if she had a person go out in a w/c. She said no. A resident said it was (Resident #35). I and (LPN Y) looked in bathroom. Then went outside. A couple was walking in p/lot (parking lot) toward door & asked if we were looking. They pointed in direction. I ran across parking lot. From top of hill/drive, (referring to the facility's steep driveway with multiple potholes at the bottom of the drive before the incline) I could see (Resident #35) down the street. I called out to him to stop. He did turn around & stop. He said he wasn't coming back. I couldn't make him. Said he had a place to go. Said we weren't doing anything for him. He sat down on the curb. We talked. Explained that we would call daughter. That he needed to talk to management. I called (Unit Manager (UM) J) (no answer). Called Nursing Home Administrator. Explained situation. Contacted 911 to get resident back into building. 2 aids (CNA N and CNA S) and (LPN Y) were outside with me trying to get him in. (CNA N) was able to get him back into w/c & on our side of the street. Police showed up & by then (Resident #35) said he'd come back inside. (LPN Y) & I pushed (Resident #35) in w/c back up hill & then he was reluctant once we got him to the door to go back inside. He stayed in foyer & refuse to leave. Review of Resident #35's Pre-Admission Hospital Notes (Hospital Name Omitted) revealed a Progress Note filed [DATE] at 2:49 AM, Upon shift change at 1900 (7:00 PM) patient was very agitated and restless stating that he is going to take off and leave the hospital. RN (name omitted) and RN (name omitted) unsuccessfully attempted to redirect patient. Pt refused all meds and attempts to make more comfortable .Pt (patient) began making statements about self harm. Stating that he did not care if he got hit by a car or died in the ditch. Also stating that he did not want to wake up and had nothing to live for . Review of Resident #35's Admission/Readmission assessment dated [DATE] revealed, .Section E. Elopement Risk Assessment 1. History of Wandering or Elopement a. Elopement attempts at previous residence Yes b. History of wandering at previous residence Yes .d. Has made 1 or more attempts to elope in the past 90 days Yes 2. Delirium Acute reversible confusion a. Caused by medical illness such as infection, diabetes, cardiac problems, oxygen compromise, altered blood chemistry. Yes 3. Adjustment Problems a. Resident makes statements regarding wish to leave, wish to go home .Yes .9. Elopement Risk a. Is the Resident At Risk for Elopement? Yes . Review of Resident #35's Progress Note dated [DATE] at 5:30 PM and authored by Nurse Practitioner (NP) MM revealed, .In the last week and a half the patient has been seen by 2 physicians and his capacity has been determined incapable so they (sic) DPOA (durable power of attorney) may be interacted (sic) . Review of Resident #35's Nursing Progress Note dated [DATE] at 4:25 PM revealed, Note Text: Therapy notified me that (Resident #35) was in the front foyer sleeping on the couch. He had self-transferred to couch. I did a standby assist to make sure he got back to wheelchair and advised him he could head down for dinner. Review of a Resident #35's Care Plan in place on [DATE] revealed a focus of I am at an increased risk for falls r/t (related to) Deconditioning, Gait/balance problems with a date initiated of [DATE]. There was no care planned focus of elopement risk in place on [DATE]. In an interview on [DATE] at 2:09 PM regarding Resident #35's elopement on [DATE], Social Services Manager (SSM) S reported resident #35 had not been safe to be out by himself. SSM S reported Resident #35 had been down the street waiting for a friend to come by when the nurse found him. SSM S reported when a resident is assessed as being at risk for elopement, there should be a care plan in place to that effect. In an interview on [DATE] at 4:37 PM, RN Z reported had last seen Resident #35 approximately 20 minutes prior to his elopement when he took his medications and was assisted to the restroom. RN Z reported she had heard the alarm go off and went to the front entrance door to shut it off. RN Z reported when arrived at the front entrance door, saw an empty wheelchair off to the side so she went outside to look but didn't see anyone other than a family who was getting into their car and thought they had set the alarm off when they exited the building. RN Z reported went to confirm with the other nurse on duty if the family had been using the wheelchair and the nurse said no. RN Z reported there was another resident who had been standing up at the front nurses station who said that the wheelchair belonged to Resident #35. RN Z reported at that time, went to look for Resident #35 in his bathroom and when she realized he was not there, she ran to the door. RN Z reported at that point, there was another couple who was coming into the building across the parking lot. RN Z stated, They could tell I was panicked, and they asked me if I was looking for someone. They told me they had just seen someone go over the hill. RN Z reported located Resident #35 across the street down the road at (House Number omitted). RN Z reported had not called a Code (referring to an Elopement/Missing Resident Code) when realized Resident #35 had left the building. When queried as to how staff would know if a resident was at risk for elopement, RN Z reported they are usually exit seeking or something. When queried as to what type of communication documentation the facility used to alert staff to a resident at risk for elopement, RN Z reported it would probably be in a progress note. RN Z reported there was also a green binder in the front office area but was unsure if or how often staff was supposed to review it. RN Z reported any resident who was ambulatory had the potential to be an elopement risk. RN Z reported a majority of the elopement risks were communicated during shift-to-shift nursing reports. RN Z reported she had not been aware that Resident #35 had been an elopement risk. RN Z reported Resident #35 used to go up to the front lobby by himself and sit on the couch, but If I had known he was an elopement risk, I would not have allowed him to be in the front room. That would not be okay. In an interview on [DATE] at 2:56 PM, Resident #35, who was seated in his wheelchair in his room on the Memory Care Unit, reported he was waiting for his brother to pick him up this afternoon because he shouldn't be here (referring to at the facility). Resident #35 reported he was tired of being at the facility and he is going to walk out again if they can't do something about him being in the Memory Care Unit. Resident #35 reported on the day he got out of the facility, he just walked out by himself. Resident #35 declined to provide any additional details regarding how he was able to exit the facility at that time. On [DATE] at 4:30 PM, Regional Director of Operations (RDO) UU was verbally notified and RDO UU and Nursing Home Administrator (NHA) A received written notification of the Immediate Jeopardy that began on [DATE] due to the facility's failure to prevent the elopement of Resident #35. A written plan for removal for the Immediate Jeopardy was received on [DATE] and the following was verified on [DATE]: * During investigation of elopement on [DATE] the facility identified that the resident did not have proper care planning or interventions in place to reduce risk of elopement for a resident identified as an elopement risk upon admission. * The facility identified that residents residing in the facility were determined to be at risk. On [DATE], the facility assessed all residents for elopement risk and implementation of elopement care plans with appropriate interventions; proper assessments and care plans were implemented if applicable. * The elopement binder was updated on [DATE]. * Education of elopement and wandering policy and care planning of elopement with proper interventions was initiated on [DATE]; any facility staff member and agency staff member who did not receive education by [DATE] will receive education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. As of [DATE], all facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their first shift. * The EVS Director assessed the facility doors for proper function of the alarm system on [DATE]; deemed to be functioning appropriately. * The facility door code was changed on [DATE]. * The Administrator notified the DPOA/daughter of the incident and discussed proper interventions, she agreed with the implementation of the interventions. Law Enforcement, physician and Director of Nursing also notified. * Resident was placed on 1:1 supervision immediately until further interventions could be implemented. * Assessments were completed on the resident to ensure the resident did not experience any adverse effects of the elopement, including skin assessment, pain assessment and vitals signs were obtained. * On [DATE], the care plan for resident #35 was updated with proper interventions to reduce future risk of elopement. * Risk Management report was completed on [DATE]. * Witness statements were obtained by primary care staff on [DATE]. Actions to Prevent Occurrence/Reoccurrence: * The Elopement and Wandering Policy was reviewed by the facility Administrator and deemed appropriate. * Beginning on [DATE], education with facility staff and agency staff was initiated on the Elopement and Wandering Policy. Any facility staff and agency staff who did not receive the education by [DATE] were education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. As of [DATE], all facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their first shift. * Beginning on [DATE], education with licensed nurses was initiated on proper implementation of elopement care plans and interventions. Any facility staff and agency staff who did not receive the education by [DATE] were education prior to the start of their next shift. All facility staff or agency staff who were present at the time of the incident were immediately educated. As of [DATE], all facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their first shift. * Director of Nursing/designee will conduct an audit with three licensed nurses weekly for four weeks and then monthly for three months to ensure understanding of proper implementation of care planning and interventions for resident at risk of elopement, until substantial compliance has been maintained. Results of these audits will be submitted to the QAA committee for review and any further recommendations. * Director of Nursing/designee will conduct an audit with five random staff members once a week for fours week and monthly for three months to ensure understanding of elopement and wandering policy, until substantial compliance has been maintained. Results of the audits will be submitted to the QAA committee for review and any further recommendations. * Residents will be evaluated for elopement risk quarterly beginning [DATE], and as needed, new residents will begin assessment for elopement risk upon admission. The initial assessment and reassessment for all residents is deemed appropriate to capture any other residents that could potentially be at risk for elopement; implementation of possible interventions to reduce occurrence. All licensed nursing staffing have begun receiving education on completing the elopement assessment with proper implementation of interventions. * Results of audits will be reviewed with the QAA committee to ensure compliance and any further recommendations. In an