Every finding on record at Franklin Restorative Care Center

Based on observation, interview, and document review, the facility failed to develop and implement effective interventions to prevent resident-to-resident physical abuse for 3 of 3 residents (R1, R2, and R3) reviewed for abuse. This resulted in the likelihood of serious harm, injury, or death when on 7/9/26 R1 wandered into R2's room and began choking R2, requiring staff intervention to separate the residents. After, R1 continued to exhibit wandering behaviors and on 7/15/26 R1 wandered into R3's room and the two exchanged punches before staff could intervene. These findings constituted an Immediate Jeopardy (IJ) situation. The Immediate Jeopardy began on 7/9/26 when the facility failed to implement and maintain effective interventions following the resident-to-resident choking incident involving R1 and R2. Although the facility initially implemented 1:1 supervision, it discontinued continuous observation on 7/14/26 and replaced it with 15-minute safety checks and a motion sensor door alarm. Within approximately 24 hours of reducing supervision, R1 again entered another resident's room and became involved in a physical altercation with R3, demonstrating the continued noncompliance and ongoing likelihood of serious harm. The recurrence of resident-to-resident physical aggression after the reduction in supervision showed that the interventions did not prevent continued exposure of residents to the risk of serious harm. The administrator and director of nursing (DON) were notified of the IJ on 7/16/26 at 1:06 p.m. The immediate jeopardy was removed on 7/20/26 at 3:15 a.m. but noncompliance remained at the lower scope and severity level 2 D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include: Review of a Facility Reported Incident (FRI) dated 7/9/26 at 7:35 a.m., indicated on 7/9/26 at 6:30 a.m., housekeeper (HSKP)-A and licensed practical nurse (LPN)-A witnessed R1 choking R2 in R2's room. R2 grabbed R1's arms to stop him. R1 had marks on his left arm. Review of a FRI dated 7/15/26 at 6:15 a.m., indicated on 7/15/26 at 4:00 a.m., LPN-B witnessed R1 trying to enter R3's room. R3 tried to push the door closed so R1 could not enter. R3 stated he and R2 exchanged hits to the chest area. R1's Vulnerable Adult Screen dated 5/5/26, identified R1's vulnerability risks were memory problems, poor decision making, wandering, the need for activities of daily living (ADL) assistance, difficulty making needs known, lack of ability to communicate reliability and no history of abuse towards others. R1's risk of harming other/exhibiting physical aggression to other residents or visitors was marked as N/A (not applicable). See care plan. R1's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R1 had severely impaired cognition and had behaviors of disorganized thinking, inattention, physical behavior toward others 1 to 3 days a week, and wandered daily. R1 had no physical impairment to upper and lower extremities and was independent with bed mobility, transferring, and walking. Diagnoses included schizophrenia (mental disorder causing disruption in thought processes, perceptions, emotional responsiveness, and social interactions), anxiety disorder, major depressive disorder, and dementia with behavioral disturbances. R1's Care Plan Safety focus last revised on 6/30/26, identified R1's safety was at risk and there was a potential for abuse related to decreased cognitive ability with dementia, schizophrenia, anxiety, major depressive disorder, and his inability to understand English as his primary language was [NAME]. Interventions were to not allow other residents to enter his room; remove R1 from dangerous situations; explain the environment to R1 if he does not understand what was going on around him; R1 would not be placed where others would disturb him; stop sign on his door to prevent others from entering his room; and redirect if R1 seemed confused.R1's Care Plan Report printed on 7/14/26, identified R1 had a behavioral mood problem related to dementia, schizophrenia, anxiety, and depression. R1 demonstrated behaviors of delusional thinking patterns, spitting on the floor, refusing cares, and engaging in physical and verbal altercations with his peers and staff. Interventions included 1:1 monitoring on 7/9/26 and revised on 7/14/26 to every 15 minute checks and a motions sensor door alarm; intervene as necessary to protect the rights and safety of others; approach in a calm manner; divert attention; remove from situation and take to an alternative location as necessary; monitor for changes in behavior, mood, cognition, spitting in public places, delusional thinking, physical and verbal altercations, and refusal of cares; and remind staff and peers not to yell at R1 as that aggravates the situation.Medical record review documented progressively increasing wandering into other residents' rooms, aggression toward staff, physical aggression toward residents, and repeated behavioral escalation despite interventions and medication adjustments.R1's medical record identified the following timeline:Physician order (PO) dated 5/5/26, to decrease Invega to 1.5mg daily every a.m. (medication for schizophrenia)R1's progress notes identified the following:-5/25/26 at 9:44 a.m.: R1 was hitting at staff, attempted redirection and distraction with no change in behavior.-5/28/26 at 9:00 a.m.: R1 entered another resident's room and the other resident yelled at R1 to get out. Staff intervened and removed R1 from the room. -6/2/26 at 2:10 p.m.: R1's Aricept (dementia medication) was discontinued, and staff were directed to monitor for changes in behavior or mood. -6/19/26 at 2:00 p.m.: R1's Cymbalta (used to treat anxiety and depression) was reduced by the nurse practitioner following R1's pharmacy drug regimen review. -6/22/26 at 10:10 a.m.: R1 was moved to a room closer to the nursing station (a more populated hallway) due to increased falls. -6/24/26 at 4:43 a.m.: R1 wandered into two other resident rooms which caused one resident to become upset and start yelling. -6/25/26 at 8:17 a.m.: R1 was going into other residents' rooms and laying on their beds. When staff tried to intervene, R1 became aggressive and started shoving his walker into staff. -6/27/26 at 4:57 a.m.: R1 went into another resident's room.-7/3/26 at 12:41 a.m.: R1 was hitting, pushing his walker into staff, yelling incoherently, and exhibiting other undefined behaviors. -7/7/26 at 11:11 a.m.: R1 had a telemedicine visit with rural psychiatric provider and no changes were noted in his baseline behavior, mood, or cognitive status reported by staff or observed during the assessment. -7/7/26 at 2:08 p.m.: R1 grabbed a mop from housekeeping staff and hit her with it and then grabbed another unidentified staff member's breast. -7/9/26 at 7:07 a.m.: LPN-A responded to yelling in R2's room and witnessed R1's hands around R2's neck. R2 stated he grabbed R1's arms when R1 started choking him. Bruise marks were noted on R1's left arm. R1's provider was notified with labs and urinalysis ordered, along with a scheduled visit for 7/14/26. -7/10/26 at 10:05 p.m.: R1 would remain with 1:1 staffing until after his psych consult on 7/14/26. -7/14/26 at 3:53 p.m.: R1 was reviewed by psychiatric provider and had been discontinued from 1:1 observation per provider recommendation. A door alarm was placed on R1's doorway to alert staff when R1 exits the room. Staff were notified of the change and told to monitor R1 closely and document all behaviors and observations. -7/14/26 at 8:18 a.m.: R1 was placed on 1:1 supervision after increased nighttime wandering behaviors. During the overnight shift, R1 was observed entering other residents' rooms on multiple occasions despite redirection. Frequent redirection had been required. While in R3's room, an altercation occurred between R1 and R3 which created a potential safety concern for both individuals. R1 continued to exhibit confusion, poor judgement, and decreased awareness of personal boundaries which contributed to wandering behaviors. R1 would remain on 1:1 supervision, with ongoing monitoring, behavioral documentation, safety checks, and redirection as needed until psychiatry appointment on 7/21/26. R1's psychiatry physician visit note dated 7/7/26 at 8:15 a.m., staff were overheard yelling, R1 don't. R1 was angry and when the housekeeper tried to redirect him, he grabbed the mop from her and attempted to strike the housekeeper with it. When another staff member attempted to intervene verbally, R1 grabbed her by the chest. Nursing reported it was the first incident of physical abuse in a long time. It appeared to be an isolated incident, and nursing was to monitor for any worsening agitation or increased physical aggression as that might warrant titrating his Invega back to prior dose. R1's psychiatry physician noted dated 7/14/26 at 11:30 a.m., documented staff reported they believed R2 provoked R1 on 7/9/26. On 7/9/26 R1 entered R2's room and R2 yelled at him to leave and physically grabbed R1 by the arms to push him out and R1 responded by choking R2. A motion sensor had been added to R1's door and he had 1:1 supervision instead of the 15-minute checks previously implemented for fall prevention. 1:1 observation was discontinued and returned to 15-minute safety checks due to fall risk and behavioral monitoring with motion sensor system to alert staff to his movements. Despite repeated documentation of wandering into other residents' rooms, physical aggression toward staff, behavioral escalation, and implementation of temporary 1:1 supervision, the facility reduced supervision before sustained behavioral stabilization was demonstrated. Within approximately 24 hours, another resident-to-resident physical altercation occurred.The medical record contained documentation regarding changes in the level of supervision on 7/14/26. Psychiatry documentation reflected discontinuation of 1:1 observation in favor of 15-minute checks with a motion sensor, while another nursing progress note documented continuation of 1:1 supervision pending psychiatric follow-up. Interview statements from the DON and psychiatric NP corroborated that continuous 1:1 supervision had been discontinued before the 7/15/26 altercation. R2: R2's Vulnerability and Susceptibility to Abuse form dated 3/19/26 identified R2's vulnerabilities were cognitive impairment; exhibited psychotic behavior such as hallucinations or delusions; inability to control their actions; physical impairment; sensory impairment; verbally threatening to others; displayed rage or poor impulse control or was unable to express anger appropriately; and exhibits personal habit patters which were offensive or antisocial. R2's Care plan revised on 6/1/26, indicated R2 had a behavior/mood problem related to a history of delusional thinking patterns, and when frustrated, would yell, scream, and curse at staff and residents. Interventions included intervene as necessary to protect the rights and safety of others; remove from situation and take to alternate location as needed. R2 displayed episodes of delusional behavior related to his belief that his room was haunted and contributed to safety events at times. Intervention included, ensure the safety of resident and others. R2's safety was at risk and there was a potential for abuse related to dementia with agitation. Interventions included, ensure R2 was safe around others that might take advantage of his confusion. R2's annual MDS dated [DATE], indicated R2 had intact cognition with no physical or verbal behaviors towards others noted. R2 was independent with transferring but did not walk and used a wheelchair. R2 had diagnoses of stroke, diabetes and dementia.R2's progress note dated 7/9/26 at 2:01 p.m. indicated, Staff responded to R2's room and witnessed R1's arms while R1 was choking R2. Staff intervened. R2 was assessed for injury with no noted findings. R1 was assessed for injury and noted to have visible bruising marks on R1's left arm and open area to face following the altercation. During an interview on 7/14/26 at 10:19 a.m., R2 identified he was mad because people came into his room several times and stole his stuff. R2 further stated he preferred the door to his room to stay shut all the time because the week prior a man came into his room and tried to choke him. R2 did not feel safe when it was open because that man (R1) would come back. R2 further explained that R1 had tried to enter his room one morning and R1 told him to get out but R1 came in anyway and tried to punch him and put his hands around his neck and R2 had to grab his arms to try to get R1 off him. R2 stated he did not want R1 to come into his room and if R1 did enter his room again, he would punch him until he could never come back again. R2 stated HSKP-A was in the room cleaning the bathroom at the time and she screamed for help. R2's Skin Check dated 7/14/26 at 3:22 p.m. indicated R2 refused to allow the skin check but no significant findings on his arms or face. R3: R3's quarterly MDS dated [DATE], indicated R3 had severe cognitive impairment and had behaviors of inattention, disorganized thinking, hallucinations, and delusions. R3 had no physical or verbal behaviors noted and did not wander. R3 required minimal assistance from staff for activity of daily living (ADL)s and used a wheelchair. R3 diagnoses included dementia, Parkinson's, post-traumatic stress disorder (PTSD), paranoid personality, insomnia, anxiety and delusional disorders. R3's care plan dated 6/30/26, identified R3 was at risk for abuse and further identified R3 was easily exploited, had antisocial behavior, sensitive to loud tones/sensory, mental health, physical health, and physical aggression. Interventions included, ensure R3 was safe around others that may take advantage of his confusion; do not have R3 near others that disturb him; and remove him from potentially dangerous situations. R3's progress note dated 7/15/26 at 1:23 p.m., identified R3 was involved in an altercation with R1 when R1 repeatedly attempted to enter R3's room and continued to try to open R3's door. R3 became upset and staff intervened and separated residents. R3 had a psychosocial well-being problem related to dementia and diagnosed mental illness. Interventions included reassure R3 that others would not harm him or take things from him. R3 had a behavior problem with identified behaviors of refusal of cares, yell and swear at others, occasional physical aggression, and throwing items. R3's behaviors were often disruptive to the environment and difficult to redirect. De-escalation techniques included lower noise levels; reduce the number of people interacting with R3, ensure he was in a safe environment. During an interview on 7/16/26 at 9:05 a.m., R3 was lying bed on top of the covers, fully dressed, and had sweatpants stuffed under the door of his room and the door leading to his shared bathroom. R3 stated he wanted his door shut and put the sweatpants under the door because the bad guys were trying to come into his room and kill him. R3 further explained he was a Vietnam veteran, and the bad guys had tracked him down, killed his sister, and had tried to kill him. R3 expressed fear and stated he did not feel safe in his room because a man tried to come into his room to kill him during the night, but he fought back. R5: R5's annual MDS dated [DATE] identified R5 had intact cognition and no behaviors. R5 was dependent on staff for bed mobility, transferring, ADLs, and did not walk. R5 had diagnoses of depression, anxiety, and major depressive disorder. During an interview on 7/15/26 at 3:42 p.m., R5 stated that R1 comes into her room sometimes and further stated, R1 came into her room three times in one night. R5 stated R1 came into her room and stood by her roommates' (R6) bed. R5 said the first two times R1 entered her room, she was able to tell R1 to leave and he left but, the third time he came into her room she had to call for staff help to get him out of her room. R5 stated that she did not want R1 in her room and that it made her feel very uncomfortable. R5 further indicated that R1 should not be allowed to enter other residents' rooms and that the staff should be watching him closer. During an interview on 7/14/26 at 12:26 p.m., nursing assistant (NA)-A stated she was doing 1:1 supervision with R1 due to an incident between him and another resident. NA-A further stated although R1 was not very busy that day but could keep you on your toes, further indicating R1 liked to wander and needed a lot of redirection and liked his 1:1 attention. During an interview on 7/14/26 at 12:46 p.m., NA-B described R1 could make his needs known and would yell when he wanted attention. Further described R1 as quick, further clarifying that he moves fast when he walks. During an observation on 7/14/26 at 1:51 p.m., R1 was in his room with the privacy curtain closed. There were 10 resident rooms in the immediate vicinity of R1's room, occupied by 12 residents. During an interview on 7/15/26 at 2:20 p.m., LPN-A stated R1 would try to hit out if you tell him he cannot do something. R1 had routinely been on 15-minute checks related to frequent falls and was recently moved to a room closer to the nurse's station to be more visible to staff. Identified the room that R1 was moved to was on a busier and more populated hallway. LPN-A described that on the morning of 7/9/26, she heard R2 yelling, get out of my room and responded, finding R1 putting his hands around R2's neck and R2 pushing R1 away. R1 was placed on 1:1 supervision at that time. LPN-A indicated she believed R1 wandered more, and wandered more into others rooms, after the room change. LPN-A stated R1 had some recent medication changes but had been seen by his provider just before the interview and the facility was discontinuing the 1:1 supervision and placing a door exit alarm on R1's door and decreasing to every 15-minute checks as care planned for fall prevention. During an interview on 7/15/26 at 2:51 p.m., NA-C stated that on 7/9/26, she heard HSKP-A screaming and responded to R2's room. NA-C states she witnessed R1 on top of R2 and had R2 in a choke hold; R2 had slid back to a reclined position in his wheelchair and had R1 by the arms trying to get R1 off him. R2 was telling R1 to get off him or he would kill him. Staff were assigned to 1:1 supervision with R1 after that incident. NA-C described R1 as a strong little guy who can get feisty. R1 had previously gone into R2's room and tried to eat food from R2's breakfast tray. Once R1's room was changed, he wandered more. R1 became aggressive over food and if you get too close to him, R1 would swing. R1 had an incident just two days prior when he hit HSKP-A over the head with a broom. R1 would wander into other residents' rooms, and the residents would tell him to get out. During an interview on 7/15/26 at 10:05 a.m., LPN-A stated the facility had filed another vulnerable adult report to the SA that morning because at approximately 4:00 a.m., R1 tried to enter R3's room and punches were exchanged. LPN-A explained that during report LPN-B reported they heard the door alarm and responded but R1 was already in R3's room with where the altercation was already occurring. Further indicated R3's usual wake time was 4:00 a.m. so he was up and able to defend himself but the incident could have been worse. LPN-A stated R1 had been wandering more since his room changed and even wandered down the west hall which he had never done before. R1 was put on 1:1 staff supervision and the facility was in the process of finding R1 a more secure facility because staff were unable to consistently prevent R1 from entering other residents' rooms despite implemented interventions. During an interview on 7/15/26 at 10:13 