interview on [DATE] at 08:22 AM, RN X reported working at the facility for several years and that the facility had not ever done a educational drill (virtual training) related to the elopements and/or the expectations for staff response to a door alarm that is sounding for an unknown reason. In an interview on [DATE] at 10:18 AM, Housekeeper (HSK) P reported that she had not received any education related to responding to a door that was alarming and reported, .I had some education about a year ago when I first started . HSK P reported that she was informed about Resident #35's elopement and stated, .they didn't talk about door alarms .I didn't get any papers .I had to sign something . HSK P reported that her responsibility if a door alarm was sounding, would be to check to see if there were any residents by the door and then to shut the alarm off. HSK P was not able to verbalize any further steps to ensure all residents were safe and accounted for. In an interview on [DATE] at 10:22 AM, HSK F reported that she thought that someone had talked to her about door alarms when she first started and stated, .I guess I would check the door and then shut the alarm off .I don't think there would be anything else . In an interview on [DATE] at 10:30 AM, Activities Director (AD) Q reported that she was very familiar with the residents that are at risk for elopement, and she would refer to the care plan to verify the elopement risk. AD Q reported that she signed an elopement paper, but when asked what she should do if there was a door alarming, reported that she did not know that answer and would have to go check with someone. Review of the facilities Immediate Jeopardy Abatement Removal Plan dated [DATE] revealed, .Education of elopement and wandering policy and care planning of elopement with proper interventions was initiated on [DATE]; any facility staff member and agency staff member who did not receive education by [DATE] will receive education prior to the start of their next shift . The interviews above from HSK P, HSK F, and AD Q indicate that the educate given was not effective and additional information was requested to removed the immediate jeopardy and ensure the safety of the residents. Addendum [DATE] In response to the survey team not being able to lift the immediate jeopardy, the following steps have been completed: * The Elopement and Wandering Policy was reviewed by the facility Administrator and deemed appropriate. * Re-education of all facility staff and agency staff on the Elopement and Wandering Resident Policy with completion of post-test to ensure retention of information. If a staff member fails to successfully complete the post-test, education will take place immediately to ensure comprehension. * Any facility staff and agency staff who did not receive the education and post-test by [DATE] will be educated prior to the start of their next shift. * Completion of an elopement drill on [DATE] on all shifts to ensure all staff respond appropriately in the event of a missing resident. Then weekly drills for four weeks to maintain compliance. * Elopement binders will be reviewed and updated. * The EVS Director assessed the facility doors for proper function of the alarm system on [DATE]; deemed to be functioning appropriately. * The facility is alleging compliance on [DATE] * As of 2:00 pm on [DATE], 34 facility and agency staff members were educated on the Elopement and Wandering Resident policy and completed a post-test. The remainder of the facility staff and agency staff will be educated and complete a post-test prior to their next shift. * A successful elopement drill was completed at 2:00 pm and the signatures recorded of those in attendance. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of no actual harm due the fact that not all facility staff have received the education and sustained compliance has not been verified by the State Agency. 41027

This citation is linked to intake MI 863 and intake MI 864 Based on interview and record review the facility failed to prevent resident to resident abuse by a resident with a known history of unpredictable behaviors in 1 of 5 residents (Resident #101) reviewed for abuse , resulting in a resident to resident incident with harm. Findings include: Resident #102 Review of a Face Sheet revealed Resident #102 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 4/26/2019 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #102 was severely cognitively impaired. Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 5/8/2019 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #101 was severely cognitively impaired. Review of Resident #101's Care Plan revealed, Focus: Resident has the potential for psychosocial distress related to: anticipated dementia progression, expressing sadness/anger/empty feeling over lost roles and status. Goal: Reduction in behavioral episodes <3-5 times per week; with no evidence of creation of danger to self or others. Date initiated 09/28/2018. Review of the facility reported incident date 3/2/19 at 9:56 pm revealed Resident #101 was found standing in the doorway of her room calling for the nurse, showed the nurse 2 skin tears on her forearm and stated he did it pointing towards the roommate (Resident #102). No blood noted in the roommates fingernails. Resident #101 was provided first aide, both roommates were placed on 15 minute checks and Resident #101 was given PRN medication because she was yelling and acting out. A progress noted dated 3/2/2019 at 11:11 PM by Licensed Practical Nurse (LPN) F revealed, Resident restless, combative with staff. assisted x2 cena (Certified Nursing Assistant) for ADL care. resident has two skin tears LFA (left forearm). resident removed dry drsg (dressing) twice. LFA open to air at this time. Review of the facility investigation dated 3/7/19 (no time) revealed Resident #101 has a history of dementia with behavioral disturbance, impulse disorder, delusional disorder and restlessness/agitation. She has a history of self harming behaviors . (Resident name) had not had a history of [REDACTED]. Root cause/analysis: After review of interviews, physical assessment of residents, and environmental assessment it is most likely that (Resident #101) caused these injuries to herself. When questioned, she did deny it. The investigation was signed and completed by Director of Nursing B. An interview on 5/21/2019 at 10:49 AM, confidential informant (CI) G indicated she received in report when she came in on 3/2/2019, Resident #101 and Resident #102 had not been getting along. CI G indicated she had gone into the room and Resident #101 was standing over Resident #102, had removed Resident #102's gown and had clawed at her face and arm. CI G indicated Resident #102 then dug her nails into Resident #101's arm, which caused them to bleed. CI G indicated it was obvious the two roommates had not been getting along and informed the nurse on duty to move one of the residents to another room, but her request had been ignored. CI G indicated she later decided to move Resident #102 because she was afraid of Resident #101 hurting Resident #102 again. CI G indicated what she saw was abuse. Review of the facility reported incident date 3/3/19 at 2:32 am revealed Certified Nurse Aide (CNA) was with Resident #101 when Resident #101 headed to her roommates bed and attempted to removed Resident #102's gown and grabbed the sides of Resident #102's head. Resident #101 had grabbed Resident #102's gown and scratched her cheek. The residents were separated, Resident #101 was placed on 1:1 supervision and Resident #102 was provided a different room. An interview on 5/20/2019 at 1:00 PM, LPN [NAME] indicated that there had been multiple occurrences between Resident #101 and Resident #102 on 3/2/2019 and 3/3/2019. LPN [NAME] indicated Resident #101 attacked Resident #102 several times and two times were on her shift. LPN [NAME] indicated the CNA's had to keep checking on her and Resident #101 was always by Resident #102, grabbing at her gown or standing over her. LPN [NAME] indicated Resident #101 had grabbed Resident #102 by the head and was hitting it on the pillow. LPN [NAME] indicated it was decided to move Resident #102 in order to prevent Resident #101 from abusing her anymore. A progress note on 3/3/2019 at 3:50 AM by LPN [NAME] revealed, Resident #101 was very aggressive and combative this shift. She ripped her roommate's gown off, grabbed her by the head and was shaking it around. She then scratched the right side of her roommate's face. Resident #101 continued to yell . A progress notes on 3/3/2019 at 3:46 AM by LPN [NAME] revealed, Resident #102 was lying in her bed when her roommate ripped her gown off of her, grabbed a hold of her head and was shaking it. The roommate (Resident #101) scratched the right side of her face and left a red mark on the right upper lip. Resident #102 has been moved to a different room. She was crying, stating I'm afraid of her (Resident #101) . An interview on 5/23/2019 at 9:24 AM, Social Services D indicated Resident #101 has been on and off since she's been here with behaviors like being physical aggressive with other people. Review of a progress noted dated 2/9/2019 at 18:30 by LPN O revealed, Res (Resident) propelled herself into the dayroom and yelling out attempting to grab at other resident. Staff redirected resident to other area. Res persisted with this behavior for a while . Review of a progress notes dated 2/11/2019 at 10:32 AM by Director of Nursing (DON) B revealed, Observed Resident #101 on the unit today. Past few days she has had increased agitation and delusions towards other residents. This is long time behavior history for her . Review of a progress note dated 2/24/2019 at 12:29 AM by Registered Nurse (RN) P revealed, Resident has been yelling out most of shift, denies pain. Got up and slammed another resident's door . Review of a progress note dated 3/2/2019 at 12:45 PM by LPN O revealed, .Res (resident) began walking into other rooms and throwing things. redirected back to her room. res refused PRN (as needed) medication. Res continued yelling and going over to roommate to take roommates things to throw . An interview on 5/21/2019 at 2:01 PM, Certified Nursing Assistant (CNA) H indicated you never know when a resident will strike out, and if she (Resident #101) is in one of her moods you need to keep an eye on her. An interview on 5/21/2019 at 1:30 PM, Unit Coordinator (UC) C indicated she was already looking into either Resident #101 or Resident #102 switching rooms (Prior to the incident on 3/2/2019) because the CNA's had been telling her Resident #101 didn't like Resident #102. An interview on 5/21/2019 at approximately 11:30 AM, CI I indicated it was no surprise to her when Resident #101 struck out at Resident #102 and it was only a matter of time because Resident #101 did not like Resident #102. CI I indicated she communicated her concerns to the nurse on duty and the unit coordinator. CI I indicated she did not know why they (facility management) didn't move Resident #102 before the incident on 3/2/2019 occurred. Using the reasonable person concept, Resident #102 would not have wanted to be abused by Resident #101. Resident #102 did voice fear of Resident #101 which clearly showed a negative psychosocial outcome for Resident #102. Resident #102 did voice fear of Resident #101 at the time of incident, but given her cognitive impairment, would likely not be able to continue to voice that fear. This does not negate the psychosocial impact on Resident #102.