a.m., HSKP-A stated she was cleaning R2's bathroom when R1 entered R2's room and put his hands around R2's neck and choked him. Further identified R2 was gasping a lot and started cussing at R1 to get out of his room then some hitting and stuff went on. HSKP-A called for help and LPN-A and NA-C intervened and took R1 out of R2's room. HSKP-A stated two days prior, R1 had pushed her cleaning cart at her and came after her with a broom and a dustpan. She screamed for help, and HSKP-B intervened. R1 had hit her in the chest with his fist. During an interview on 7/15/26 at 11:32 am., HSKP-B identified she witnessed the event on 7/7/26 when R1 had a mop in his hand and went after HSPK-A. She took the mope from R1 and notified the nurse. During an interview on 7/15/26 at 12:28 p.m., R1's psychiatric nurse practitioner (NP)-A indicated that R1 had three resident- to- resident altercations in the two weeks prior. R1 had been having aggressive behaviors approximately a year ago which decreased when they increased his Invega. Because of R1's falls, the Invega was decreased in 5/26, but the falls continued so discontinued his Aricept in 6/26 which decreased R1's falls but increased his agitation. NP-A was aware of R1's 7/7/26 incident with the housekeeper and instructed staff to monitor his behaviors and schedule R1's follow up for two weeks. They became aware of the second incident and was told by facility staff that R1's actions were because he was provoked by another resident and were doing 1:1 staff supervision of R1. NP-A saw him on 7/14/26 and was told by facility staff that he was doing well so decreased 1:1 supervision to 15-minute checks because of his high fall risk; increased R1's Invega at that time. NP-A also indicated R1 had a urinary tract infection and had several head injuries from his recent falls that likely contributed to his behaviors. During an interview on 7/15/26 at 12:40 p.m., the director of nursing (DON) stated she had been employed at the facility for two weeks. The DON stated R1 had 1:1 staff supervision discontinued on 7/14/26 because of R1's psych NP's recommendations and R1 had been good with no wandering into other residents' rooms, no behavioral concerns, and easily redirected by staff. During an interview on 7/15/26 at 1:34 p.m., LPN-B indicated R1 had been restless during the night shift of 7/14/26 and but had been ok through 4:00 a.m. when she was caring for another resident, one NA was giving a resident a shower, and the other NA was making a bed. LPN-B heard R1's door alarm and responded within 3-4 minutes and witnessed R1 pushing R3's door open while R3 was trying to push the door shut on R1. LPN-B stated R3 told her that he had told R1 to get out, when R1 did not, he was pushing R1 out of the room when R1 punched R3 in the chest so R3 punched R1 in the chest. LPN-B described R1 as aggressive most of the time and staff needed to take care of R1's needs immediately or he became aggressive, in which staff could not tell R1 no or take something away from him or he would get aggressive. R1's behavior trigger was other residents telling him to get out of their room. During an interview on 7/15/26 at 2:00 p.m., NA-D stated she had done 1:1 supervision of R1 and he was active during that time and would try to enter other residents' rooms, but she would redirect and distract him. During an interview on 7/16/26 at 11:12 a.m., the facility's consultant pharmacist stated that the onset of Invega was 1-2 weeks but could take up to 4-6 weeks for the full effect of medication. Review of facility's undated policy titled Abuse, Neglect, and Exploitation, explained it was the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse is defined as the willful infliction of injury and includes certain resident altercations. The facility would identify, correct, and intervene in situations in which abuse, is more likely to occur with the deployment of trained and qualified, registered, and licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; Assign responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors The IJ was removed on 7/20/26 at 3:15 p.m., when it was verified, the facility completed the following actions:R1 was placed on 1:1 supervision and care plan was updated.The facility provided education to all facility staff on the Abuse, Neglect, and Exploitation policyEducation was done with the interdisciplinary team to ensure a thorough review of resident behavior, effectiveness of medication changes as well as the psych consult recommendations prior to removing ore decreasing any level of supervision on residents receiving 1:1 supervision. Skin checks were completed on residents to look for any signs or symptoms of abuse.Vulnerable adult and Psychosocial assessments were completed on all in-house residentsProgress notes and incident reports were reviewed for the past 30 days for new or worsening behavior of aggressionInterviews with staff were completed to identify 4 residents with the potential for physical aggression toward staff or others. Care plans for those identified residents were reviewed for appropriate levels of supervision and diversion techniques.Interviews were completed with other residents in the facility with all denying any resident had an altercation with them.

Based on observation, interview and document review, the facility failed to comprehensively assess falls and injuries, identify causal factors and implement interventions to decrease the risk of fall or injury for 2 of 3 residents (R1 and R4) reviewed for injury and falls. Findings include:R1: R1's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R1 had severely impaired cognition and had behaviors of disorganized thinking, inattention, physical behavior toward others 1 to 3 days a week, and wandered daily. R1 had no physical impairment to upper and lower extremities and was independent with bed mobility, transferring, and walking. Diagnoses included schizophrenia (mental disorder causing disruption in thought processes, perceptions, emotional responsiveness, and social interactions), anxiety disorder, major depressive disorder, and dementia with behavioral disturbances. R1's Fall Risk Assessment, dated 5/8/26, identified R1 was at high risk for falls due to disorientation; 3 or more falls in the past 3 months; ambulatory and incontinent; took 3-4 high risk medications; recent medication changes; and 3 or more high risk diseases. R1's care plan, initiated 8/23/25, identified R1 was a fall risk related to abnormalities of gait and mobility, cognitive impairment, bilateral hearing deficit with tinnitus (ringing in the ear), insomnia, and will self-transfer without calling for help. Interventions included analyzing all falls to determine the cause, reviewing medications for possible changes; appropriate footwear to prevent slipping, R1's bed at appropriate height to get R1 to a standing position; if R1 exhibited increased ambulation or pacing, anticipate needs, and offer snacks, or assist to sit down; keep environment well-lit and clutter free; put items away after using to prevent R1 from tripping. R1's Un-witnessed Fall Report, dated 4/29/26, at 8:20 a.m., indicated that R1 was lying flat on the floor, head near closet and feet were pointed towards clothing rack. R1 was noted to have a gash on his right rear skull that was seeping blood and redness along his spine. R1 transferred to the emergency department (ED) for evaluation. R1 was wearing gripper socks. The fall report lacked a comprehensive assessment, root cause analysis, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks. R1's Witnessed Fall Report, dated 5/3/26 at 9:06 a.m., identified licensed practical nurse (LPN)-C witnessed R1 fall to the floor and land on his butt. R1 appeared to have lost strength in his legs, and they gave out. R1 was restless all morning. R1 was wearing gripper socks. Immediate action taken was R1 was assisted to his feet and brought to the day room. The fall report lacked a comprehensive assessment, root cause analysis, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks. R1's Unwitnessed Fall Report, dated 5/3/26 at 9:30 a.m. indicated that R1 was observed walking out of his room with one hand on the back of his head which was bleeding profusely. R1 transferred to ED. The fall report lacked a comprehensive assessment, root cause analysis, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks. R1's fall focused care plan was updated on 5/4/26 to encourage R1 to use the bathroom upon waking from night and daytime nap; a sign was posted to remind R1 to use walker. R1's Unwitnessed Fall Report, dated 5/15/26 at 10:15 p.m., indicated staff heard a bang and found R1 sitting by his door facing the hallway and holding onto his walker. R1 had gripper socks on and was using the wheelchair for stability before the fall. R1 had no injuries noted. Immediate action taken was resident was assessed, was offered snack and fluids related to low blood pressure and walked R1 back to bed. Follow up progress note on 5/18/26 at 5:21 p.m., fall care plan updated to provide increased frequency of safety rounds when R1 is in his room. The report lacked parameters of what increased frequency was. The fall report lacked a comprehensive assessment, root cause analysis, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks.R1's Unwitnessed Fall Report, dated 6/1/26 at 9:45 a.m., indicated R1 was found sitting on buttocks on the floor. No injuries noted. R1 was assisted to his feet and to the bathroom. The fall report lacked a comprehensive assessment, root cause analysis, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks.R1's Progress Note dated 6/1/26 at 3:22 p.m., R1 was on the floor in his room with his walker tipped over next to him. R1 received a new reddened area to back right head near previous staple site and pain to hips. R1 was offered to use the bathroom and fall protocol initiated. Fall was unwitnessed. The facility lacked evidence of a Fall Report for the fall, comprehensive assessment, root cause analysis, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks. R1's Progress Note dated 6/1/26 at 3:28 p.m., R1 on the floor and was getting himself up from a sitting position. R1 was hungry and had an upset stomach. An IDT note dated 6/2/26, identified the root cause of the fall was improper footwear as R1 was wearing regular socks at the time of the fall. The interdisciplinary team identified improper footwear as the root cause of the fall. The subsequent care plan identified gripper socks as an intervention; however, the existing care plan already included gripper socks as a fall intervention before the fall occurred. The facility lacked evidence of a Fall Report for the fall, comprehensive assessment, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks R1's Progress Note dated 6/2/26 at 10:05 a.m., R1 fell at 7:15 a.m. and received 2 gashes on rear skull. R1 was transferred to the ED. The facility lacked evidence of a Fall Report for the fall, comprehensive assessment, root cause analysis, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks.R1's Progress Note dated 6/2/26 at 10:52 a.m., R1 returned from ED with 4 staples placed to laceration to back of head. R1's Progress Note dated 6/3/26 at 11:14 a.m., R1 found on buttocks on the floor of his room. The progress note indicated R1 had experienced several recent falls related to a shuffling gait. R1 was restless and incontinent of bowel and bladder. R1 was on 15-minute checks related to previous fall intervention. The facility lacked evidence of a Fall Report for the fall, comprehensive assessment, root cause analysis, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks. R1's Progress Note dated 6/6/26 at 4:39 p.m., indicated an unidentified resident observed R1 miss the chair while attempting to sit and slide to the floor. R1's stapled wound area to his head was noted to be bleeding but staples remained intact. Neuro checks were initiated. The facility lacked evidence of a Fall Report for the fall, comprehensive assessment, root cause analysis, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks. R1's fall focused care plan was updated on 6/16/26, R1 was to wear gripper socks; on 6/18/26, pharmacy review; toilet upon rising, before and after meals, and when agitated; when checking on R1, offer fluids, and on 6/23/26, room changed. R1's Progress Initial Fall Note dated 6/21/26 at 7:50 p.m., R1 fell in room by his bed. R1 sustained an open area at the back of his head where his staples were removed a few days prior. Immediate intervention was to continue 15-minute checks and to do frequent checks when he is awake. Documentation did not define the frequency of the additional checks. The facility lacked evidence of a Fall Report for the fall, comprehensive assessment, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks. R1's Progress Note dated 6/22/26 at 10:10 a.m., R2 moved to a room closer to nurse's station due to recent falls. Post-fall assessment dated [DATE] at 9:02 a.m., root cause analysis identified impaired gait and poor safety awareness. R1's Witnessed Fall Report dated 6/29/26 at 7:04 p.m., R1 had fallen next to the table in the dayroom. No injuries noted. Resident witness indicated R1 had attempted to pick something off the ground and fell. Second resident witness indicated R1 tried to get through the group of wheelchairs and fell. R1 did not have any apparent injuries. The fall report lacked a comprehensive assessment, root cause analysis, and available documentation lacked evidence that resident-specific interventions were developed or implemented to address the identified fall risks. R1's fall focused care plan was updated on 6/30/26, advised staff to keep bathroom door and room entrance open to help R1 find his bathroom and room entrance/exit, keep R1's door open for visual assessment of his location and status; place R1's walker within his reach; provide R1 assistance if observed ambulating independently; R1 to use his two wheel walker when ambulating; sign printed on green paper with large font to remind R1 to use his walker. On 7/2/26, intervention added to attempt to have R1 stay out of cluttered areas; redirect R1 to less congested area; bring walker to R1 when seen without it; call for staff assistance and stay with R1 until walker arrives. On 7/14/26, added instruction to keep dining style chairs out of room related to fall from chair; and requested physical therapy to evaluate and treat. R4 R4's quarterly MDS dated [DATE], indicated R4 had moderately impaired cognition and delusions. R4 required staff assist with dressing, toileting, transferring, wheeling wheelchair, and dressing. R4 did not walk. Diagnoses included Alzheimer's Disease, seizure disorder, diabetes, and arthritis. R4 received hospice services. R4's Vulnerability and Susceptibility to Abuse dated 7/16/26 at 4:24 p.m., identified R4 was at risk for abuse related to cognitive impairment, psychotic behavior, unable to control their actions, physical impairment, communication impairment, sensory impairment. R4 was identified as a vulnerable adult unable to report but no signs of abuse or neglect present. R4's Care Plan Report did not identify risk of abuse, risk of bruising, or vulnerable adult risk. R4's Injury of Known Cause Report dated 6/18/26 at 1:30 p.m., identified R4 had 4 bruises to right lower inner arm; 3 are purplish in color and one is red in color; unknown where they came from; R4 unable to state what happened. The injury report did not document a comprehensive assessment regarding the cause of the bruising, contributing factors, or resident-specific interventions to reduce the risk of additional unexplained injuries. R4's Injury of Known Cause Report dated 6/29/26 at 9:00 a.m., identified R4 had a 3 centimeter (cm) fading bruise on her left knee; R4 unaware of how the bruise occurred; denied that anyone hurt her; no immediate interventions required. The injury report did not document a comprehensive assessment regarding the cause of the bruising, contributing factors, or resident-specific interventions to reduce the risk of additional unexplained injuries. During an interview on 7/14/26 at 2:10 a.m., the regional clinical consultant (RCC) stated she could not answer questions regarding the facility. The director of nursing (DON) indicated she had been employed at the facility for two weeks but stated if there was an incident or a fall, the comprehensive assessment, root cause analysis, and interventions should be in a post incident progress note. During an interview on 7/14/26 at 2:20 p.m., LPN-A stated R1 fell frequently during the late evening shifts, and they had implemented the walker, checked him for orthostatic hypotension, and moved his room. If there was an incident or a fall, an incident report should be done and follow fall protocol. During an interview on 7/15/26 at 12:28 p.m., R1's psychiatric nurse practitioner (NP) indicated that R1 had fallen frequently and had some medication changes because they were concerned the medications were lowering his blood pressure. The facility also did 15-minute checks for fall prevention. The NP stated R1 had sustained multiple head injuries from recent falls and believed those injuries likely contributed to R1's behaviors. During an interview on 7/15/26 at 12:40 p.m., the DON indicated the facility does not have any evidence of fall investigations, root cause analysis, or interventions for R1's falls or R4's bruising and did not know why some fall reports were not done. Review of facility's undated policy titled, Accidents and Supervision indicated the resident environment would remain as free of accident hazards as is possible. Each resident would receive adequate supervision (intervention and means of mitigating risk of accidents) and assistive devices to prevent accidents. This included identifying and evaluating hazards (elements of the resident environment that have the potential to cause injury or illness) and risks (any external factor, facility characteristic (staffing, or physical environment) or characteristic of an individual resident that influences the likelihood of an accident); implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Additionally, the facility should establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents in which all staff are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. Review of the facility's undated policy titled, Fall Prevention Program indicated each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not because of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. The nurse as to refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. The High-Risk Protocols instructed, but is not limited to: - The resident was to be placed on the facility's Fall Prevention program which would be identified on the care plan which was to be developed based on risk factors and environmental hazards for the resident. Once developed, the care plan interventions were to be monitored for effectiveness and revised as needed.- Implement interventions from the Low/Moderate Risk Protocols. - Provide interventions that address unique risk factors measured by the risk assessment tool; medications, psychological, cognitive status, or recent change in functional status. - Provide additional interventions as directed by the resident's assessment, including but not limited to: increased frequency of rounds, sitter, if indicated, medication regimen review, low bed, alternate call system access, scheduled ambulation or toileting assistance, therapy services referral, etc. - When a fall occurred, the facility was expected to assess the resident, complete a post-fall assessment and an incident report, notify the physician and family, review the care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of an injury.

Based on interview, video/audio recording review and document review, the facility administration directed staff not to report or document a resident elopement. The administration's direction not to report, prevented immediate identification and correction of failures in supervision, alarm response, staff training, and elopement prevention, leaving residents exposed to continued risk of elopement and serious injury and demonstrated a breakdown of the facility's governing systems for resident protection, quality assurance, and promoted an ongoing culture of fear of the facility being shut down, retaliation and regulatory noncompliance. The former director of nursing (DON), regional clinical consultant (RCC), chief operating officer (COO), social service designee (SSD), and owner all failed to ensure allegations of reportable events were reported to the State Agency (SA) and thoroughly investigated to protect a resident (R4) from further occurrence. This noncompliance had the potential to affect all 31 residents that resided at this facility. The IJ began on 6/6/26 when the former DON notified the administrator and RCC that R4 eloped from the facility, entered an employee's vehicle with the keys inside, and drove the vehicle independently to a loading/delivery dock next to the facility. In addition, when the former DON reported the incident internally, the RCC told the former DON not to report to the SA and not to document the reportable elopement event. The immediate jeopardy was identified on 6/18/26 and the administrator, assistant administrator, and the RCC were informed of the IJ on 6/18/23 at 4:53 p.m. The immediate jeopardy was removed on 6/23/26 at 2:20 p.m., but noncompliance remained at the lower scope and severity of F, which is widespread, level 2, indicating no actual harm with potential for more than minimal harm that is not immediate jeopardyFindings Include:Refer to F689, F609, F610R4's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and indicated he experienced delusions; had acute mental changes; behaviors of inattention, disorganized thinking; and physical and verbal behaviors towards others. R4's MDS indicated he ambulated independently without assistive devices on and off the unit and indicated he displayed wandering behaviors daily. During interview on 6/16/26 at 2:01 p.m., employee (E)-A identified that on 6/9/26 the former DON reported that R4 had eloped on 6/6/26, took an employee's car from the employee parking lot, and drove it down the road. E-A was concerned about R4's and other people's safety. E-A also stated the former DON told her that the elopement was not documented in R4's medical record and that it was to look like the elopement never happened per regional clinical consultant (RCC) direction. During an interview on 6/17/26 at 10:25 a.m., E-B revealed that the former DON had reported that on 6/6/26, R4 had gotten into and drove an employee's vehicle, and administration including the RCC and administrator directed not to report or document the elopement. Further, E-B stated R4 should have had more supervision as he has made several attempts to elope with two elopement events since May that they were aware of, in which neither were reported nor documented. E-B indicated R4's elopement events occurred when he was not accompanied by staff, nor were his elopements immediately recognized by staff. E-B indicated knowledge of reporting requirements and identified although the administrator and RCC were notified immediately, they did not report the elopement event to the state agency (SA). E-B further stated the administrator and corporate overall were not reporting reportable events and were threatening staff jobs and licenses if they did report. E-B defined corporate as the administrator and RCC. Further identified nursing staff was not allowed to report any event to the SA and there was a fear of retaliation for going against what corporate advises. E-B also voiced concerns related to adequate staff training. During an interview on 6/17/26 at 11:22 a.m., the former DON stated she had been employed at the facility for about a month. On 6/6/26, she was covering as charge nurse at approximately 11:20 a.m. to 11:40 a.m., she and other staff were in rooms assisting residents when she heard a beeping noise, she investigated and found that it was the door alarm system but the zones on the master alarm board were not labeled so did not know which door was activated. She had available staff check rooms and she went out the east door by the offices and asked a resident who was outside smoking if he had seen anyone leave; he had not. The former DON continued across the visitors parking lot and saw a white pickup truck driving into the dock or delivery bay area and noted the man in the driver's seat as R4. R4 exited the running truck and tried to get into the locked employees' door when she was able to intervene. R4 then proceeded to get back into the driver's side of the running truck but the former DON was able to enter the passenger's side, shut off the truck, and pull the keys out of the ignition. The former DON was then able to safely assist R4 back into the building without any apparent injuries. The former DON also identified the facility is surrounded by a corn field, deep gulch or drop-off, and a road. The former DON called the administrator at 11:57 a.m. and the administrator returned her call at 12:34 p.m. The former DON then called the RCC at 12:48 p.m. per the administrator's direction. The former DON reported she was told, you don't say anything, don't document it, don't report it, like it never happened because they [SA] will shut the building down and it will be all your fault; listen to what I tell you or I will have your license. The former DON confirmed she did not document the event in R4's medical record, do an incident report, investigate the elopement, or report to the SA. The former DON reported there was an interdisciplinary meeting (IDT) on 6/9/26 at 10:30 a.m. and discussed the elopement event and identified the administrator, social service designee (SSD), corporate SSD, owner, RCC, and COO were present at the meeting and again discussed not reporting the elopement incident to the SA. The former DON stated she was walked out by the administrator and RCC the day the abbreviated survey began (6/16/26). The former DON further indicated she was walked out of the building and employment terminated when she told the RCC and administrator that she wanted to talk to the SA surveyor and was not aware of any previous issues with her job performance.During an interview on 6/17/26 at 1:56 p.m., E-H indicated the former DON reported R4's elopement on 6/6/26, but did not know much about the elopement except that it should have been reported and investigated but facility nursing leadership were threatened by the administration defined as RCC and administrator not to report the elopement to the SA and was not sure if R4's elopement was investigated. E-H further stated, there is lots of issues with retaliation threats around here. During an interview on 6/17/26 at 2:40 p.m., the administrator stated on 6/6/26 she was unavailable and did not have cellular service so did not have the details of R4's elopement incident; the former DON did not notify her. The administrator stated, he [R4] was supervised from what I know. The administrator stated it was not reported to the SA because R4 was supervised the whole time he was out of the building on 6/6/26 so it was not considered an elopement and not reportable. The administrator further stated, unless I see it first-hand, I don't report it and there are a lot of differing opinions The administrator indicated if staff came to her with concerns she would not automatically report. She would request the concern be in writing and then would review the concern to determine if it was reportable or not. The administrator said she is not a nurse and counts on the nursing judgement to decide. The administrator added staff were to report concerns to the rapid response team which includes the RCC. She further stated we got chewed out by the medical director at QAPI because they weren't reporting reportable events. And further identified, we need to be more diligent about our risk management and were going to be doing training with the staff today at 5:00 pm. The administrator denied ever telling a staff person not to report to the SA. During a follow-up interview on 6/23/25 at 11:56 a.m., the former DON reviewed her call history log, and it identified the following calls sent and received following R4's elopement on 6/6/26:11:57 a.m. the former DON called the administrator and left a voicemail.12:34 p.m. the administrator returned the DON's call.12:48 p.m. the former DON called the RCC and had a 22-minute conversation,1:11 p.m. the DON called the administrator and had an 18-minute conversation. The former DON stated R4's elopements were discussed during the phone calls. During an interview on 6/17/26 at 3:58 p.m., the RCC stated, their system is broke and an elopement is considered neglect and should be reported to the SA. The RCC further stated, I was not notified on 6/6/26 [of R4's elopement], the only thing I know was from reviewing his chart and insisted R4 had direct supervision by staff during the incident on 6/6/26. The RCC further identified she was told by nursing assistants (NA)s and nursing staff and that egress alarms were not loud enough and could not be discerned between them and a call light, so the egress alarms were installed after R4's 6/6/26 incident and they did not know what the zones to the door alarm were. The RCC stated she would not tell anyone not to report, that she was an over reporter, and if she had known about R4's elopements, they would have been reported to the SA. During an interview on 6/18/26 at 10:06 a.m., E-E indicated on 6/6/26 just before lunch, she witnessed R4 drive her truck up to the side of the building, got out of the truck, attempted to re-enter a locked employee entrance door, and then get back into the running vehicle before the former DON was able to intervene and pulled the keys out of the ignition. E-E stated she immediately called the administrator to tell her what happened, but the administrator wanted to talk to the former DON and was instructed to submit her statement of the incident in writing. E-E then called her immediate supervisor to report the incident as well. E-E stated she wrote a two-page statement of the incident and submitted it to the administrator on 6/8/26 but she had not been contacted or had any follow-up from the administrator.6/23/26 at 11:13 a.m., a review of screenshots from E-E's phone call history log identified the following calls sent and received following R4's elopement on 6/6/26:11:50 a.m. E-E called the administrator12:49 p.m. received a voicemail back from the administrator that stated the administrator thought she had already talked to E-E about the situation and was directed to write out a statement about the situation with her car and she would be talking with the former DON again shortly. On 6/18/26 at 4:33 p.m., a review of E-E's undated written statement to the administrator, identified on 6/6/26 at approximately 11:30 a.m., R4 was able to leave the facility without staff knowledge and get to the employees parking lot and drive her vehicle. Before the resident was able to enter her vehicle, he had exited the building and traveled across the property undetected by staff. R4 operated the vehicle for a short time before the situation was contained. R4 was under supervision and care of the facility at the time of the incident but was still able to leave the building and reach the parking lot with her knowledge or involvement to help search for R4. This statement also identified E-E's biggest concern was the knowledge of R4's history of wandering and wanted to document that R4 was able to exit the facility one or two more times that same day after the elopement and once the following day (6/7/26). E-E understood the fire door alarms inside the building were only activated after the other three elopement incidents occurred later that day and the next day. E-E's written statement also identified E-E had been informed by a nurse that the same door alarms had been turned off because it was disturbing to the other residents at night. E-E also wrote that she was informed that R4 on a different occasion, had entered the former DON's office after it had been left open and began eating Hot Cheetos, despite R4's diet of pureed and thickened-liquid diet.During an interview on 6/18/26 at 2:31 p.m., the facility medical director (MD) indicated R4's elopements were discussed at the 6/15/26 QAPI (Quality Assurance Performance Improvement) meeting and there had been some confusion amongst facility management about what an elopement was. The medical director stated he had not been informed that R4 had gotten into a vehicle and drove it but, even without the knowledge of R4 driving an employee's vehicle, he felt it was reportable to SA. The MD did not know why the facility did not report it, but they should have reported it to the SA and investigated. As a result of the 6/15/26 meeting, he requested they review every elopement for reportability. The MD identified the facility leadership had a lot of turnover.During an interview on 6/18/26 at 1:48 p.m., the administrator stated she was out of town on the weekend of 6/6/26 and there was no record of herself or the RCC being notified of R4's eloping and driving an employee's truck on 6/6/26. When asked about receiving a note from E-E regarding the incident, she stated she had received a note but did not recall when she had received it and presented the note to the surveyor from a file cabinet with an unrelated coaching moment stapled over the top of the two-page note. The administrator then indicated E-E had called her on 6/6/26 to complain about her vehicle and told her not to leave her keys in it. RCC, also present during the interview, stated she was unaware the administrator had received a statement from E-E and was not notified until sometime the next day (6/7/26). When asked about a meeting to discuss R4's elopement, RCC stated they had a meeting on Tuesday (6/9/26) about what to do to keep the residents safe but not about reportability. At this time, the surveyor played the video/audio recording of the 6/9/26 meeting and the Administrator and RCC provided no further comments. Review of an employee provided video/audio recording of the meeting that occurred on Tuesday, 6/9/26 at 10:30 a.m., identified those present included the former DON, administrator, social service designee, corporate social service designee, owner, RCC, and COO. The audio identified RCC starting the meeting by stating, I want everyone to truly be clear and understand why we didn't report this [6/6/26 elopement] this weekend. You all need to understand that we didn't report this, we talked about it in QAPI, because he has done this numerous times that wasn't reported; he left the building. Anytime any resident leaves a secure area unattended, it's technically an elopement; so, when he [R4] went down the basement, it was an elopement and should have been reported. If we report this now, they [SA] will dig through his chart with a fine-tooth comb, and your building will be shut down. The RCC further stated, I'm gonna tell you it's killing me because I said at one point that I would never compromise our principles again, but I am having to because you all have decided to keep things in house and not tell us and communicate with us in the past numerous times. If they come in on [referenced another resident's name] that would be an IJ when she was banging her head against the wall until she was black and blue and no one protected her, that would be an IJ. If they go through your chart and look and dig, there is enough that they could find, so we need to shut the book, we need to start keeping our residents safe, and doing the right thing . so what are we doing right now to keep them safe SSD then explained the steps about how they are keeping R4 safe. RCC summarized the meeting by stating, I just need everyone to understand why we didn't report it. The former DON stated I need to say that this weekend I can't attest that people were standing at the nursing station watching him walk out the building just that they were at the desk after that, looking like they did not know where the zones were, so the zones are labeled as well nowReview of the facility's Licensed Nursing Home Administrator job description indicated the administrator is responsible for ensuring residents receive quality care and services in compliance with all applicable regulations. Responsibilities include oversee compliance with regulatory standards (CMS, state, and local); maintain open communications with residents, families, and staff; ensure ongoing survey readiness and regulatory compliance; promote a positive culture of accountability, respect, and teamwork. Review of facilities undated rapid response protocol indicated in case of a resident elopement, send email to corporate rapid response group; call will be scheduled with the following to review the incident with administrator, DON, COO, RCC, owner, and other staff as necessary. The immediate jeopardy that began on 6/6/26 was removed on 6/23/26, when the regional director of operations educated the corporate clinical consultant and administrator on reporting; the facility educated all staff on abuse neglect exploitation requirements, reporting requirements, reporting timelines, mandated reporter, free from retaliation, expectation of the report, investigative process; reviewed 30 days of resident progress notes, grievances, and incident for reportable incidents; and reported R4's elopement to the SA.