Based on observation, interview and record review, the facility failed to prevent the development of an avoidable pressure ulcer for 2 of 2 sampled residents (Resident #19 and #18) reviewed for alterations in skin integrity, from a total sample of 18 Residents, resulting in the development of an avoidable pressure ulcer for Resident #19 and the potential for skin breakdown, wound healing, infection, and overall deterioration in health status for Resident #18. Findings include: Review of the Facility Policy and Procedure Skin at Risk Assessment last revised in (MONTH) (YEAR) revealed, Policy: It is the policy of this facility to assess resident risk factors for impaired skin integrity and intervene as indicated utilizing the admission plan of care and Minimum Data Set as formal assessment tools. Purpose: To ensure prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors .The following guidelines are reviewed and implemented as indicated for each individual risk factors .Prevention of skin injury due to friction or shearing through proper positioning .change of residents position every 2 hours and more frequently if redness or irriation of the skin develops .individualize the resident goals and interventions as documented on the plan of care. Review of Fundamentals of Nursing (Potter and Perry) 8th edition revealed, Positioning interventions reduce pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces .patient's need repositioning on a schedule of at least every 2 hours .Some patients are able to sit in a chair. Make sure to limit the total amount of time they sit to 2 hours or less. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 1196-1197 Resident #19 Review of a Face Sheet revealed Resident # 19 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 4/12/18 revealed a Staff Assessment for Mental Status score of 3, which indicated Resident #19 had severe cognitive impairment. Review of Resident #19's Functional Status for transferring and personal hygiene revealed Resident #19 was an extensive assist of two staff members. Resident #19 was an extensive assist of one staff member for bed mobility. During an observation on 06/12/18 at 07:00 A.M., Resident #19 was lying in bed on her back. During an observation on 06/12/18 at 08:08 A.M., Resident #19 was lying in bed on her back. During an observation on 06/12/18 at 09:11 A.M., Resident #19 was lying in bed on her back. During an observation on 06/12/18 at 09:45 A.M., Resident #19 was lying in bed on her back. During an observation on 06/13/18 at 08:15 A.M., Resident #19 was lying in bed on her back. During an observation on 06/13/18 at 09:30 A.M., Resident #19 was lying in bed on her back. During an observation on 06/13/18 at 10:36 A.M., Resident #19 was lying in bed on her back. During an observation on 06/13/18 at 11:16 A.M., Resident #19 was lying flat on her back with a pillow behind her head on the shower cot (bed used to bring residents into the shower room). Assessment of her buttocks revealed two open areas on her right buttocks near the horizontal gluteal crease. One of the open areas was near Resident #19's intergluteal cleft and the other open area was on the outer aspect of the buttocks. Each open area was approximately 2-3 centimeters round. Each open area was reddened. Additionally, there was a reddened open area in the top crease of Resident #19's intergluteal cleft. During an interview on 06/13/18 at 11:16 A.M., Certified Nurse Assistant (CNA) CC reported that residents that cannot reposition themselves should be repositioned at least every two hours. CNA CC stated, (Resident #19) should probably be turned every hour since she has sores on her bottom. Review of Resident #19's Care Plan for Activities of Daily Living last revised on 10/9/17 revealed, ADL'S: Dependent for ADL'S .Bathing: Total assist with bathing, monitor for impaired skin integrity and notify charge nurse as indicated. Review of Resident #19's Care Plan for Skin Integrity last revised on 2/5/18 revealed, Assess postural alignment, weight distribution, sitting balance, & pressure redistribution on admit and prn .assist with re-positioning with use of draw sheet as needed to prevent friction/shear .measure open areas upon admission, weekly, prn. There was no documented turning schedule to prevent impairment in skin integrity on the care plan to indicate how often Resident #19 should have been turned. Review of the Facility Skin Assessment revealed 6/8/2018 skin is warm and dry. mucous membranes are pink and moist. res has a reddened sacral area. Center is nonblanchable. res had a recent stage II ulcer (indicating the presence of new skin breakdown). Resident #18 Review of a Face Sheet revealed Resident #18 was a 67 -year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident # 18, with a reference date of 4/12/18 revealed a Staff Assessment for Mental Status score of 3, which indicated Resident #18 had severe cognitive impairment. Review of Resident #18's Functional Status for bed mobility, transferring, dressing, and personal hygiene revealed Resident #18 was an extensive assist of two staff members. Review of Resident #18's Care Plan for Activities of Daily Living last revised on 5/31/18 revealed, ADL'S: Dependent for ADL'S .Bathing: Total assist with bathing, monitor for impaired skin integrity and notify charge nurse as indicated. Review of Resident #18's Care Plan for Skin Integrity last revised on 2/24/16 revealed, Assess postural alignment, weight distribution, sitting balance, & pressure redistribution on admit and prn .assist with re-positioning with use of draw sheet as needed to prevent friction/shear .measure open areas upon admission, weekly, prn (as needed). Review of Resident #18's Care Plan for Skin Integrity last revised on 2/24/16 revealed no turn schedule to prevent impairment in skin integrity. During an observation on 06/13/18 at 08:17 A.M., Resident #18 was lying on his back with the head of his bed elevated approximately 30 degrees. During an observation on 06/13/18 at 09:31 A.M., Resident #18 was lying on his back with the head of his bed elevated approximately 30 degrees. During an observation on 06/13/18 at 10:37 A.M., Resident #18 was lying on his back with the head of his bed elevated approximately 30 degrees. During an observation on 06/13/18 at 10:33 A.M., Resident #18 was lying on his back with the head of his bed elevated approximately 30 degrees. Resident #18's legs diagonal off bed: head top right and legs off to left. During an observation on 06/13/18 at 11:25 A.M., Resident #18 was lying on his back with the head of his bed elevated approximately 30 degrees. Resident #18's legs diagonal off bed: head top right and legs off to left. During an observation on 06/13/18 at 11:52 A.M., Resident #18 was lying on his back with the head of his bed elevated approximately 30 degrees. Resident #18's legs diagonal off bed: head top right and legs off to left. Resident #18's head was approximately 18 inches from the top of the bed. During an interview on 06/13/18 at 11:52 A.M., Certified Nursing Assistant (CNA) M reported that Resident #18 is often combative. CNA M attempted to assess Resident #18's brief. Resident #18 became combative and CNA M left the room without assessing Resident #18's brief and did not reposition Resident #18. During an observation on 06/13/18 at 12:09 P.M., Resident #18 was lying on his back with the head of his bed elevated approximately 30 degrees. Resident #18's legs diagonal off bed: head top right and legs off to left. Resident #18's head was approximately 18 inches from the top of the bed. During an observation on 06/13/18 at 12:44 P.M., Resident #18 was lying on his back with the head of his bed elevated approximately 30 degrees. Resident #18's legs diagonal off bed: head top right and legs off to left. Resident #18's head was approximately 24 inches from the top of the bed. During an observation on 06/13/18 at 01:53 P.M., Resident #18's buttocks was observed. Resident #18 had redness noted on the top of his buttocks on his left gluteus near the intergluteal cleft. The reddened area was non-blanchable and was approximately the size of a nickel.

This citation pertains to intake numbers MI 974 & MI 066. Based on interview and record review the facility failed to provide adequate supervision to prevent a fall for 1 out of 4 residents (Resident #500), out of a total sample of 4 residents, resulting in Resident #500 falling which resulted in Resident #500 receiving a subdural and subarachnoid hemorrhage (bleeding in the brain in two different areas) status [REDACTED]. Findings: Per the facility face sheet Resident #500 was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #500 no longer resided at the facility at the time of the investigation. Review of a Minimum Data Set ((MDS) dated [DATE] revealed that Resident #500 was admitted to the facility from a psychiatric hospital. The MDS revealed Resident #500 scored a ,[DATE] on his Brief Interview for Mental Status (BIMS). Review of facility incident reports revealed Resident #500 had a fall on [DATE], no increase of supervision was noted as an intervention, on [DATE] Resident #500 had a fall and no increase in supervision was noted as an intervention, and on [DATE] Resident #500 had a fall and no increase in supervision was noted as an intervention. Record review of the incident report dated [DATE] at 11:15 AM, revealed that Licensed Practical Nurse (LPN) #8 was walking into the unit and observed Resident #500 lying on his left side perpendicular to his bed. The incident report revealed that Resident #500 stated that he had gotten up so he wouldn't urinate on the floor. The incident report revealed that Resident #500 had been toileted at 9:30 AM, and was checked 10 minutes prior to finding him on the floor. The incident report revealed that Resident #500 was on 15 minute checks, bed was low to the floor and locked, call light was within reach, and Resident was wearing appropriate footwear. The incident report revealed, His (Resident #500) actions could not be predicted resulting in an unavoidable fall .(Resident #500) has cognitive deficits that fluctuates but his BIMS is 13 at the time of the fall. (Resident #500) is not safe to transfer self without assistance and with his cognitive deficits he lacks safety awareness as well. The report revealed Resident #500 hit his head on the floor when he fell that resulted in a hematoma (blood filled bump) to the back of Resident #500's head. The report revealed Resident #500 was reaching for his urinal and fell to the floor in the process, and indicated that the urinal would be placed closer to Resident #500 in the event he returned to the facility, but no intervention of increased supervision was noted. Review of nurses' notes dated [DATE] revealed, Poor safety awareness noted as (Resident #500) was seen self-transferring several times this shift.Record review of nurses' notes dated [DATE] at 6:51 PM, revealed Resident #500 was found lying on his left side on the floor in his room. The note revealed that Resident #500 was alert to his self, but stated that he was getting up to get the milk bottle (urinal) so that he would not urinate on the floor. The note revealed that a skin tear to Resident #500's left lateral knee was noted, along with a hematoma, the size of a golf ball, noted to the occipital (back of head) area of his head, and small amount of blood was noted. The note revealed that Resident #500 ate part of his supper, but at 5:40 PM Resident #500 was found to be slouched in a chair with his head back and non-responsive (the note did not reveal where Resident #500 was at the time he was found non-responsive). Per the nurse's note, Resident #500 was not able to follow commands, such as following a finger, performing a hand grasp, or smile. Per the note Resident #500 left the facility at 6:00 PM via an ambulance en-route to the hospital. Record review of the hospital emergency room (ER) medical records dated [DATE] revealed that Resident #500 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The ER record revealed that Resident #500 had a frontal lobe (front of the brain) contusion (a bruise), and was admitted to the hospital. Additional review of the hospital records History & Physical (H&P) dated [DATE] revealed that Resident #500 sustained a fall at the nursing facility on [DATE], and the details of the fall were unclear, and noted that resident #500 was found slumped over in his chair at the nursing facility, after reading some Christmas cards, but revealed that Resident #500 was not able to provide any meaningful information the the ER physician. The H&P revealed the results of a cat scan Resident #500 had of his brain. The cat scan results revealed, . a small acute bilateral (both sides) frontal lobe contusion with small amounts of acute subdural (between the brain and the lining around the skull) hemorrhage (abnormal bleeding into an area) seen along the anterior (front) margins of the frontal lobes as well as a small amount of subarachnoid (between the brain tissue and the lining around the inside of the skull) hemorrhage . Review of a physician Progress Note dated [DATE] revealed Resident #500 had no meaningful response, unable to swallow, having seizures, Resident #500's prognosis was very poor, hospice was recommended, and Resident #500's life expectancy was short and prognosis and condition were terminal. Review of the medical examiner's (M.E.) report dated [DATE] revealed that Resident #500 expired while residing at the hospice home on [DATE] at 12:20 PM. The M.E. report confirmed that Resident #500 had a known history of hallucinations, causing himself harm and throwing himself on the floor. Review of the death certifcate, dated [DATE], revealed that Resident #500 passed away on [DATE] due to complications of traumatic head injury (cerebral contusions and subdural hemorrhage) as a result of a fall on [DATE] in the nursing home. Review of a care plan titled Potential for altered mobility and ADLs (activities of daily living) dated [DATE] revealed interventions as follows: 15 minute safety checks for Resident #500 dated [DATE], no increase in supervision was noted after Resident #500's falls dated ,[DATE] & [DATE]. Under Fall Intervention dated [DATE] and revised on [DATE] revealed no increase in supervision after Resident #500's falls on ,[DATE], ,[DATE] or [DATE]. Record review of a care plan titled, Potential risk for falls dated [DATE] revealed interventions that were all dated [DATE], and no new interventions after any of Resident #500's falls for increase in supervision. The care plan revealed that Resident #500 was not able to use his call light to obtain assistance from staff so Resident #500's needs needed to be anticipated by staff. Review of printed documentation received from Registered Nurse (RN) #7 on [DATE] during a 2:44 PM interview, titled Item changes revealed that on [DATE] and [DATE] fall interventions for prevention of falls were added to Resident #500's plan of care, but no increase in supervision for Resident #500 was noted. No interventions were added after Resident #500's fall on [DATE] until [DATE], but no increase in supervision. No interventions were added after Resident #500's fall on [DATE], and on [DATE] no interventions for increase in supervision were added. In an interview on [DATE] at 10:40 AM, RN #4 stated that Resident #500 had been on 15 minute checks for weeks, and stated that she did not know the original reason for the 15 minute checks. RN #4 said she was not aware of any changes in the 15 minute checks for increase on supervision for Resident #500. RN #4 said that the facility did not use 1:1 supervision because it might upset the resident. In an interview on [DATE] at 1:58 PM, RN #1 said Resident #500 did not ever use his call light for assistance. In an interview on [DATE] at 2:44 PM, RN #7 said that all new residents admitted to the facility were put on 15 minute checks. RN #7 said