Based on interview, observation and document reviews, the facility failed to adequately supervise and maintain resident safety when resident (R4), with a history of exiting the facility unsupervised, eloped through the front door of the facility, and drove an employee vehicle in the parking lot. This resulted in an Immediate Jeopardy (IJ) situation for R4. In addition, the facility failed to implement a system to ensure adequate supervision was provided for R4, when the exit alarm system panel was not labeled to alert staff to the exit door that R4 opened. The IJ began on 6/6/2026, when R4, who was assessed to be an elopement risk, was exhibiting exit seeking behavior just prior to the incident, exited through the front door of the facility, was able to enter an employee's vehicle with the keys inside, and drove across the employee parking lot before being observed by staff. The facility Administrator and the regional clinical coordinator (RCC) were notified of the IJ on 6/18/26 at 4:35 p.m. The IJ was removed on 6/8/26 and the deficient practice corrected on 6/11/26, prior to the start of the survey and was therefore past noncompliance. Findings include:R4's admission Record indicated he was admitted to the facility on [DATE]. Diagnoses included Lewy bodies dementia (a progressive brain disorder that affects thinking, memory, movement, sleep, and behavior), depression, hallucinations, anxiety disorder, and bipolar disorder (mental health condition characterized by severe, unusual shifts in mood and energy levels). R4's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and indicated he experienced delusions; had acute mental changes; behaviors of inattention, disorganized thinking; and physical and verbal behaviors towards others. R4's MDS indicated he ambulated independently without assistive devices on and off the unit and indicated he displayed wandering behaviors daily. R4's Elopement Risk Evaluation dated 5/21/26, identified R4 was at risk for elopement with a score of 8.0. Elopement risk identified due to R4 being ambulatory, had a habit/history of wandering or attempts to leave the unit/building; exhibited pacing or agitated behavior; asked to go home or other specific destinations; had a diagnoses of dementia, psychosis, and/or other psychiatric diagnoses; had a history of elopement from this facility or another setting; voiced concern from family that R4 had a tendency to wander or elope; and was taking medication which may cause confusion. Interventions included exit alarm, frequent monitoring, behavior log and analysis, staff were aware of elopement risk, and personalization of room. Analysis and elopement prevention plan and care plan updated sections lacked any additional information. R4's elopement focused care plan updated on 5/19/26, indicated he was at risk for elopement related to dementia with behavioral disturbances, impaired cognition with delusions/disorientation to time and place as evidenced by elopement events and exit seeking from skilled nursing facility. The care plan lacked elopement event dates, circumstances, and triggers. On 5/19/26, interventions of monitoring R4's location every 15 minutes for safety and to document per protocol, and an alarm to double fire doors on E (east wing) to alert staff when opened for prompt immediate assessment of R4's location. R4's care plan also identified him as a high fall risk related to diagnoses and ambulation without well-fit gripped footwear. R4's facility Progress Notes identified the following: 5/17/26 at 11:02 a.m., behavior charting indicated R4 exhibited exit seeking at all doors and agitation. Attempted redirection, distractions, and PRN's (as needed medications) but were ineffective. 5/18/26 at 1:01 p.m., R4 continued to exit seek; was agitated and wanted to go home. R4 was unable to be redirected which led to increased behaviors. The note lacked information related to which behaviors R4 demonstrated. 5/20/26 at 5:22 a.m., during the night R4 was confused and tried to get out the doors, R4 redirected. 5/22/26 at 3:07 p.m., R4's son was notified of R4 wandering out of the building and his attempts at trying to elope after learning the door codes from watching staff. The nature of the call was to discuss possible elopement; the facility provided 15-minute checks. 5/24/26 at 4:45 a.m., R4 wandered into other resident rooms, looked for exits to elope, stated he was going home, and was aggressive and combative to redirection. R4 refused to take PRN risperidone (antipsychotic medication). 15-minute checks continued. 5/24/26 at 6:46 p.m., R4 had gotten out into the locked courtyard within a minute or two, but staff redirected him back into the building. The administrator and prior DON were notified by phone. The note lacked additional information or interventions to mitigate continued self-entry into the locked courtyard.5/25/26 at 9:15 a.m., R4 continued to exit seek with increased agitation when staff redirected. R4 ignored door alarms and any other devices used to keep him away from doors. The note lacked information on intervention(s) to mitigate R4's increased agitation or decrease his exit-seeking behavior.5/25/26 at 8:49 p.m., R4 was actively exit seeking, wandering, and entering other residents' rooms during the PM (evening) shift, difficult to redirect or reassure; voiced concerns about farm equipment and hogs; asked other residents for a ride just a few miles up the road. Redirection was only successful for a couple of minutes and repeated behaviors. The note lacked information on intervention(s) to mitigate R4's behaviors or decrease his exit-seeking behavior.5/31/26 at 10:42 a.m., R4 was agitated, aggressive, and unstoppable, and headed out through an exit door. An ambulance was called and he was transferred to the emergency department for evaluation. R4 returned at 2:00 p.m. with notes to schedule an appointment with physician to follow up on medication adjustments. 6/2/26 at 10:35 a.m., facility reached out to locked facilities for R4's relocation. 6/3/26 at 9:02 a.m., R4 managed to get out of the locked door by pushing on it for an extended period of time which released the lock's safety feature. R4 immediately tried to re-enter the building. Staff unlocked the door and R4 re-entered. The note lacked information on intervention(s) to mitigate or decrease his exit-seeking behavior.6/3/26 at 3:57 p.m., R4 wandered hallways, attempted to elope through the exterior door by the business offices. R4 wanted to leave the building to go to work and check on the status of his farm. Interventions attempted were 1:1 time with staff, redirection, and activities but were ineffective. 6/6/26 at 11:18 a.m., R4 wandered and was exit seeking. R4 had been walking with conviction all morning since 6:30 a.m. and seemed to be on edge about how hot it is outside and getting the hogs he had loaded to [NAME]. Interventions attempted included removal of departure cues (keys, coats, shoes) from sight, redirection, food, sensory board, socialization with peers and staff but he continued to wander, and exit seek.R4's progress notes, including his medical record, lacked information related to R4's 6/6/26 elopement from the facility and driving an employee's vehicle as evidenced below in staff interviews.6/6/26 at 3:47 p.m., R4 continued to wander, pushed doors, and went into other residents' rooms. R4 stated he just wanted to get out the door. The note lacked information on intervention(s) to mitigate or decrease his exit-seeking behaviors.6/7/26 at 1:03 p.m., R4 exhibited severe agitation, anxiety, and exit-seeking behavior throughout the shift; continued to make attempts to leave despite staff interventions. 6/11/26 at 9:09 p.m., R4 was assigned a 1:1 (one-on-one) staff supervision. 6/12/26 at 9:39 a.m., R4 discharged to an assisted living facility. R4's Resident Location Charting from 5/29/26 to 6/8/26, lacked care planned 15-minute checks documentation at the following times:5/29/26, from 6:45 a.m. to 6:00p.m.5/30/26, from 6:45 a.m. to 6:00 p.m.5/31/26, from 6:30 a.m. to 6:00 p.m.6/1/26, from 9:30 a.m. to 10:30 a.m. and 2:15 p.m. to 6:00 p.m.6/2/26 from 12:15 p.m. to 1:15 p.m.6/4/26 from 5:45 a.m. to 12:00 p.m.6/5/26 from 6:45 a.m. to 6:00 p.m.6/6/26 (day of the elopement), from 6:45 a.m. to 6:00 p.m. 6/7/26 from 7:15 a.m. to 6:00 p.m.6/8/26, from 9:45 a.m. to 12:00 p.m., then identified 1:1 staffing. R4's Every 15-Minute Check Sheet dated 6/8/26 had 15-minute checks crossed out and at all times written in because R4 got outside. This form started at 3:30 p.m. with complete documentation until discharge. During interview on 6/16/26 at 2:01 p.m., employee (E)-A identified that on 6/9/26 the former director of nursing (DON) reported that R4 had eloped on 6/6/26, took an employee's car from the employee parking lot, and drove it down the road. E-A was concerned for R4's and other people's safety. E-A also stated the former DON told her that the elopement was not documented in R4's medical record and that it was to look like the elopement never happened per regional clinical consultant (RCC) direction. During an interview on 6/17/26 at 10:25 a.m., E-B revealed that the former DON had reported that on 6/6/26, R4 had gotten into and drove an employee's vehicle, and administration including the RCC and administrator directed not to report or document the elopement. Further, E-B stated R4 should have had more supervision as he has made several attempts to elope with two elopement events since May that they were aware of, in which neither were reported nor documented. E-B indicated R4's elopement events occurred when he was not accompanied by staff, nor were his elopements immediately recognized by staff. During an interview on 6/17/26 at 11:22 a.m., the former DON stated she had been employed at the facility for about a month. On 6/6/26, she was covering as charge nurse and at approximately 11:20 a.m. to 11:40 a.m., she and two other staff were on duty but were in rooms assisting residents when she heard a beeping noise. At first, she thought the beeping noise was a call light and then investigated and realized it was the exit door alarm system, but the zones on the master alarm board were not labeled so she did not know which door had been opened and activated. She had available staff checking rooms and she went out the East door by the business offices and asked a resident who was outside smoking if he had seen anyone leave; he had not. The DON continued across the visitors parking lot and saw a white pickup truck heading into the dock or delivery bay and recognized the man in the driver's seat as R4. Once R4 arrived at the delivery bay area, R4 exited the running truck and tried to get into the locked employees' door, where she was able to intervene. After unsuccessful attempts to get R4 back into the building, R4 then proceeded to get back into the driver's side of the running truck, but the DON was able to enter the passenger's side, shut off the truck, and pull the keys out of the ignition. The DON was then able to safely assist R4 back into the building without any apparent injuries. The DON identified the facility is surrounded by a corn field, deep gulch or drop-off, and a road and all posed risks to R4's safety. The DON called the administrator at 11:57 a.m. and the administrator returned her call at 12:34 p.m. The DON then called the RCC at 12:48 p.m. and was instructed to not chart the incident in R4's medical record, not to do an incident report, and not report it to the State agency (SA). In response to this direction, she confirmed she did not document the event in R4's medical record, did not do an incident report, nor report it to the SA. The DON stated she was walked out by the administrator and RCC the day the abbreviated survey began (6/16/26). The former DON further indicated she was walked out of the building and employment terminated when she told the RCC and administrator that she wanted to talk to the SA surveyor and was not aware of any previous issues with her job performance. During interview on 6/17/26 at 1:13 p.m., E-C identified on 6/6/26 just before lunch the door alarms went off as they were busy with another resident. The door alarms sounded like call lights, and thus it was hard to tell if it was the call light system or the door alarm. E-C stated they figured it was R4 because R4 frequently tried to get out, and they were unaware which door he went out. By the time R4 was found, he was coming in the back door by the employee parking lot. E-C denied seeing R4 drive the vehicle but heard about it. E-C explained she thought R4 was on 15-minute checks on 6/6/26, but indicated they did not have enough staff that day to do the 15 minute checks on R4. On 6/8/26, new door alarms were placed on the doors. During an interview on 6/17/26 at 1:27 p.m., E-D indicated on 6/6/26 at approximately 11:30 a.m., she heard the door buzzers but was not sure which door it was. By the time they found out which door had alarmed, the DON found R4 in the truck. R4 tried to elope a lot and was on 15-minute checks but this was changed to 1:1 staff at all times after the elopement. After the 6/6/26 incident, the zones were labeled on the exit door main panel for staff to know which door was alarming. During an interview on 6/17/26 at 1:51 p.m., social service designee (SSD) indicated R4 had two elopements the beginning of May and now the one in June that prompted R4's move to a more secured home. The SSD stated he was not present during the recent elopement, the former DON reported that R4 had gotten into an employee's vehicle and pulled it forward. He explained the facility front yard sits next to a steep drop off, valley, gulch with trees and brush which put R4 at risk if he were to get too close to the edge and fall down the valley. R4 was on 15-minute checks but after the elopement was changed to 1:1 staffing until his discharge. During an interview on 6/18/26 at 10:06 a.m., E-E identified that on 6/6/26 she parked her truck in the employee parking lot with the keys in the ignition. Just before lunch time, she observed R4 driving her truck to the delivery/docking bay next to the employee entrance. R4 got out of the truck, walked around to the employee entrance door, and tried to pull the locked door open. R4 appeared to be talking to someone. Upon further inspection, she saw the DON met him at the employee entrance, in which R4 then walked back to the running truck and got in the driver's side. At that time, the DON was able to get into the passenger side of the vehicle, shut the ignition off, and pull the keys out of the ignition. E-E explained her truck was parked approximately 5-6 parking spots from the employee entrance and R4 would have had to back up the truck and drive around other parked vehicles and drive by the garage before pulling into the docking/delivery bay. E-E did not know how long R4 had driven the truck. She described the weather that day as hot and muggy and R4 was wearing a sweatshirt, sweatpants, and yellow grippy socks that had grass and gravel stuck to them. E-E identified R4 was an elopement risk and had eloped through the front door by the offices two more times the day after he drove her truck. One time, another resident alerted staff that R4 was outside; however, she was not sure where they found him the second time he eloped. Additionally, E-E stated there were a set of double fire doors at the end of the East hall before the actual facility exit doors that were always supposed to be shut and alarmed because he tried to elope so often. The purpose of the double door alarms were to alert staff prior to R4 exiting the building but she had frequently observed that the door alarms were shut off and was told by an un-named charge nurse that the door alarms were shut off because R4 set them off so often, it disturbed the residents. E-E provided two videos of the double fire doors at the end of the hall; one video of the doors alarmed and one that she stated she took on 6/7/26 (after R4's elopement) of the double door alarms not working. E-E stated she took the videos because the facility administration had tried to make R4's elopement on 6/6/26 her fault and she wanted proof that the doors were not alarmed. During interview on 6/22/26 at 12:07 p.m., family member (FM)-A stated R4 did not have a valid driver's license as it was revoked after R4 got into trouble while driving around lost, and when the police tried to pull him over, R4 tried to flee the police officer. FM-A indicated the facility told him R4 tried to get into a vehicle on 6/6/26 but he was not aware that R4 had driven it and further stated, he was not surprised by this because R4 roamed the halls and tried to get out of the facility constantly, FM-A further indicated when he visited R4 on 6/7/26, he learned R4 had just eloped out the back and got away from staff. During an interview on 6/23/26 at 10:04 a.m., E-F indicated she was not present when R4 took an employee's vehicle, but she had observed R4 escape out into the courtyard without staff knowledge many times, and on one occasion, he was in the bushes trying to climb the fence. E-F stated that R4 should have had more supervision because of his history of escaping. During an interview on 6/23/26 at 10:10 a.m., E-G stated she had observed R4 enter the kitchen and was attempting to elope out the door but went down the basement stairs instead. E-G stated she called for nursing, and they responded and redirected him. E-G stated, they should be supervising him more closely.During an observation with E-E on 6/23/26 at 10:55 a.m., and following the route out the door R4 exited, based on interviews where the truck was parked in the employee parking lot and the initial sighting of R4 driving in the vehicle, took a person out the front door by the business offices which has a sharp, wooded, drop off behind a two open rail fence beyond approximately 25 feet of grassy area; he then went East and walked through the visitor parking lot and windows of an unoccupied area of the business offices and physical therapy room; walked [NAME] across the lawn and between the garage and trash dumpsters to the vehicle parked approximately 50-100 feet into the gravel parking lot with other employee vehicles parked in the lot; a corn field and gravel road were adjacent to the parking lot to the south; entered the truck and backed the truck out forward 50-100 feet to the east edge of the employee parking lot and turned the vehicle to the south between the employee's smoking area and facility garage; pulled the vehicle up the docking/delivery bay with approximately 10 feet between the front of the truck and the facility. During a Follow up interview on 6/23/26 at 11:56 a.m., the prior DON stated she did not document the elopement in R4's medical record because the RCC and administrator told her not to. The former DON reiterated that on 6/6/26, R4 left the building unsupervised. The following facility's corrective actions dated 6/11/2026, were verified as implemented prior to the survey: 6/8/26, zones on the door alarm panel were labeled.6/9/26 screamer door alarms were installed on the exit doors.6/9/26 elopement assessments were completed on all in-house residents.6/10/26, the elopement book was reviewed and updated, and care plans were reviewed6/11/26, education completed with all staff on Abuse, Neglect, and Exploitation Policy, Elopements and Wandering Policy, and Accidents and Supervision Policy to include the 15 second egress on all exit doors and Screamers. Additionally, documentation supports 1:1 staff supervision for R4 was initiated. The undated facility policy titled, Elopements and Wandering Residents indicated the facility ensured that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Defines elopement when a resident leaves the premises or safe area without authorization and/or any necessary supervision to do so. The facility is equipped with door locs/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. The undated facility policy titled, Accidents and Supervision, identified the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This included: identifying hazard(s) and risk(s), Evaluating and analyzing hazard(s) and risk(s), Implementing interventions to reduce hazard(s) and risk(s), Monitoring for effectiveness and modifying interventions when necessaryDefinitions: Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident; Environment refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas; Hazards refers to elements of the resident environment that have the potential to cause injury or illness; Risk refers to any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident.; Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision; defined by type and frequency; based on the individual resident's assessed needs and identified hazards in the resident environment