residents who did not require the 15 minute checks would be taken off of them after one week, but stated that Resident #500 was not taken off of the 15 minute checks because he was non-compliant and had poor safety awareness. RN #7 said Resident #500 was kept on 15 minute checks to ensure his needs were met. RN #7 said all interventions for falls for Resident #500 would not show up on Resident #500's fall care plan, but only on his activities of daily living care plan, because that is what the Certified Nurse Aids would use. RN #7 was asked what the fall care plan was used for then, and RN #7 did not know, but stated, I see what you mean RN #7 said the 15 minute checks that Resident #500 was on was not an actual fall intervention, but rather was for safety, and because Resident #500 was a high risk for falls. RN #7 said no pattern was identified for when Resident #500 was going to get up on his own. RN #7 said no increase in supervision was done for Resident #500, and stated that no 1:1 supervision was done. In an interview on [DATE] at 3:30 PM, RN #3 said she knew Resident #500 had several falls. RN #3 said she knew Resident #500 very well and stated that Resident #500 was very confused. RN #3 said Resident #500 was, one you could walk by his room and he would be hallucinating, then 5 minutes later he was on the floor. In an interview on [DATE] at 12:45 PM, Administrator #6 stated that there was absolutely nothing more that the facility could have or would have done for Resident #500. Administrator #6 said that the facility could not prevent falls, and stated that Resident #500 was going to fall and all the facility could do was try to minimize injury. Administrator #6 said that it was not ever considered to put Resident #500 on 1:1 supervision, because the 1:1 would have agitated him. Administrator #6 once again stated that Resident #500 was going to fall and there was nothing to facility could do to stop Resident #500 from falling, and the facility could not prevent falls, and stated that the facility did not do 1:1 supervision. On [DATE] at 2:43 PM, during the exit conference, Administrator #6 and Director of Nursing (DON) #2 were present. Administrator #6 again stated that there was nothing more the facility could have done for Resident #500, and stated that Resident #500 was on 15 minute checks. DON #2 stated that the 15 minute checks worked because Resident #500 did not have any falls for a few weeks. Administrator #6 again stated that the facility did not do 1:1 supervision. No other increase in supervision was verbalized by Administrator #6 or DON #2 other than the 15 minute checks Resident #500 had already been on. ( )

This citation pertains to intake number MI 990. Based on interview and record review the facility failed to implement the advanced directives for 1 of 4 sampled residents (Resident #101) reviewed for advance directives from a total sample of 4 sampled residents, resulting in an Immediate Jeopardy when Resident #101 who was a Full Code, was found unresponsive with no pulse or respirations on [DATE] at approximately 3:30 AM and facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) and did not activate Emergency Medical Services (EMS). These deficient practices placed 28 residents, identified as Full Code status, at the facility at risk for serious harm, injury and/or death. Findings including: Review of the Face Sheet revealed Resident #101 was a [AGE] year-old male, who was re-admitted to the facility on [DATE]. Review of the Minimum Data Sheet (MDS), dated [DATE], revealed Resident #101 had [DIAGNOSES REDACTED]. The MDS revealed Resident #101's ability to make daily decisions was severely impaired. Review of the Resident Preferred Treatment Option, dated [DATE], revealed Resident #101 chose the option of Status 4: "The resident is to be hospitalized for [REDACTED]. Such treatments are to include resuscitation and surgical intervention "The Resident Preferred Treatment Option was signed by Resident #101's Guardian, two witnesses, and the physician. The Resident Preferred Treatment Option revealed handwritten orders by the physician for "full cardiopulmonary resuscitation", signed and dated [DATE]. Review of the Facility 24-Hour Report, dated [DATE], for Resident #101 revealed "Conclusion: The charge nurse did not initiate C.P.R. (sic) according to the advanced directive on file." Review of the Facility Advanced Directives Policy and Procedure dated revised [DATE], revealed "It is the policy of this facility to honor the health care decision made by residents with decision-making capacity or the resident's legal representative if the resident has been deemed not capable of making decisions...Guardian..a person who, in accordance with state law, has been selected by a resident, or who, in accordance with state law, has been appointed, and has been given the authority to make informed health care decisions for the resident in the event the resident loses decision-making capability...Cardiopulmonary Resuscitation (CPR): A procedure performed to attempt to support and restore ventilation and circulation in a resident experiencing [MEDICAL CONDITION] (systole, ventricular fibrillation, or pulse-less activity) or respiratory arrest (cessation of respiratory effort). It includes establishment and maintenance of an airway, assisted ventilation, chest compressions, call to 911 emergency medical technicians / paramedics to provide; establishment of intravenous access, cardiac monitoring, administration of medications, defibrillation or other control of arrhythmias, and immediate care after resuscitation." In interviews conducted on [DATE] at 11:30 AM and 3:30 PM, Licensed Practical Nurse (LPN) #1 reported that on [DATE] around 3:30 AM, Certified Nursing Assistant (CNA) #3 came and told her she thought Resident #101 was dead. LPN #1 reported that she, CNA #3 and CNA #2 hurried to Resident #101's room, where she found Resident #101 with no respirations "saw no visual rise or fall in his chest", no radial (wrist) pulses, and his axillary temperature was 97.4 (normal temperature 98.6). LPN #1 reported that she had CNA #3 get LPN #2 at about 3:35 AM to verify Resident #101's death. LPN #2 entered the room, looked at Resident #101 for respirations, and stated "Yea he's gone." LPN #1 reported that, at this time, she went to check Resident #101's chart and saw he was a Status 4, which was a Full Code, returned to the room and informed LPN #2, who "just stood there." LPN #1 reported that she was new to the facility, "which was no excuse", but she was looking to LPN #2 for guidance in this situation since she was more experienced in facility protocol. LPN #1 reported that she told LPN #2 she was going to call the physician and LPN #2 left the floor. LPN #1 reported that no CPR was started and EMS was not contacted. LPN #1 reported that she contacted the on-call physician to report Resident #101 had no pulse or respiration and had passed away. LPN #1 reported that she did not inform the on-call physician that Resident #101 was a Full Code or ask him about CPR, because she thought if Resident #101 needed CPR, LPN #2 as a seasoned nurse would have told her to do it. LPN #1 reported that the physician okayed the release of Resident #101 to the funeral home and she contacted Family Member #1 to let him know Resident #101 passed away. LPN #1 reported that she called the Director of Nursing (DON) #2 to inform her of Resident #101's death and she did not ask if he was a Full Code or if staff had had done CPR. In an interview on [DATE] at 12:40 PM, LPN #2 reported that a CNA requested she come to the other unit as there had been a "fatality". LPN #2 reported she ran to Resident #101's room and noted his color was grey ashen, eyes fixed, no respirations, no body movement, and stated he "clearly had