Based on observation, interview, and document review the facility failed to ensure call lights were functional and within reach for 3 of 8 residents (R1, R5, and R7) reviewed for call light placement.Findings include:R1's significant change in status Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and needed staff assistance with toileting, transfers, dressing, and bed mobility. Diagnoses included schizophrenia, acute respiratory failure with hypoxia, and malnutrition. R1's fall focus care plan identified R1 was at risk for falls related to incontinence, poor communication/comprehension, psychoactive drug use, mental health diagnoses, and behavior of throwing herself backwards. Interventions included be sure call light is within reach and courage her to use it for assistance if needed. During observation and interview on 6/17/26 at 9:34 a.m., R1 was lying in bed and stating she needed to use the bathroom. R1 was unable to locate her call light and when it was given to her, she could not push the button. R1 stated she couldn't hold it anymore and needed to go to the bathroom. Evaluator pushed the call light for her and ADON responded and acknowledged R1 likely did not have the strength to push that button and would get a soft touch call light for her.R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 had moderately impaired cognition and needed staff assistance for toileting, dressing, bed mobility, and transferring. Diagnoses included cervical disc disorder with myelopathy (arthritic condition affect the neck joints), bipolar disorder (mental health disorder that causes extreme mood swings), and chronic obstructive pulmonary disease (lung disease causing breathing problems). R5's fall focus care plan identified R5 was a high risk for falls related to gait/balance problems and safety awareness (history of impulsiveness). Interventions included to be sure R5's call light was within reach and encourage the resident to use it for assistance. R5 needed prompt response to all requests for assistance. During an observation and interview on 6/16/26 at 9:55 a.m., R5 was sitting in his wheelchair watching television. R5 stated he was sitting in his torture chair and had a lot of pain in his bottom, rating his pain a 9 on a 0-10 pain scale. R5 wanted a pain pill but could not reach either of the two call lights in his room and stated he could not move his wheelchair to get to them. Defined himself as being stuck. Both call lights were closed inside his bedside table drawer and were out of reach. One call light cord appeared frayed with exposed wires. At 10:05 a.m., Licensed practical nurse (LPN)-A entered the room with R5's pain pill and acknowledged R5 could not reach his call lights and proceeded to tie the frayed call light cord to the metal handlebar of his wheelchair. Assistant Director of Nursing (ADON) verified call light cord was frayed and replaced it. R7's quarterly MDS dated [DATE], R7 had moderately impaired cognition; had impairment to both legs; used a wheelchair; was dependent on staff for personal hygiene, toileting, bed mobility and transfers.R7's fall focus care plan identified R7 was at high risk for falls related to limited mobility, weakness, cellulitis, history of falls, deconditioning, gait/balance problems, and diagnosis of tremors. The care plan lacked call light placement as an intervention. During observation and interview on 6/16/26 at 12:46 p.m., R7 was sitting in his wheelchair in his room and hollering that he wanted to go to bed. R7's call lights in his room were not within his reach to call staff for assistance. Call light observed clipped to the curtain divider in his room. R7 stated he could not reach them so would just holler until they came. R7 stated he was very uncomfortable and needed to get out of his chair while adjusting his weight in the chair. At 12:54 p.m., the ADON entered the room and acknowledged that R7's call light was not within his reach. During an interview on 6/16/26 at 12:54 p.m., the ADON stated all residents should always have call lights within reach, and her expectation would be for all staff to ensure the call lights are placed within their reach and be able to push them. Review of the facility's Call Light: Accessibility and Timely Response Policy dated 1/2026, identified the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines included: Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations with the resident's room. Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly (examples included touch pads, larger buttons, bright colors, etc.).

Based on interview and record review the facility failed to notify the resident representative regarding changes to skin integrity, weight loss, and accidents for 1 of 1 residents (R1) reviewed for change in condition. Findings include:R1's significant change in status Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and needed staff assistance with toileting, transfers, dressing, and bed mobility. Diagnoses included intellectual disability, schizophrenia, acute respiratory failure with hypoxia, malnutrition, and dehydration. The MDS also indicated R1 had no skin issues, had two or more falls without injury, required a mechanically altered diet, and had a significant weight loss. R1's care plan lacked a focus or intervention that related to when and why to contact R1's guardian. There was no documentation of R1 having a guardian. R1's Department of Human Services letter dated 12/5/24, identified R1's guardian was a delegate or designee of the Commission of Human Services through [NAME], may act in the Commissioner's stead as a local guardian of R1. Significant weight loss:R1's weight log identified on 3/19/26 R1 was 166.2 pounds; on 5/5/26 R1 was 124.9 which was a loss of 41.3 pounds. R1's Nutritional Assessment identified a significant weight loss related to weight loss of greater than 6.6 pounds, severe decrease in food intake, severe dementia or depression, and a body mass index (BMI) of less than 19. R1's Progress Notes revealed the following:-5/8/26 at 2:41 p.m. - Dietary Note indicated weight warning for a weight of 124.9 pounds. The medical record lacks evidence of guardian notifications related to weight loss or nutrition concerns. -5/18/26 at 5:03 p.m. current weight of 130 pounds continues to show a significant weight loss from 179 pounds in 12/25. The medical record lacks evidence of guardian notification. Skin: R1's Bath Skin assessment dated [DATE] indicated R1 had an open area to coccyx/sacral area and right knee has scabbed areas with treatments in place. R1 also had bruising on arms.R1's Progress Notes revealed the following:-5/11/26 at 3:40 p.m., R1 noted to have skin tears on her buttocks directly above anus. A note was put in for nurse practitioner to evaluate the next day. R1 has bruising around right eye. No facility incident report related to the skin tears or bruising of right eye and lacked documentation that R1's guardian was notified.-5/15/26 at 1:20 p.m., R1 has open area to inside of anus; wound pictures taken and assessment completed but lacked documentation that R1's guardian was notified.Falls:Facility incident report revealed the following:-2/4/26 at 9:45 a.m., identified R1 had been hitting herself in the face, kicking doors, hitting her head on the wall and had bruising of yes and mid to right shoulder area. The incident report lacked documentation of guardian notification-5/5/26 at 11:30 a.m., R1 had a fall. The incident report lacked documentation of guardian notification. -5/9/26 at 5:30 p.m., R1 fell and had a laceration above her right eyebrow 1 centimeter (cm) x 0.3 cm. The incident report lacked documentation of guardian notification-5/10/26 at 12:55 p.m., R1 fell with no apparent injuries. The incident report lacked documentation of guardian notification-6/12/26 at 8:21 p.m., indicated resident fell with complaints of pain in her right knee; hospice, DON and administrator were notified but the noted lacked documentation that the guardian was informed. There was no facility incident report related to this fall. R1's Personal Safety Plan Worksheet dated 1/16/26, identified trusted supporters and people R1 could to when she needed help included guardian Barb.During an interview on 6/16/26 at 1:21 p.m., R1's guardian indicated she had not been notified of R1's significant weight loss of 50 pounds, was not always notified of R1's falls specifically the fall on the 6/12/26 and was not notified of R1's skin issues. The guardian was surprised at the amount of skin issues R1 received treatment for. During an interview on 6/17/26 at 10:25 a.m., employee (E)-B identified as part of the interdisciplinary team (IDT) and stated all notifications to resident's families, guardians, or responsible party were only to be done by the social worker during business hours. E-B stated any change of condition, fall, incident, new orders should have been communicated to the residents' responsible parties, but the facility had not been making those notifications as they should have. During an interview on 6/17/26 at 12:32 p.m., E-I indicated R1's guardian was not getting notified of condition changes, behaviors, or med changes because there was some confusion in the facility about who R1's guardian was. E-I stated that resident families, responsible parties, guardians should have been notified if there was significant change like weight loss, behaviors, changes with medications or orders. Also stated the prior social worker was supposed to make all those notifications, but the facility process changed, and nurses are supposed to make those notifications. During an interview on 6/17/26 at 2:05 p.m., the social service designee (SSD) stated all family, guardian, responsible party notifications had been made by the social worker but recognized that was an area that they needed to improve in. The SSD further stated nurses should contact residents' responsible parties for emergent situations, and the SSD made the non-emergent notifications. The SSD said he needed to review the facility policies. During an interview on 6/17/26 at 3:58 p.m., the regional clinical consultant (RCC) noticed that the facility lacked documentation of notifications and would expect families, responsible parties, and guardians to be notified according to the facility policy. The facility's undated policy titled, Notification of Changes identified the purpose of the policy was to ensure the facility promptly informs the resident, consults with the resident's physician; and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification and included accidents resulting in injury or potential to require physician intervention; significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial state which may include: life-threatening conditions or clinical complications and circumstances that require a need to alter treatment which may include new treatment, discontinuation of current treatment, transfer or discharge of a resident, change of room or room assignment, and a change in resident rights. For residents incapable of making their own decision, the representative would make any decisions that need to be made, and the resident should still be told what is happening to him or her.

Based on observation, interview, and record review the facility failed to ensure an elopement from the facility was recognized and reported to the state agency (SA) for 1 of 1 resident (R4) reviewed for elopement. Findings include:R4's admission Record indicated he was admitted to the facility on [DATE]. Diagnoses included Lewy bodies dementia (a progressive brain disorder that affects thinking, memory, movement, sleep, and behavior), depression, hallucinations, anxiety disorder, and bipolar disorder (mental health condition characterized by severe, unusual shifts in mood and energy levels). R4's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and indicated he experienced delusions; had acute mental status changes; behaviors of inattention, disorganized thinking; and physical and verbal behaviors towards others. R4's MDS indicated he ambulated independently without assistive devices on and off the unit and indicated he displayed wandering behaviors daily. R4's Elopement Risk Evaluation dated 5/21/26, identified R4 was at risk for elopement with a score of 8.0. Elopement risk identified due to R4 being ambulatory, had a habit/history of wandering or attempts to leave the unit/building; exhibited pacing or agitated behavior; asked to go home or other specific destinations; had a diagnoses of dementia, psychosis, and/or other psychiatric diagnoses; had a history of elopement from this facility or another setting; voiced concern from family that R4 had a tendency to wander or elope; and was taking medication which may cause confusion. Interventions included exit alarm, frequent monitoring, behavior log and analysis, staff were aware of elopement risk, and personalization of room. Analysis and elopement prevention plan and care plan updated sections lacked any additional information. R4's elopement focused care plan updated on 5/19/26, indicated he was at risk for elopement related to dementia with behavioral disturbances, impaired cognition with delusions/disorientation to time and place as evidenced by elopement events and exit seeking from skilled nursing facility. The care plan lacked elopement event dates, circumstances, and triggers. On 5/19/26, interventions of monitoring R4's location every 15 minutes for safety and to document per protocol, and an alarm to double fire doors on E (east wing) to alert staff when opened for prompt immediate assessment of R4's location. R4's care plan also identified him as a high fall risk related to diagnoses and ambulation without well-fit gripped footwear. R4's medical record lacked any documentation of an elopement on 6/6/26.Review of the facility's incident reports lacked any documentation of the 6/6/26 elopement incident.The State Agencies Minnesota Adult Abuse Reporting Center did not contain any facility reported incidents related to R4's reported elopement attempts on 6/6/26. During interview on 6/16/26 at 2:01 p.m., employee (E)-A identified that on 6/9/26 the former director of nursing (DON) reported that on 6/6/26, R4 had eloped, took an employee's car from the employee parking lot, and drove it down the road. E-A was concerned for R4's and other people's safety. E-A also stated the former DON told her that the elopement was not documented in R4's medical record and that it was to look like the elopement never happened per regional clinical consultant (RCC)'s direction. During an interview on 6/17/26 at 10:25 a.m., E-B revealed that the former DON had reported that on 6/6/26, R4 had gotten into and drove an employee's vehicle, and administration directed not to report or document the elopement. Further, E-B stated R4 had made several attempts to elope with two elopement events since May that they were aware of, in which neither were reported to the SA nor documented in R4's record or a facility incident report completed. E-B indicated R4's elopement events occurred when he was not accompanied by staff, nor were his elopements immediately recognized by staff.During an interview on 6/17/26 at 11:22 a.m., the former DON stated she had been employed at the facility for about a month. On 6/6/26, she was covering as charge nurse and at approximately 11:20 a.m. to 11:40 a.m., she and two other staff were on duty but were in rooms assisting residents when she heard a beeping noise. At first, she thought the beeping noise was a call light and then investigated and realized it was the exit door alarm system, but the zones on the master alarm board were not labeled so she did not know which door had been opened and activated. She had available staff checking rooms and she went out the East door by the business offices and asked a resident who was outside smoking if he had seen anyone leave; he had not. The former DON continued across the visitors parking lot and saw a white pickup truck heading into the dock or delivery bay and recognized the man in the driver's seat as R4. Once R4 arrived at the delivery bay area, R4 exited the running truck and tried to get into the locked employees' door, where she was able to intervene. After unsuccessful attempts to get R4 back into the building, R4 then proceeded to get back into the driver's side of the running truck, but the former DON was able to enter the passenger's side, shut off the truck, and pull the keys out of the ignition. The former DON was then able to safely assist R4 back into the building without any apparent injuries. The former DON identified the facility is surrounded by a corn field, deep gulch or drop-off, and a road and all posed risks to R4's safety. The former DON called the administrator at 11:57 a.m. and the administrator returned her call at 12:34 p.m. The former DON then called the RCC at 12:48 p.m. and was instructed to not chart the incident in R4's medical record, not to do an incident report, and not report it to the State agency (SA). In response to this direction, she confirmed she did not document the event in R4's medical record, did not do an incident report, nor report it to the SA. The former DON stated she was walked out by the administrator and RCC the day the abbreviated survey began (6/16/26).During an interview on 6/17/26 at 1:27 p.m., E-D indicated she heard the door buzzers but was not sure which door it was. By the time they found out which door had alarmed, the former DON found him in the truck. During an interview on 6/17/26 at 1:51 p.m., social service designee (SSD) indicated R4 had two elopements at the beginning of May and now the one in June that prompted R4's move to a more secured home. The SSD stated he was not present during the elopement, but on 6/8/26, the former DON reported R4's elopement incident that occurred on 6/6/26, to him. The former DON reported that R4 had gotten into an employee's vehicle and drove it without staff supervision. The SSD stated he did not report to the SA and did not know what the facility vulnerable adult policy directed. During an interview on 6/18/26 at 10:06 a.m., E-E identified that on 6/6/26 she parked her truck in the employee parking lot with the keys in the ignition. Just before lunch time, she observed R4 driving her truck to the delivery/docking bay next to the employee entrance. E-E identified R4 was an elopement risk and had eloped through that front door by the business offices two more times that day after he drove her truck. One time, another resident alerted staff that R4 was outside; however, she was not sure where they found him the second time he eloped. Follow up interview on 6/23/26 at 11:56 a.m., the former DON stated she did not document the elopement in R4's medical record because the RCC and administrator told her not to. The former DON reiterated that on 6/6/26, R4 left the building unsupervised.During an interview on 6/17/26 at 2:40 p.m., the administrator stated on 6/6/26 she was unavailable and did not have cellular service so did not have the details of R4's elopement incident; the former DON did not notify her. The administrator stated, he [R4] was supervised from what I know. The administrator stated it was not reported to the SA because R4 was supervised the whole time he was out of the building on 6/6/26 so it was not considered an elopement and not reportable. The administrator further stated, unless I see it first-hand, I don't report it and there are a lot of differing opinions. The administrator indicated if staff came to her with concerns she would not automatically report. She would request the concern be in writing and then would review the concern to determine if it was reportable or not. The administrator said she is not a nurse and counts on the nursing judgement to decide. Staff was to report concerns to the rapid response team which includes the RCC. During an interview on 6/17/26 at 3:58 p.m., the RCC stated, their system is broke and an elopement is considered neglect and should be reported to the SA. The RCC further stated, I was not notified on 6/6/26 [of R4's elopement], the only thing I know was from reviewing his chart and insisted R4 had direct supervision by staff. The RCC stated she would not tell anyone not to report, that she was an over reporter, and if she had known about R4's elopement, it would have been reported to the SA. The undated facility policy titled, Abuse, Neglect, and Exploitation identified the facility will report all alleged violations to the administrator, state agency, adult protective services and to all other required agencies no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury; assure the reporters are free from retaliation or reprisal; promote a culture of safety and open communication in the work environment. The administrator will follow up with government agencies during business hours to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies. The undated facility policy titled Elopement and Wandering Residents defines elopement as occurring when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Appropriate reporting requirements to the State Survey agency shall be conducted.