expired". This Surveyor asked LPN #2 if she touched Resident #101 when she assessed him and LPN #2 stated she "did not touch him. I could tell, I have been through a lot of deaths." LPN #2 reported that someone said he was a Full Code, but she knew he was gone and there was nothing more that we could do. This Surveyor asked that if a resident was a Full Code what are you supposed to do? LPN #2 stated, "Start the CPR process." LPN #2 reported that she did not initiate CPR even though she was informed Resident #101 was a Full Code, because he was gone, "expired" LPN #2 reported that she was in Resident #101's room for about 8 minutes before she returned to her unit. In an interview on [DATE] at 2:00 PM, CNA #2 reported on [DATE] she ran to Resident #101's room with LPN #1 and CNA #3. CNA #2 reported that Resident #101 was lying angled in bed and LPN #2 came in the room not long after she did. CNA #2 stated that someone said Resident #101 was a Full Code and she said, "When someone is a Full Code, you are supposed to do CPR." In interviews conducted on [DATE] at 3:30 PM and [DATE] at 10:27 AM, CNA #1 reported that on [DATE] at about 3:35 AM, CNA #3 noted Resident #101 wasn't moving and went to get LPN #1 who arrived in Resident #101's room at about 3:37 AM. CNA #1 reported that LPN #1 looked at Resident #101's breathing, checked his pulse and temperature, and sent CNA #3 to get LPN #2. CNA #1 reported that LPN #1 then went to check Resident #101's chart and came to the room and stated he was a Status 4 and looked to LPN #2 for guidance. CNA #1 reported that CNA #2 stated, "When someone is a Full Code, you are supposed to do CPR." CNA #1 reported that LPN #2 left the floor. In an interview on [DATE] at 4:40 PM, Registered Nurse (RN) #1 reported that on [DATE] at 7:00 AM, LPN #1 was giving report and happened to mention Resident #101's had passed away during the night and family was in with him at the facility. RN #1 reported that LPN #1 told me she did not do CPR and started crying, asked about the facility CPR policy, and what she was suppose to have done since Resident #101 was a Status 4. RN #1 reported that starting CPR 4 hours after the fact with the family in the room and the funeral home on the way was inappropriate. RN #1 reported that she informed LPN #1 to contact DON #2 about not doing CPR and to document what had happened with Resident #101. In interviews conducted [DATE] at 4:57 PM and [DATE] at 2:25 PM, DON #2 reported that LPN #1 contacted her on [DATE] at 4:18 AM, to inform her that Resident #101 had passed away. DON #2 reported that LPN #1 stated Resident #101 was cool to the touch when he was found, with no pulse, no respiration, and no blood pressure. DON #2 reported that LPN #1 informed her the physician released the body to the funeral home, the family had been called, and was coming in. DON #2 reported that she did not ask LPN #1 what Resident #101's code status was. DON #2 reported that on the morning of [DATE], Clinical Support #1 informed her that Resident #101 had been a Full Code and that no CPR had been performed. In an interview on [DATE] at 5:15 PM, Clinical Support #1 reported that on [DATE] while looking through the computer she noted Resident #101 was discharged on [DATE]. Clinical Support #1 reported that when she went to review Resident #101's file she noted he was a Full Code, but did not see any documentation for CPR. Clinical Support #1 reported that was how the facility found out about the incident and an investigation was started. On [DATE] at 4:05 PM, the Administrator was notified of the Immediate Jeopardy which began on [DATE], and was identified on [DATE], when the facility failed to implement advanced directives on a Full Code resident (Resident #101), who had advanced directives in place for CPR. Resident #101 was found unresponsive with no pulse or respirations on [DATE] at approximately 3:30 AM, facility staff failed to initiate Cardiopulmonary Resuscitation (CPR), and did not activate Emergency Medical Services. On [DATE], this Surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. On [DATE], Clinical Support educated the DON to question "Preferred Treatment Option" upon notification of a resident expiring in the facility 2. On [DATE], the Medical Director was contacted to review procedures for Advanced Directives and Resuscitation, and educated by the DON to inquired about code status upon receiving notification of a resident expiring. 3. On [DATE] the Advanced Directives and Resuscitation Policy and Procedure was conducted and was observed to be consistent with Standards of Practice. 4. On [DATE] 28 like residents with Full Code status were identified out of a total of 77 residents and their "Preferred Treatment Option" document was concluded. 5. On [DATE] -[DATE], 16 of 18 licensed nurses were educated regarding "Executing Advanced Directives". The 2 additional nurses will be educated prior to their next day worked. 6. On [DATE] the DON contacted physician extenders to educate them regarding questioning preferred treatment option when they are notified of a residents' expiration. 7. On [DATE] the Social Services Director and Admission Director received education regarding reviewing the advanced directive with re-admissions. 8. On-going monitoring of Code Status was initiated on [DATE] the Charge Nurses will be interviewed individually 1 x weekly x's 4 weeks by Clinical Support and/or the DON to ensure they can verbalize the policy for following advanced directives for resuscitation. The policy will be re-enforced with each Charge Nurse who is unable to verbalize the correct procedures. The DON will assume responsibility for this audit and a report to the Quality Assurance Committee on [DATE]. Although the Immediate Jeopardy was removed [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, due to the State Agency not being able to verify sustained compliance. #

This citation pertains to intake number MI 990 Based on interview and record review, the facility failed to provide the necessary care according to professional standards of quality and facility policy (immediately perform cardiopulmonary resuscitation (CPR) and activate Emergency Medical Services (EMS), despite Resident #101 being a Full Code) in 1 of 4 sampled residents (Resident #101), reviewed for advanced directives, from a total of 4 sampled residents, resulting in Resident #101 not receiving CPR when he was found unresponsive. Resident #101 subsequently died . Findings include: Review of the Facility Advanced Directives Policy and Procedure dated revised [DATE], revealed "It is the policy of this facility to honor the health care decision made by residents with decision-making capacity or the resident's legal representative if the resident has been deemed not capable of making decisions...Guardian...a person who, in accordance with state law, has been selected by a resident, or who, in accordance with state law, has been appointed, and has been given the authority to make informed health care decisions for the resident in the event the resident loses decision-making capability...Procedure: 1. Admitting personal assess whether the resident is capable of making decisions or has a legal medical decision maker. This information is documented on the preferred treatment option form. 2. An inquiry is made upon admissions to whether the resident possesses or wishes to execute as Advance Directive. Information regarding Advanced Directives will be provided to residents...4. The validity of the resident advocate's acceptance will be reviewed by Admissions and Social Services Departments. The resident wishes will be noted on the preferred treatment option." Per the American Red Cross First Aid and Safety Handbook (2011), "A person in [MEDICAL CONDITION] is unconscious, not breathing and has no