Based on interview and document review the facility failed to thoroughly investigate a report of elopement for 1 of 1 resident (R4). Findings include:R4's admission Record indicated he was admitted to the facility on [DATE]. Diagnoses included Lewy bodies dementia (a progressive brain disorder that affects thinking, memory, movement, sleep, and behavior), depression, hallucinations, anxiety disorder, and bipolar disorder (mental health condition characterized by severe, unusual shifts in mood and energy levels). R4's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and indicated he experienced delusions; had acute mental status changes; behaviors of inattention, disorganized thinking; and physical and verbal behaviors towards others. R4's MDS indicated he ambulated independently without assistive devices on and off the unit and indicated he displayed wandering behaviors daily. R4's Elopement Risk Evaluation dated 5/21/26, identified R4 was at risk for elopement with a score of 8.0. Elopement risk identified due to R4 being ambulatory, had a habit/history of wandering or attempts to leave the unit/building; exhibited pacing or agitated behavior; asked to go home or other specific destinations; had a diagnoses of dementia, psychosis, and/or other psychiatric diagnoses; had a history of elopement care of from this facility or another setting; voiced concern from family that R4 had a tendency to wander or elope; and was taking medication which may cause confusion. Interventions included exit alarm, frequent monitoring, behavior log and analysis, staff were aware of elopement risk, and personalization of room. Analysis and elopement prevention plan and care plan updated sections lacked any additional information. R4's elopement focused care plan updated on 5/19/26, indicated he was at risk for elopement related to dementia with behavioral disturbances, impaired cognition with delusions/disorientation to time and place as evidenced by elopement events and exit seeking from skilled nursing facility. The care plan lacked elopement event dates, circumstances, and triggers. On 5/19/26, interventions of monitoring R4's location every 15 minutes for safety and to document per protocol, and an alarm to double fire doors on E (east wing) to alert staff when opened for prompt immediate assessment of R4's location. During interview on 6/16/26 at 2:01 p.m., employee (E)-A identified that on 6/9/26 former director of nurse (DON) reported that on 6/6/26, R4 had eloped, took an employee's car from the employee parking lot, and drove it down the road. E-A also stated the former DON told her that the elopement was not documented in R4's medical record and that it was to look like the elopement never happened per regional clinical consultant (RCC)'s direction and not investigated any further. During an interview on 6/17/26 at 10:25 a.m., E-B revealed that R4 had gotten into and drove an employee's vehicle on 6/6/26, and administration defined as the RCC and administrator, directed not to report or document the elopement. Further, E-B stated R4 should have had more supervision as he has made several attempts to elope with two elopement events since May that they were aware of, in which neither were reported, investigated, nor documented. E-B indicated R4's elopement events occurred when he was not accompanied by staff, nor were his elopements immediately recognized by staff.During an interview on 6/17/26 at 11:22 a.m., the former DON stated she had been employed at the facility for about a month. On 6/6/26, she was covering as charge nurse and at approximately 11:20 a.m. to 11:40 a.m., she and other staff were in rooms assisting residents when she heard a beeping noise. , She investigated and found that it was the door alarm system, but the zones on the master alarm board were not labeled so she did not know which door was activated. She had available staff checking rooms and she went out the East door by the business offices and asked a resident who was outside smoking if he had seen anyone leave; he had not. The former DON continued across the visitors parking lot and saw a white pickup truck heading into the dock or delivery bay and noted the man in the driver's seat as R4. Once R4 arrived at the delivery bay area, R4 exited the running truck and tried to get into the locked employees' door, where she was able to intervene. After unsuccessful attempts to get R4 back into the building, R4 then proceeded to get back into the driver's side of the running truck, but the former DON was able to enter the passenger's side, shut off the truck, and pull the keys out of the ignition. The former DON called the administrator and the regional clinical consultant (RCC) and was instructed to not chart the incident in R4's medical record, do an incident report, or report it to the State agency (SA). In response to this direction, she confirmed she did not document the event in R4's medical record, do an incident report, investigate the elopement, nor report it to the SA. During interview on 6/17/26 at 1:13 p.m., E-C identified on 6/6/26 just before lunch the door alarms went off as they were busy with another resident. The door alarms sounded like call lights, and thus it was hard to tell if it was the call light system or the door alarm. E-C stated they figured it was R4 because he frequently tried to get out, and they were unaware which door he went out. By the time R4 was found, he was coming in the back door by the employee parking lot. E-C denied being asked any questions by administration about the elopement. During an interview on 6/17/26 at 1:27 p.m., E-D indicated she heard the door buzzers but was not sure which door it was. By the time they found out which door had alarmed, the former DON found him in the truck. E-D denied being asked any questions by administration about the incident. During an interview on 6/17/26 at 1:51 p.m., social service designee (SSD) indicated R4 had two elopements at the beginning of May and now the one in June that prompted R4's move to a more secured home. The SSD stated he was not present during the elopement, but it was reported on 6/8/26, that R4 had gotten into an employee's vehicle and pulled it forward. The SSD was not aware if the elopement was investigated or not. During an interview on 6/18/26 at 10:06 a.m., E-E identified that on 6/6/26 she parked her truck in the employee parking lot with the keys in the ignition. Just before lunch time, she observed R4 driving her truck to the delivery/docking bay next to the employee entrance. R4 got out of the truck, walked around to the employee entrance door, and tried to pull the locked door open. R4 appeared to be talking to someone. Upon further inspection, she saw the former DON met him at the employee entrance, in which R4 then walked back to the running truck and got in the driver's side. At that time, the former DON was able to get into the passenger side of the vehicle, shut the ignition off, and pull the keys out of the ignition. E-E explained her truck was parked approximately 5-6 parking spots from the employee entrance and R4 would have had to back up the truck and drive around other parked vehicles and drive by the garage before pulling into the docking/delivery bay. E-E indicated they notified the administrator and her immediate supervisor and was asked to provide a written statement but then did not have any further conversations with the former DON or the administrator regarding the elopement. R4's medical record was reviewed and lacked any documentation related to the reported elopements.Review of facility incident reports did not include any risk management, incident reports, or investigations related to the reported elopements.The State Agencies Minnesota Adult Abuse Reporting Center did not contain any facility reported incidents related to R4's reported elopement attempts.R4's nurse progress notes lacked any documentation of the elopement on 6/6/26.R4's nursing progress note on 6/7/26 (the day after the elopement) was noted to have a left great toenail almost detached from the nail bed with the nail hanging loosely. On-call provider notified and advised to soak the toe and trim/remove as much detached nail as possible. The medical record lacked any further investigation; the facility lacked any incident report/risk management or investigation regarding R4's injury.During interview on 6/17/26 at 2:40 p.m., the administrator stated she was aware of R4's alleged elopement incident but she did not know the details of the incident and stated she thought he was supervised the whole time. She further indicated she did not have an investigation into R4's alleged elopement because she did not think it was a true elopement. During an interview on 6/17/26 at 3:58 p.m., the RCC stated she was aware of R4's alleged elopement incident and elopement should be investigated and reported. The RCC further denied being notified on 6/6/26 of R4's elopement and the only information she had was by reviewing R4's medical record and it said he had direct supervision. The RCC was a part of an interdisciplinary meeting on 6/9/26 at 10:30 a.m. that discussed R4's elopement incident. During a follow up interview on 6/18/26 at 1:48 p.m., the RCC stated R4's alleged elopement was discussed on 6/8/26 but lacked documentation of further investigation.Review of the facility's undated Rapid Response protocol indicated post elopement documentation should include an incident report/risk management; report DHS (department of human services); timeline of search and actions taken; resident assessment after recovery; notifications; and investigative findings. Follow up should include a root cause analysis and after action summary. Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It defined alleged violation as a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigation and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of property. The policy directs an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Written procedures for investigations include: Identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation; investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation and determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, the cause, and proving complete and thorough documentation of the incident. The administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies.

Based on interview and document review, the facility failed to monitor, report, and implement timely interventions for 1 of 2 residents (R1) reviewed for significant weight loss.Findings include:R1's significant change in status minimum data set (MDS) dated [DATE], indicated severely impaired cognition. Diagnoses included paranoid schizophrenia, moderate intellectual disabilities, protein-calorie malnutrition, acute respiratory failure with hypoxia, and dysphagia.R1's Nutritional assessment dated [DATE], identified R1 was malnourished, independent with eating after meal set up, did not receive a therapeutic nutritional supplement, did not use dentures as they were poor fitting, had poor meal intakes, was at risk for dehydration due to vomiting. The assessment further identified R1's admission weight 30 days prior was 179 pounds, but current weight was not documented and left blank. There was no change in weight and either no weight loss or gain or unknown if there was a weight loss or gain. R1's total nutritional intakes and supplements met her nutritional needs. Nutritional goals and interventions were updated and in R1's care plan. Dietary was to monitor for any abnormal weight changes. R1's nutrition focused care plan initiated on 5/18/26, identified R1 was at risk for nutrition/hydration problems related to the need for hospice services, dentures not fitting properly, advanced age, compromised appetite due to refusing meals, nausea/vomiting, weakness, refused weights, open areas on bottom, dysphagia, weight loss. Interventions included monitoring weights per MD (medical doctor)/hospice orders and/or facility policy; offer extra fluids between meals for hydration at activities; monitor for signs of dehydration; provide diet per MD/hospice order of a 7 regular diet as tolerated; provide R1 with assistance and cues as needed; safe swallowing strategies; sit upright; limit distractions, and meds crushed. R1's treatment administration record for April 2026, identified an order dated 3/5/26, for weekly weights and vital signs on bath day every Thursday. R1's weight on 4/2/26, was documented as 166.1 pounds; on 4/9/26, not applicable (NA) was documented; on 4/16/26, no documented weight; on 4/23/26, NA was documented; on 4/30/26, NA was documented. R1's treatment administration record for May 2026, identified an order dated 3/5/26, for weekly weights and vital signs on bath day every Thursday. R1's weight on 5/7/26 was not documented and all vital signs left blank; on 5/14/26 weight documented as 130 pounds (loss of 36.1 pounds in 6 weeks). R1's Weight Summary identified on 4/2/26, weight was 166.1 pounds and no other weights documented until 5/5/26, when R1's weight was 124.9 pounds (loss of 41.2 pounds).R1's Care Conference Summary dated 3/25/26, did not contain a dietary summary, nursing summary, and no weight or dietary concerns. R1's dietary progress notes reflected the following:-3/13/26, at 10:50 a.m., R1 had weight loss over time and continued compromised appetite and recommended a house supplement between meals. Dietary was to continue to monitor weights and appetite.-R1's progress notes lacked any dietary note from 3/13/26 to 5/8/26 and no evidence of implementation of nutritional supplement. -5/8/26 at 2:41 a.m., identified weight warning for R1 with a weight of 124.9 pounds and requested a reweigh. -5/13/26 at 10:54 a.m., R1 needed more cues and assistance with meals and provided lipped plate and straws to aide with independence with meals. Weight Note on 6/05/26 at 9:55 a.m., identified weight warning with R1's weight at 121.7 pounds; R1 had decreased meal intakes, was sleeping through meals, and having emesis after most meals causing weight loss. R1 was recently admitted to hospice and per dietician recommendation, fax sent to hospice for a supplement order to aide with nutritional intake due to her compromised appetite. On 6/5/26 at 12:17 p.m., hospice and R1's guardian approved use of a nutritional supplement and order was requested from physician. During interview on 6/16/26 at 1:21 p.m., R1's guardian indicated R1 had always had a bit of an issue with eating but had concerns with the facility's monitoring of R1's weight and had not received any notifications of R1's significant weight loss until she requested a care conference in May. R1 was 178 pounds when she was admitted to the facility on 12/25, and weight had decreased to 120 pounds without any interventions. R1's guardian also stated that the facility did not try any nutritional supplements or interventions until recently which she felt was after the fact and too late. During an interview on 6/17/26 at 3:58 p.m., the regional clinical consultant (RCC) indicated overall documentation is lacking. The RCC indicated her expectations of the facility nursing staff was to monitor weights, track and trend weights, put interventions in place, and document. During an interview on 6/23/26 at 10:30 a.m., the dietary manager (DM) indicated R1 would have behaviors of throwing up but did eat relatively ok until she went to the hospital in May. The DM further explained the nurses did not get R1's weights so when R1 returned from the hospital, a huge weight loss triggered. The DM stated that nursing is expected to notify her of any residents' weight changes but, some will, and some will not. The facility policy related to monitoring resident weights, reporting weight changes, and implementing interventions was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure the infection prevention and control program included ongoing surveillance, analysis, and trending of resident and staff infections. Additionally, the facility failed to maintain knowledge of a current list of reportable communicable diseases, including when and to whom communicable diseases, healthcare-associated infections, and potential outbreaks must be reported. This had the potential to affect all 34 residents who resided in the facility. In addition, the facility failed to ensure adherence to enhanced barrier precautions (EBP) when nursing staff failed to wear personal protective equipment (gowns) when providing direct care to 2 of 2 residents (R4, R22) reviewed for pressure wounds. Findings include: INFECTION CONTROL PROGRAM/ COMMUNICABLE DISEASE LIST Review of the Infection Surveillance Report dated 1/1/26–3/31/26 revealed documentation that included resident name, room number, infection onset date, signs and symptoms, status, and pharmacy orders. However, the report contained missing data related to signs and symptoms and lacked evidence of analysis of infections and illnesses, including identification of patterns or trends, implemented interventions, and required precautions. The facility was unable to provide documentation demonstrating analysis, trending, or evaluation of infection data. Review of the Employee Line List printed 4/22/26 included employee name, department, title, date, and symptoms. The documentation lacked evidence of analysis of infections or illnesses, including patterns or trends, interventions implemented, and precautions required. The facility did not provide evidence of trending or analysis of staff infection data. On 4/21/26 at 11:21 a.m., registered nurse (RN)-A, identified as the Infection Preventionist and employed at the facility for approximately one month, stated infections were tracked within the electronic medical record (EMR). RN-A reviewed EMR data for February and March 2026 and confirmed the data did not include comprehensive information such as signs and symptoms and primarily included infections associated with medication orders. RN-A confirmed gaps existed in the infection surveillance process and that some data was missing from tracking logs. RN-A further stated that monthly analysis of infections and illnesses is important to identify trends or patterns and to initiate interventions such as staff education and process improvements. RN-A also confirmed lack of awareness of a current list of reportable communicable diseases and was unable to describe the reporting protocol, including communication with local or state public health officials or identification of reportable outbreaks. On 4/22/26 at 11:49 a.m., the interim director of nursing (DON) and RN-A stated they were not aware of employee illness tracking processes. Both indicated that tracking employee illness would be important to identify symptoms and determine necessary precautions within the facility. The DON acknowledged the facility is expected to follow regulatory requirements related to infection surveillance. RN-A stated it is important for the infection preventionist to track employee illnesses to identify potential correlations with resident infections. On 4/22/26 at 12:32 p.m., the administrator stated the facility maintained a document tracking employee illnesses; however, the information had not been shared with RN-A and confirmed the data was not utilized for trending or analysis of staff infections. The facility Infection Prevention and Control Program Policy dated 3/5/25, indicated : Surveillance: A system of surveillance is utilized for prevention identifying reporting investigating and controlling infections and communicable diseases for all resident, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a civility assessment and accepted national standards. The infection preventionist serves as a leader in surveillance activities, maintains documentation of incidents, findings, and any other corrective actions made by the facility and report surveillance findings to the facilities quality assessment and assurance committee. The RNS and LPNS participate in surveillance through assessment of residents and reporting changes and conditions to the residents physicians and management staff per protocol for notification of changes and in-house reporting of communicable diseases and infections. EBP R4's face sheet provided on 4/22/26, included paraplegia (paralysis causing impairment of motor sensory function of lower extremities), pressure ulcers to right and left buttock and neuromuscular dysfunction of bladder (loss of bladder control due to disease or injury). R4's annual Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. Pressure ulcer to sacral region. Indwelling supra-pubic catheter (tube inserted into bladder through abdominal incision to drain urine). Independent with most activities of daily living. Mobility per motorized wheelchair. R4's provider orders included: 10/31/21: foley catheter 4/22/26: sacrum dressing: cleanse coccyx with wound cleanser. Place calcium alginate (absorbent dressing used primarily for managing exudate in wounds) in wound bed. Place barrier cream around peri-wound. Cover with ABD (abdominal pad) and tape down. Two times a day. No orders for enhanced barrier precautions (EBP). R4's care plan with revised date of 4/7/26, indicated R4 had a pressure injury stage 4 to coccyx, and that R4's pressure injuries would show signs of healing and remain free from infection by/through review date. Care plan dated 4/21/23, indicated R4 had an indwelling suprapubic catheter with history of chronic infections and had a history of ESBL (a bacteria) resistance in urine. The care plan did not indicate R4 had been in EBP. During an interview on 4/22/26 at 10:36 a.m., observed an EBP sign on R4's door. No cart outside the door containing personal protective equipment (PPE) including gowns. R4 had been lying in bed. When asked for permission to observe his dressing change, R4 stated he wanted to wait. Without asking, R4 stated, Staff don't wear gowns when they empty my catheter or change my dressing – they never do. Observed two large, plastic, three-drawer organizers in R4's room and did not see any gowns. One tall, plastic doffing receptable was observed on top of one of the three-drawer organizers in the corner and hard to reach. Inside the receptable was one non-disposable blue gown. During an interview and observation on 4/23/26 at 8:50 a.m., when asked to observe his dressing change, R4 stated, You won't see anything. When asked what he meant, stated staff will do what they are supposed to do – they will wear gowns. Again, looked around the room and did not see any PPE gowns. The receptible to doff reusable gowns still had only one blue gown in it for the past two days despite staff emptying urinary catheter bag each shift. In addition, the doffing receptable was still on top of the three-drawer supply bin and hard to reach, potentially indicating lack of use. During an interview and observation on 4/23/26 at 9:17 a.m., nursing assistant (NA)-B stated she was aware R4 was in EBP and stated she needed to wear PPE when she emptied R4's urine bag. NA-B could not recall the last time she emptied his bag. When asked where R4's PPE gowns were, NA-B stated they were in his room. Together went into R4's room. NA-B looked around and stated there were none. NA-B stated he was supposed to have a cart outside his room with gowns in it. When asked where staff put gowns when they take them off, NA-B pointed to the receptable on top of the three-drawer organizer and said that shouldn't be there. The receptable was removed and shown to NA-B who confirmed the cloth inside was one, blue reusable PPE gown. NA-B acknowledged there should have been more gowns in the receptable because staff emptied R4's urine bag every shift and changed his dressing every day. During an interview and observation on 4/23/26 at 9:44 a.m., together in R4's room, licensed practical nurse (LPN)-C was asked to locate the PPE gowns used for emptying R4's catheter and changing his dressing. LPN-C looked around the room and stated there were none, adding gowns and gloves should have been available outside R4's door. During an interview and observation on 4/23/26 at 10:02 a.m., together with RN-A who was also the infection preventionist, entered R4's room. RN-A verified R4 had been on EBP and verified a PPE cart had not been located outside of R4's door. RN-A stated residents in EBP should have a PPE cart outside their door and did not know what had happened to R4's. RN-A was asked to locate PPE gowns in the room and stated there were none. RN-A was asked if the doffing receptable was in an appropriate location and stated it was not. R4 who was lying in bed, informed RN-A staff never wore gowns to empty his urine or change his dressing. RN-A admitted to not noticing the lack of a PPE cart outside or R4's room and to not monitoring staff for adherence to EBP guidelines. During an observation on 4/23/2026 at 10:28 a.m., upon exiting R4's room, observed a PPE cart outside of R4's room and a doffing receptable just inside R4's room. Facility Enhanced Barrier Precautions policy with revised date of 3/5/25, indicated staff received training on EBP upon hire and annually, and were expected to comply with all designated precautions. An order for EBP would be obtained for residents with chronic wounds and urinary catheters. Gowns and gloves were immediately available near or outside of the residents room. PPE for EBP was only necessary when performing high-contact care activities. A trash can was to be positioned inside the room and near the exit to discard PPE after removal and prior to exit. The infection preventionist performed periodic monitoring of adherence to determine the need for additional training. High-contact resident care activities included wound care and device care including urinary catheters. R22's face sheet printed 4/22/26, indicated diagnoses of mild cognitive impairment, weakness, mood disorder, and excoriation skin-picking disorder. R22's annual MDS assessment dated [DATE], indicated intact cognition, no behaviors or rejection of care, use of wheelchair, dependent for personal hygiene and dressing, and no pressure ulcers, open lesions, or wounds. R22's physician's order dated 3/8/25, indicated weekly skin review on bath day every Sunday. R22's physician's order dated 3/20/26, indicated cleanse coccyx wound. Cover with foam dressing. Replace every other day. R22's care plan printed 4/22/26, indicated potential for impairment to skin integrity related to obesity with goal of maintaining intact skin by review date. Apply medications as directed when ordered for skin treatments. Keep skin clean and dry. Use lotion on dry skin. Do not use wet wipes. During interview on 4/20/26 at 3:09 p.m., R22 stated she had a pressure ulcer on her coccyx. R22 stated she did not recall staff wearing gowns when changing her brief or providing wound care. During observation and interview on 4/21/26 at 11:10 a.m., LPN-A completed R22's wound order. LPN-A removed R22's brief, cleansed her wound, and applied foam dressing. LPN-A did not wear a gown while completing wound care. LPN-A stated she was unsure if she needed to wear a gown while completing wound care for R22, and stated she did not see an enhanced barrier precautions (EBP) sign on R22's door or an EBP supply cart outside her room. LPN-A stated she would normally expect to wear a gown while completing a dressing change on a pressure ulcer. During observation on 4/21/26 at 3:15 p.m., R22's door had a new sign indicating EBP should be worn in her room when providing cares and had an EBP cart with gowns placed outside her door. During interview on 4/22/26 at 12:32 p.m., interim director of nursing (DON) stated he would expect EBP to be used for wounds that required a dressing to prevent spread of infection. Facility Enhanced Barrier Precautions policy with revised date of 3/5/25, indicated staff received training on EBP upon hire and annually, and were expected to comply with all designated precautions. An order for EBP would be obtained for residents with chronic wounds and urinary catheters. Gowns and gloves were immediately available near or outside of the residents room. PPE for EBP was only necessary when performing high-contact care activities. A trash can was to be positioned inside the room and near the exit to discard PPE after removal and prior to exit. The infection preventionist performed periodic monitoring of adherence to determine the need for additional training. High-contact resident care activities included wound care and device care including urinary catheters.

Based on interview and document review the facility failed to implement and maintain an effective infection prevention and control program specific to antibiotic stewardship. The facility did not have a system to track antibiotic use, culture results, organisms identified, or antibiotic resistance to ensure residents received appropriate treatment, this had the ability to affect all 34 residents. Findings Include:Review of the Infection Prevention and Control (IPC) case list dated 1/1/26-3/31/26, , documentation included resident name, room number, onset date, signs and symptoms, current prescription, prescriber, infection type, organism, diagnosis, and category. However, the log lacked documentation of the date cultures were obtained, organisms identified from culture results, and whether organisms were resistant to prescribed antibiotics.On 4/21/26 at 11:21 a.m., registered nurse (RN)-A , identified as the infection prevention nurse, stated antibiotic use was not tracked. RN-A stated the facility completed a log to monitor possible infections and confirmed antibiotic tracking was identified as a gap to ensure residents were on the correct antibiotic. RN-A stated follow-up of cultures and ensuring residents were prescribed the correct antibiotic was a gap and there was no current process for antibiotic stewardship. RN-A stated providers were responsible for reviewing and tracking culture results to ensure appropriate antibiotics were prescribed. RN-A confirmed the facility did not track antibiotic indications for use, dosage, duration, culture results, or whether antibiotics were discontinued timely. RN-A further stated if a resident had a urinary tract infection and a urine culture was obtained, the provider was expected to track and communicate results to the facility, and the facility did not have a process to ensure culture results were received or addressed.On 4/22/26 at 11:49 a.m., the interim director of nursing (DON) and RN-A verified infection surveillance related to antibiotic use and resistance was not tracked on the IPC log and confirmed the facility did not have a formal antibiotic stewardship process as expected.Facility Antibiotic Stewardship Program Policy and Procedure dated 1/26, indicated It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.Director of Nursing - establish standards for nursing staff to assess, monitor and communicate changes in a resident's condition that could impact the need for antibiotics, use their influence as nurse leaders to help ensure antibiotics are prescribed only when appropriate, and educate front line nursing staff about the importance of antibiotic stewardship and explain policies in place to improve antibiotic use.The Antibiotic Stewardship Program leaders utilize existing resources to support antibiotic stewards' efforts by working with the following partners:Infection Preventionist - utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms.Monitoring antibiotic use:Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated, or adjustments should be made (e.g., antibiotic time-out).Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness.Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness.Monitor each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic or any antibiotic regimen review as requested by the QAA committee.Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure).Antibiotic use shall be measured by (monthly prevalence, antibiotic starts, and/or antibiotic days of therapy).At least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data.Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings.New or changed orders for antibiotics based on the antibiotic timeout recommendations will be obtained from the practitioner.