heartbeat." The Handbook revealed that a person in [MEDICAL CONDITION] will have the greatest chance of survival if there is 1) early access to the EMS system, 2) early CPR, 3) early defibrillation, and 4) early advanced medical care. The Handbook also revealed that "without early CPR and defibrillation, the chance for survival is greatly reduced." The Handbook mentioned that "once you begin CPR, do not stop except in one of these situations...another trained responder or EMS personnel take over." According to The Fundamental of Nursing (Potter and Perry, 6 th Edition, 2005), "[MEDICAL CONDITION] is characterized by an absence of pulse and respiration. If the nurse determines that the client has [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) must be initiated. CPR is basic emergency procedure of artifical respiration and manual external cardiac massage." According to The Legal and Ethical Issues In Nursing, Fourth Edition, by Guido (2006), "Standards of care must have and use the knowledge and skill ordinarily possessed and used by nurses actively [MEDICATION NAME] in the nurse's specialty area." According to the Nurse's Problem Solver, (1995), "by providing emergency resuscitative support, these procedures restore spontaneous heart rate and respirations and prevent hypoxic damage to the brain and other vital organs. Responding to a code swiftly and effectively is essential to saving a patients life." Review of the Face Sheet revealed Resident #101 was a [AGE] year-old male, who was re-admitted to the facility on [DATE]. Review of the Minimum Data Sheet (MDS), dated [DATE], revealed Resident #101 had [DIAGNOSES REDACTED]. The MDS revealed Resident #101's ability to make daily decisions was severely impaired. Review of the facility 24-hour report, dated [DATE], for Resident #101 revealed "Conclusion: The charge nurse did not initiate C.P.R. (sic) according to the advanced directive on file." Review of the Resident Preferred Treatment Option, dated [DATE], revealed Resident #101 chose the option of Status 4: "The resident is to be hospitalized for [REDACTED]. Such treatments are to include resuscitation and surgical intervention "The Resident Preferred Treatment Option was signed by Resident #101's Guardian, two witnesses, and the physician. The Resident Preferred Treatment Option revealed handwritten orders by the physician for "full cardiopulmonary resuscitation", signed and dated [DATE]. Review of the Nursing Admission assessment dated [DATE] at 1900 (7:00 PM), revealed Resident #101 arrived via EMS, happy and cooperative, accompanied by the EMS driver. Review of the Interdisciplinary Notes dated [DATE] at 2000 (8:00 PM), revealed Resident #101 arrived via ambulance after discharge from hospital, nursing assessment completed, and physician and family informed. In a telephone interview on [DATE] at 3:59 PM, Licensed Practical Nurse (LPN) #6 reported that she readmitted Resident #101 on [DATE] and did not update the advanced directives. LPN #6 reported that she was not aware that the advanced directive needed to be updated with a re-admission. LPN #6 reported that she was educated privately, that with each admission and re-admission she needed to explain the "Preferred Treatment Option" in detail so that whomever she was educating was well informed. LPN #6 reported that she could not recall when she was educated, but it was after the death of Resident #101. In interviews conducted on [DATE] at 11:30 AM and 3:30 PM, Licensed Practical Nurse (LPN) #1 reported that on [DATE] around 3:30 AM, Certified Nursing Assistant (CNA) #3 came and told her she thought Resident #101 was dead. LPN #1 reported that she, CNA #3 and CNA #2 hurried to Resident #101's room, where she found Resident #101 with no respirations "saw no visual rise or fall in his chest", no radial (wrist) pulses, and his axillary temperature was 97.4 (normal temperature 98.6). LPN #1 reported that she had CNA #3 get LPN #2 at about 3:35 AM to verify Resident #101's death. LPN #2 entered the room, looked at Resident #101 for respirations, and stated "Yea he's gone." LPN #1 reported that, at this time, she went to check Resident #101's chart and saw he was a Status 4, which was a Full Code, returned to the room and informed LPN #2, who "just stood there." LPN #1 reported that she was new to the facility, "which was no excuse", but she was looking to LPN #2 for guidance in this situation since she was more experienced in facility protocol. LPN #1 reported that she told LPN #2 she was going to call the physician and LPN #2 left the floor. LPN #1 reported that no cardiopulmonary resuscitation (CPR) was started and emergency medical services (EMS) were not contacted. LPN #1 reported that she called the on-call physician to report Resident #101 had no pulse or respiration and had passed away. LPN #1 reported that she did not inform the on-call physician that Resident #101 was a Full Code or ask him about CPR, because she thought if Resident #101 needed CPR, LPN #2 as a seasoned nurse would have told her to do it. LPN #1 reported that the physician okayed the release of Resident #101 to the funeral home and she contacted Family Member #1 to let him know Resident #101 passed away. LPN #1 reported that she called the Director of Nursing (DON) #2 to inform her of Resident #101's death and she did not ask if he was a Full Code or if we had done CPR. In an interview on [DATE] at 12:40 PM, LPN #2 reported that a CNA requested she come to the other unit as there had been a "fatality". LPN #2 reported she ran to Resident #101's room and noted his color was grey ashen, eyes fixed, no respirations, no body movement, and stated he "clearly had expired". This Surveyor asked LPN #2 if she touched Resident #101 when she assessed him and LPN #2 stated she "did not touch him. I could tell, I have been through a lot of deaths." LPN #2 reported that someone said he was a Full Code, but she knew he was gone and there was nothing more that we could do. This Surveyor asked that if a resident was a Full Code what are you supposed to do? LPN #2 stated, "Start the CPR process." LPN #2 reported that she did not initiate CPR even though she was informed Resident #101 was a Full Code, because he was gone, "expired" LPN #2 reported that she was in Resident #101's room for about 8 minutes before she returned to her unit. In an interview on [DATE] at 2:00 PM, CNA #2 stated that someone said Resident #101 was a Full Code and she said, "When someone is a Full Code, you are supposed to do CPR." In interviews conducted on [DATE] at 3:30 PM and [DATE] at 10:27 AM, CNA #1 reported that on [DATE] at about 3:35 AM, CNA #3 noted Resident #101 wasn't moving and went to get LPN #1 who arrived in Resident #101's room at about 3:37 AM. CNA #1 reported that LPN #1 looked at Resident #101's breathing, checked his pulse and temperature, and sent CNA #3 to get LPN #2. CNA #1 reported that LPN #1 then went to check Resident #101's chart and came to the room and stated he was a Status 4 and looked to LPN #2 for guidance. CNA #1 reported that CNA #2 stated, "When someone is a Full Code, you are supposed to do CPR." CNA #1 reported that LPN #2 left the floor. In an interview on [DATE] at 4:40 PM, Registered Nurse (RN) #1 reported that on [DATE] at 7:00 AM, LPN #1 was giving report and happened to mention Resident #101's had passed away and family was at the facility. RN #1 reported that LPN #1 told me she did not do CPR, started crying and asked about the facility CPR policy, and want she was suppose to have done since Resident #101 was a Status 4. RN #1 reported that starting CPR 4 hours after the fact with the family in the room and the funeral home on the way was inappropriate. RN #1 reported that she informed LPN #1 to contact DON #2 about not doing CPR and to document what happened. #

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE MEANINGFUL ACTIVITIES BASED ON LEVEL OF COGNITION AND IDENTIFIED INTERESTS FOR 4 OF 4 (#9, #10, #11, & # 17) SAMPLED RESIDENTS FROM A TOTAL OF 15 SAMPLED RESIDENTS REVIEWED FOR AN ACTIVITIES PROGRAM RESULTING IN A DIMINISH IN PSYCHOSOCIAL WELL-BEING FOR RESIDENT #17, AND THE POTENTIAL FOR ALL 75 RESIDENTS TO EXPERIENCE BOREDOM AND THE LOSS OF QUALITY OF LIFE. FINDINGS INCLUDE: A GROUP MEETING WITH 11 CONFIDENTIAL RESIDENTS TOOK PLACE ON 3/6/2013 AT 11:00 AM IN THE RESIDENTS DINING ROOM. WHEN THE RESIDENTS WERE ASKED ABOUT THE ACTIVITIES IN THE FACILITY, SEVERAL OF THE RESIDENTS BEGAN LAUGHING AND STATED, "WHAT ACTIVITIES." A CONFIDENTIAL RESIDENT STATED, "YOU ARE IN BIG TROUBLE IF YOU DON'T LIKE BINGO." ACCORDING TO THE RESIDENTS IN THE GROUP MEETING, THE FACILITY HAD RECENTLY UNDERGONE A BIG RENOVATION IN THE BUILDING. PRIOR TO THE REMODEL, "THERE WAS A BIG ACTIVITY ROOM WHERE THE RESIDENTS COULD SEW WITH THEIR SEWING MACHINES, DO PUZZLES AND LAY PROJECTS OUT ON THE TABLES. NOW, THE ROOM HAS BEEN TURNED INTO A DINING ROOM AND IT IS LOCKED DURING THE DAY WHEN NO ONE IS IN THERE." THE RESIDENTS STATED THAT THEY HAVE SPOKE WITH THE ADMINISTRATOR BUT THEY DON'T GET ANY WHERE. THE RESIDENTS STATED THEY WERE "MAD" ABOUT THE ACTIVITY ROOM BEING TAKEN AWAY FROM THEM. AN INTERVIEW WITH RESIDENT #9 TOOK PLACE IN HER ROOM ON 3/8/2013 AT 10:05 AM. RESIDENT #9 WAS ASKED ABOUT HER ACTIVITY PROGRAMS IN THE FACILITY AND SHE STATED, "I BRING MY OWN STUFF FROM HOME AND I AM A LONER IN MY ROOM." RESIDENT #9 STATED THAT SHE HAS NEVER HAD A ROOM VISIT FROM AN ACTIVITY PERSON. A REVIEW OF RESIDENT #9'S CARE PLAN FOR ACTIVITIES INCLUDED INTERVENTIONS FOR ASSISTING RESIDENT TO AND FROM ACTIVITIES OF SPECIAL INTEREST, ...DOCUMENT AND ANALYZE ACTIVITY PREFERENCES, ...RECORD ACTIVITY ATTENDANCE AND ABILITY TO MEET. WHEN REQUESTED, THE FACILITY WAS UNABLE TO PROVIDE ANY ACTIVITY LOG ATTENDANCE RECORD AT ANY GROUP ACTIVITIES OR ONE-ON-ONE ROOM ACTIVITIES. REVIEW OF RESIDENT #11'S CARE PLAN FOR ACTIVITIES INCLUDED AN INTEREST IN EDUCATIONAL PROGRAMS, ANIMAL MOVIES AND COMEDIES, INTERACTING WITH ANIMALS, LISTENING TO MELODIES AND BEING OUTDOORS. THE INTERVENTIONS INCLUDED ENCOURAGEMENT FOR GROUP PROGRAMS AND PROVIDE ROOM VISITS FOR SOCIAL INTERACTION. A REVIEW OF THE FEBRUARY AND MARCH ACTIVITY CALENDARS FAILED TO REVEAL ANY PET PROGRAMS OR TRIPS OUT OF THE BUILDING. AN INTERVIEW WITH THE ACTIVITIES DIRECTOR, STAFF "L" TOOK PLACE ON 3/6/2013 AT APPROXIMATELY 4:00 PM IN THE ACTIVITY OFFICE. STAFF "L" WAS UNABLE TO PROVIDE ACTIVITY LOGS FOR RESIDENT #11 DURING FEBRUARY AND MARCH 2013. STAFF "L" STATED THAT SHE HAD ONLY WORKED IN THE FACILITY FOR 3 WEEKS AND THE PREVIOUS ACTIVITY DIRECTOR HAD LEFT IN NOVEMBER 2012. STAFF "L" VERIFIED THAT SHE HAD NOT DONE ONE-ON-ONE VISITS OR PROVIDED ANY PET THERAPY FOR RESIDENT #11. ( ) ACCORDING TO THE MARCH 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE MOST RECENT MINIMUM DATA SET (MDS) WITH AN ASSESSMENT REFERENCE DATE (ARD) OF 12/25/12, REFLECTED A BRIEF INTERVIEW OF MENTAL STATUS (BIMS) OF 15, INDICATING RESIDENT #17 WAS COGNITIVELY INTACT. ON 3/5/13 AT APPROXIMATELY 12:00 PM, RESIDENT #17 WAS INTERVIEWED IN HER ROOM. RESIDENT #17 STATED THAT SHE CURRENTLY DOES NOT ATTEND ACTIVITIES AND CONVEYED DISSATISFACTION WITH THE ACTIVITY PROGRAM. RESIDENT #17 STATED THAT WHEN SHE FIRST CAME TO LIVE AT THE FACILITY SHE DIDN'T ATTEND ACTIVITIES, BUT THE PREVIOUS ACTIVITY DIRECTOR CALLED UP HER DAUGHTER AND ASKED HER TO BRING IN HER SEWING MACHINE; "I SET UP MY SEWING MACHINE IN THE ACTIVITY ROOM" AND DECIDED THAT I ENJOYED GROUP ACTIVITIES, BUT THE FACILITY RE-MODELED AND TOOK THE ACTIVITY ROOM AWAY AND REPLACED IT WITH A DINING ROOM. RESIDENT #17 STATED THAT HER SEWING MACHINE WAS IN STORAGE SOMEWHERE NOW. RESIDENT #17 STATED THAT BEFORE THE FACILITY RE-MODELING, THERE WERE ALL KINDS OF ACTIVITIES, INCLUDING HER FAVORITES, COOKING CLUB AND SEWING. RESIDENT #17 STATED IN THE SAME INTERVIEW THAT SHE WAS "VERY DEPRESSED" NOW, AND DOES NOT ATTEND ANY ACTIVITIES. RESIDENT #17 WENT ON TO SAY THAT SHE MISSES INTERACTION WITH OTHER PEOPLE. RESIDENT #17 STATED THAT SHE HAD DISCUSSED DISPLEASURE WITH THE ACTIVITIES PROGRAM WITH THE FACILITY STAFF. THE MDS WITH AN ARD OF 9/25/12, REFECTED THAT WHEN INTERVIEWED ABOUT HOW IMPORTANT IT WAS TO PARTICIPATE IN HER FAVORITE ACTIVITIES, RESIDENT #17 RESPONDED THAT THIS WAS "VERY IMPORTANT" TO HER. RESIDENT #17'S MDS WITH AN ARD OF 10/11/11, REFLECTED A PHQ-9 (DEPRESSION ASSESSMENT, SCORES OF 5, 10, 15, 20 REPRESENT MILD, MODERATE, MODERATELY SEVERE, AND SEVERE DEPRESSION); SCORE OF 2, INDICATING LESS THAN MILD DEPRESSION. RESIDENT #17'S MDS WITH AN ARD OF 9/25/12, REFLECTED A PHQ-9 SCORE OF 5, INDICATING MILD DEPRESSION. RESIDENT #17'S MOST RECENT MDS WITH AN ARD OF 12/25/12, INDICATED A PHQ-9 SCORE OF 9, INDICATING RESIDENT #17'S DEPRESSION WAS MORE OF A PROBLEM, ALMOST TO THE LEVEL OF MODERATE DEPRESSION. RESIDENT #17'S "RECREATIONAL PURSUITS LOG" WAS REVIEWED FROM NOVEMBER 2012 THROUGH FEBRUARY 2013. RESIDENT #17 HAD A GOAL OF ACCEPTING AN INVITATION TO AN ACTIVITY. RESIDENT #17 HAD NOT ATTENDED A SINGLE ACTIVITY ON ANY SINGLE DAY BETWEEN NOVEMBER 2012 THROUGH FEBRUARY 2013. ON 3/8/13 AT APPROXIMATELY 11:50 AM, ACTIVITY DIRECTOR "L" STATED THAT IF A RESIDENT DID NOT MEET THEIR ACTIVITY GOALS, THAT THEY WOULD BE RE-ASSESSED ON A QUARTERLY BASIS. STAFF "L" STATED THAT SHE HAD HER FIRST SEWING CLUB ACTIVITY THIS MORNING, SINCE SHE HAD STARTED APPROXIMATELY ONE MONTH AGO, AND THAT A SEWING MACHINE WAS NOT SET UP FOR THE SEWING CLUB ACTIVITY. IN AN INTERVIEW ON 3/7/13 AT 10:45 AM, SOCIAL WORKER "H" STATED THAT RESIDENT #17 USED TO PARTICIPATE IN STORY HOUR AND READ TO OTHER RESIDENTS, BUT HAS STOPPED. STAFF "H" INDICATED THAT RESIDENT #17 COULD SET HER SEWING MACHINE UP IN HER ROOM, BUT WAS FIXATED ON SETTING IT UP IN THE ACTIVITY ROOM. ACCORDING TO THE RESIDENT ADMISSION RECORD (NO DATE), RESIDENT #10 WAS A [AGE] year OLD FEMALE WITH THE [DIAGNOSES REDACTED].#10 WAS CATHOLIC. ON 3/7/13 AT APPROXIMATELY 10:15 AM, RESIDENT #10 WAS OBSERVED SLEEPING IN HER WHEELCHAIR WITH HER HEAD DROPPED BACK, IN THE DAY ROOM ON THE MEMORY CARE UNIT (MCU). ON 3/7/13 AT 11:00 AM, THE ACTIVITY CALENDAR WAS OBSERVED ON A BULLETIN BOARD IN THE HALLWAY, NEAR THE MAIN DINING ROOM. THE MARCH ACTIVITY CALENDAR TITLED "A SIDE-REHAB", REFLECTED "CURRENT EVENTS" WAS SCHEDULED ON 3/7/13 AT 11:00 AM. ON 3/7/13 AT 11:00 AM, IN THE MAIN DINING ROOM, COMMUNION WAS OBSERVED WITH ONLY 4 RESIDENTS IN ATTENDANCE. THIS ACTIVITY LASTED LESS THAN 15 MINUTES. FOLLOWING THE ABOVE ACTIVITY, STAFF "L" WAS INTERVIEWED IN THE HALLWAY NEAR THE MAIN DINING ROOM ON 3/7/13 AT 11:20 AM. THE ACTIVITY DIRECTOR STATED THAT SHE HAD CHANGED THE CURRENT EVENTS ACTIVITY TO COMMUNION EARLIER IN THE WEEK, BUT DID NOT UPDATE THE ACTIVITY CALENDAR TO REFLECT THIS CHANGE. STAFF "L" STATED AN ANNOUNCEMENT WAS MADE EARLIER IN THE WEEK TO NOTIFY RESIDENTS OF THE CHANGE IN ACTIVITIES. ON 3/8/13 AT APPROXIMATELY 11:40 AM, STAFF "L" INDICATED THAT THERE WERE NOT ANY RESIDENTS ON THE MCU THAT WERE CATHOLIC AND THAT THERE WERE NO RESIDENTS FROM THE MCU THAT ATTENDED COMMUNION THIS MORNING. AFTER SHARING THAT RESIDENT #10 WAS CATHOLIC ACCORDING TO THE "ACTIVITY ASSESSMENT", SIGNED ON 2/23/12, STAFF "L" STATED THAT SHE WAS NOT AWARE RESIDENT #10 WAS CATHOLIC. STAFF "L" STATED THAT THERE HAD NOT BEEN ANY CATHOLIC PROGRAMS OR COMMUNION OFFERED OVER THE PAST MONTH ON THE MCU. ON 3/7/13, AT APPROXIMATELY 11:40 AM, CNA "O" TURNED ON A RADIO IN THE MCU DINING ROOM, AND AN 80'S ROCK SONG, THE EYE OF THE TIGER, WAS PLAYED DURING THE START OF THE LUNCH MEAL. BASED ON RESIDENT #10'S "ACTIVITY ASSESSMENT", SIGNED ON 2/23/12, SHE WOULD HAVE ENJOYED LISTENING TO GOSPEL HYMN'S INSTEAD OF ROCK MUSIC. ( )