Based on observation, interview, and document review, the facility failed to ensure residents were free from involuntary seclusion when the facility maintained locked exit doors that prevented residents from freely exiting the building, without conducting individualized assessments, clinical justification, or care planning to support the restriction. This deficient practice had the potential to affect 8 of 34 residents (R4, R6, R11, R16, R20, R7, R29, R39) residing at the facility.Findings include: R4's annual Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, very important to go outside to get fresh air when the weather is good, no exhibited behaviors of wandering, utilized a motorized wheelchair independently. R4's care plan printed [DATE], indicated able to use powered wheelchair without any issue, able to wheel w/c (wheelchair) independently throughout and outside facility, independent for going in/out of facility backdoor to courtyard to smoke, not an elopement risk/wanderer, independent with transfers from bed/chair. R4's Elopement Risk Evaluation dated [DATE], indicated R4 was not at risk for elopement. R4's record review revealed no evidence of individualized assessments, care plans, physician orders, or clinical justification to support restricting R4's ability to leave the facility. R6's annual MDS assessment dated [DATE], indicated no cognitive impairment, no exhibited behaviors of wandering, very important to go outside to get fresh air when the weather is good, independent with walking. R6's care plan printed on [DATE], indicated R6 enjoys walking, allowed to walk outside on grounds with notifying nursing staff, not an elopement risk/wanderer, walk independently. supervision assistance in corridors: ambulates without device, steady gait. R6's Elopement Risk Evaluation dated [DATE], indicated R6 was not at risk for elopement. R6's record review revealed no evidence of individualized assessments, care plans, physician orders, or clinical justification to support restricting residents' ability to leave the facility. R11's quarterly MDS assessment dated [DATE], indicated intact cognition, no rejection of care, use of wheelchair, independent with transfers, independent with wheeling 150ft in wheelchair. R11's care plan revised [DATE], indicated resident is able to self-propel in wheelchair as well as walk with walker. R11's Elopement Risk Evaluation dated [DATE], indicated R11 was not at risk for elopement. R11's record review revealed no evidence of individualized assessments, care plans, physician orders, or clinical justification to support restricting R11's ability to leave the facility. R16's quarterly MDS assessment dated [DATE], no cognitive impairment, no exhibited behaviors of wandering, and utilized a motorized independently wheelchair. R16's care plan printed [DATE], indicated R16 was independent with mobility via use of his electric wheelchair, able to independently maneuver on and off the unit with his electric W/C, and not an elopement risk/wanderer. R16's Elopement Risk Evaluation dated [DATE], indicated R16 was not at risk for elopement. R16's record review revealed no evidence of individualized assessments, care plans, physician orders, or clinical justification to support restricting residents' ability to leave the facility. R20's quarterly MDS assessment dated [DATE], indicated severely impaired cognition, no exhibited behaviors of wandering, utilized a manual wheelchair independently. R20's care plan printed [DATE], indicated occasionally uses front wheeled walker independently for ambulation in his room, locomotion: able to wheel himself independently in manual wheelchair, 1 assist prn (as needed), uses a w/c when outside of his room, independent for transferring, and not an elopement risk/wanderer. R20's Elopement Risk Evaluation dated [DATE], indicated R20 was not at risk for elopement. R20's record review revealed no evidence of individualized assessments, care plans, physician orders, or clinical justification to support restricting residents' ability to leave the facility. R7's annual MDS assessment dated [DATE], indicated intact cognition, no behaviors, use of walker and wheelchair, independent with transfers and walking and propelling wheelchair. R7's care plan dated [DATE], indicated no risk for elopement, able to propel her own wheelchair to all location. R7's Elopement Risk Evaluation dated [DATE], indicated R7 was not at risk for elopement. R7's record review revealed no evidence of individualized assessments, care plans, physician orders, or clinical justification to support restricting R7's ability to leave the facility. R29's quarterly MDS assessment dated [DATE], indicated intact cognition, rejection of care one to three days, use of wheelchair, independent with transfers and propelling wheelchair. R29's care plan revised [DATE], indicated low risk for elopement, independent with transfers, okay to ambulate with four wheel walker (4WW) independently. R29's Elopement Risk Evaluation dated [DATE], indicated R29 was not at risk for elopement. R29's record review revealed no evidence of individualized assessments, care plans, physician orders, or clinical justification to support restricting R29's ability to leave the facility. R39's discharge return not anticipated Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no behaviors or wandering, no rejection of care, wheelchair use, independent with wheeling with manual wheelchair, independent with transfers. R39's care plan printed [DATE], indicated indicated activities of daily living (ADL) self-care deficit related to paraplegia. The resident is able to: wheel self independently in manual wheelchair, low risk for elopement. R39's record review revealed no evidence of individualized assessments, care plans, physician orders, or clinical justification to support restricting R39's ability to leave the facility. On [DATE] at 8:30 a.m., the administrator stated the facility doors were locked from the outside and inside for safety and security, and that overrode resident rights. The administrator further stated it was her job to keep everyone safe, and no one was getting hurt or lost on her time. The administrator stated residents still had rights, staff could let them in and out and were always available. In addition, administrator stated residents were not told they were admitting to a locked building, and it was not in their admission packet that the building was locked from the inside. The administrator also stated there were some rules about when residents could go outside based on weather and time of day. The administrator stated residents at the facility were not committed by law to be in a locked facility, did not have a provider's order to be in a locked facility, and did not sign a consent to be in a locked facility. On [DATE] at 8:31 a.m., during further interview the administrator stated only staff had access to the codes to unlock the doors. The administrator confirmed residents, including those who were independent and without cognitive impairment, were unable to leave the building without requesting staff assistance. The administrator stated no individualized assessments, or waivers had been completed to support restricting residents' ability to leave without staff assistance. The administrator further confirmed residents had not been formally educated regarding the locked door system. On [DATE] at 12:49 p.m., activities aide (AA)-A stated all facility doors were locked and only staff possessed the code to open the doors, confirming residents could not independently leave through any door. On [DATE] at 12:52 p.m., R7 stated all doors were locked and only staff had access to the codes, and stated the doors were locked due to concerns about other residents. On [DATE] at 12:52 p.m., health unit coordinator (HUC)-H stated all facility doors were locked from the inside and outside at all times and only staff had access to the codes. HUC-H stated the front door was expected to unlock after applying continuous pressure to the push bar for 15 seconds. During observation, the front door, which was constructed of solid wood with a keypad mounted on the adjacent wall, was pushed continuously for 15 seconds and did not unlock or release. HUC-Confirmed the door should have unlocked after sustained pressure. On [DATE] at 12:55 p.m., during a tour of the facility with maintenance director (MD)-A, the following was observed: On the north side of the building in the dining room an exit sign hung above a metal door with a glass upper panel and a horizontal push bar across the center. A keypad was mounted on the wall next to the door. The push bar was pressed continuously for approximately 30 seconds; however, the door remained locked and did not unlock or open. On the south side of the building, the main entrance door located in the day room area was a solid wood door with a keypad installed next to it and an exit sign above. The door remained locked and did not open without entering a code. On the east side of the building, near the administrative offices, there was a full glass, wide door with a metal push bar across the middle and a keypad mounted to the side. There were no visible instructions indicating how long to press the bar to unlock the door. When the push bar was pressed continuously for approximately 15 seconds, the locking mechanism disengaged, and the door unlocked. On the west side of the building in the activity room, there was a metal door with a glass upper panel, a horizontal push bar, a keypad mounted next to the door, and an exit sign posted above. The push bar was pressed continuously for approximately 30 seconds; however, the door did not unlock or open. On [DATE] at 1:07 p.m., MD-A stated the doors were intended to unlock after 15 seconds of continuous pressure on the push bar. MD-A confirmed that, except for the east side door, the doors did not function as intended. MD-A further stated the facility previously had a locked dementia unit, which had been discontinued, and the door system had not been converted to allow unlocking after sustained pressure. MD-A stated the current configuration was consistent with a fully locked system rather than one designed to unlock after delay. On [DATE] at 1:11 p.m., during a telephone interview, the maintenance consultant confirmed the facility previously operated a locked unit requiring physician orders for placement and stated that when the unit was discontinued, the door system should have been changed to allow doors to unlock after sustained pressure. The consultant confirmed the current door function was not consistent with that expectation. On [DATE] at 9:33 a.m., R24 stated they walked without staff assistance and was independently able to perform self-cares, stated all doors were locked, required a code, and residents must ask permission to leave the building. R24 stated almost like jail. During an interview on [DATE] at 8:29 a.m., with the administrator and the regional clinical consultant (RCC)-D, the administrator who had been employed by the facility for two years, stated she didn't know how many years the doors had been locked from the inside, adding it had been that way since she started. The administrator stated she never looked at the doors as being locked, she looked at them as a security measure for residents to be safe from a variety of issues. Issues identified included the facility being located in a remote area, the steep bluff in front of the facility, farm fields around the facility, the opioid epidemic and potential drug seekers. Further, the administrator stated due to their isolation, they were a prime target for potential criminal activity. When that didn't fully explain the rationale for locking doors from the inside, the administrator stated staff were always available to let residents and visitors in and out of the facility, and that family members appreciated the safety the facility provided. The administrator stated they had never considered giving a passcode to residents who were independent and able to come and go freely for fear the code would be shared with others and/or a confused resident would follow a resident or visitor out the door. During the same interview, RCC-D stated the facility was small and staff were always available to let people out. RCC-D stated she did not believe the facility was treating residents as if they were in a secure unit and believed the intent of the regulation pertained to a unit, not a facility. RCC-D stated, This isn't a specialty unit; we see it as a skilled facility where we are keeping residents safe, adding, We are not limiting the ability of residents to get out, we are ensuring we are providing adequate supervision. The administrator stated, We need to know who is outside, we worry about the cornfields as much as the ravines. With regard to concerns expressed by R39 about being not being able to freely leave the facility when desired, the administrator stated R39 had been in a wheelchair and had not been able-bodied to leave the facility. The administrator stated the facility did not utilize a wander or elopement management system. On [DATE] at 8:41 a.m., during a telephone interview, the medical director stated they were not aware the facility doors were locked in a manner that prevented residents from independently leaving the building. The medical director stated they would expect to be informed if residents did not have the ability to leave the building freely. The medical director stated an individualized assessment should be completed for each resident, including evaluation of elopement risk, cognitive status, physical ability, and decision-making capacity, to determine whether the resident could safely leave the building independently or required supervision. The medical director stated if a resident did not demonstrate an elopement risk and had the ability to safely leave, the expectation would be that the resident could do so without restriction. The medical director further stated that if the facility restricted a resident's ability to leave, there should be clear documentation supporting the rationale, including clinical assessment findings, care planning interventions, and, when appropriate, physician involvement or orders. The medical director stated the determination of safety versus resident rights must be individualized, and one generalized safety concern could not be applied to all residents. The medical director emphasized that without individualized assessment and supporting documentation, restricting all residents from leaving the building would not be appropriate. Facility policy on resident seclusion was requested. In an email dated [DATE] at 2:37 p.m., RCC-D indicated the facility did not have a policy on seclusion. Facility Resident Rights policy, dated 2025, indicated residents had the right to be treated with respect and dignity, including: the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Residents had a right to a safe, clean, comfortable and homelike environment. Facility Accident and Supervision policy dated 2/2023, indicated the facility would establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Process included: 1) Identification of Hazards and Risks - the process through which the facility became aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. 2) Evaluation and Analysis - the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. 3) Supervision was an intervention and a means of mitigating accident risk. The facility would provide adequate supervision to prevent accidents. Adequacy of supervision was defined by type and frequency and based on the individual resident's assessed needs and identified hazards in the resident environment. Facility Elopement and Wandering Residents policy dated 2024, indicated the facility ensured residents who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility was equipped with door locks/alarms to help avoid elopements. Alarms were not a replacement for necessary supervision. Staff were to be vigilant in responding to alarms in a timely manner. The facility would establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Facility Outdoor Safety policy dated [DATE], indicated it was the policy of the facility to provide a safe and healthy environment for residents. All residents were allowed and encouraged to enjoy outdoor activities if mentally and physically able to participate and weather conditions deemed safe. Residents were only allowed to participate in outside activities under specific conditions including the resident had been assessed to determine whether they were physically and cognitively safe to be out without supervision or whether they required supervision. If supervision was required, residents were to remain on the patio just outside the main entrance door or the enclosed area outside the activities office. If assessments indicated a resident was safe for outdoor activity independently, they must remain on sidewalks, patio, or enclosed area outside the activities office.

Based on observation, interview and document review, the facility failed to follow provider orders for wound care dressing changes for 1 of 1 resident (R4) reviewed for pressure injury.Findings include:R4's face sheet provided on 4/22/26, included diagnoses of paraplegia (paralysis causing impairment of motor sensory function of lower extremities) and pressure ulcers to right and left buttock.R4's annual Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. No behaviors. Pressure ulcer to sacral region. Independent with most activities of daily living. Mobility per motorized wheelchair.R4's provider orders dated 4/22/26, indicated: sacrum dressing: cleanse coccyx with wound cleanser. Place calcium alginate (absorbent dressing used primarily for managing exudate in wounds) in wound bed. Place barrier cream around peri-wound. Cover with ABD (abdominal pad) and tape down. Two times a day, start 4/22/26.R4's care plan dated 11/23/21, indicated R4 had a pressure injury stage 4 to coccyx, and that R4's pressure injuries would show signs of healing and remain free from infection by/through review date of 6/17/26. R4 requested his bed as flat as possible to reduce shear and preferred to be repositioned independently. Care plan with revised date of 4/21/23, indicated staff to administer treatments as ordered and monitor for effectiveness. Provide treatment at times requested by resident. R4 preferred to sleep in every day.R4 was seen by wound care provider on 4/21/26, with subsequent note documented at 3:38 p.m.:Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Stage 4, full thickness skin and tissue loss. Wound was present on admission. No signs and symptoms of infection.Measurements: Length 10.18 cm (centimeters). Width 9.6 cm. Depth 0 cm. Area (cm2): 72.33 cm.Exudate amount: Moderate. Seropurulent: mixture of purulent and serous. Nursing progress note dated 4/22/26 at 12:52 p.m., indicated new wound care orders received on 4/21/26: Discontinue previous wound care orders, cleanse coccyx wound BID (twice a day) with wound cleanser, place calcium alginate (absorbent dressing used primarily for managing exudate in wounds) in wound bed, place barrier cream around peri wound, cover with ABD and tape down.During an interview on 4/23/26 at 9:10 a.m., LPN-C was shown R4's treatment administration record (TAR) for the day prior, 4/22/26, which indicated R4's dressing which had been ordered to be changed twice a day had not been changed at all. One space on the TAR was blank and the other indicated the number seven, which LPN-C stated meant R4 had been sleeping. In addition, the TAR indicated a daily dressing change to the coccyx had not been done on 4/15/26. LPN-C verified the dates where a dressing change had not been documented as being done and could not speculate as to why they had not been done. During an interview and observation on 4/23/26 at 9:44 a.m., in R4's room, LPN-C stated generally R4 prioritized his wound care and she was not aware of him refusing dressing changes. LPN-C stated she generally talked to R4 at the start of her shift and the two agreed upon a time to do the dressing change. While LPN-C was preparing supplies for the dressing change, R4 stated his dressing had not been changed since the provider changed it on 4/21/26. R4 stated he didn't know why the nurse on duty had not changed it the evening prior. R4 stated he rarely refused care and did not mind if staff woke him to change his dressing. R4's sacral wound was significant and covered nearly the entirety of both buttocks and was approximately the size of a woman's hand. Minimal exudate observed, flesh and pink in color. No odor. LPN-C changed the dressing according to the orders. During an interview on 4/23/26 at 1:02 p.m., regional clinical consultant (RCC)-D was informed a twice a day dressing changes had not been done at all on 4/22/26. RCC-D stated she would have expected staff to have completed dressing changes on 4/22/26, as ordered by the provider, and especially since the provider changed the wound care orders on 4/21/26, potentially indicating previous orders were not effective. During a telephone interview on 4/23/26 at 3:48 p.m., advanced practice registered nurse (APRN)-F was informed after his visit to R4 on 4/21/26, and changing the R4's dressing change orders, R4's dressing had not been changed until today, 4/23/26. APRN-F stated he expected staff to perform R4's dressing changes as ordered. APRN-F stated he changed the order because R4 had been having problems with his skin from the Mepilex (a dressing with absorbent foam and an adhesive border) so he changed the order to cloth tape. In addition, APRN-F stated he added calcium alginate to the dressing change orders to absorb more of the drainage, adding R4's wound had seemed to plateau in healing, and therefore, Important to stay on top of it.Facility Wound Treatment Management policy dated 2023, indicated to promote wound healing of various types of wounds, it was the policy of the facility to provide evidence -based treatments in accordance with current standards of practice and physician orders. Wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Treatments would be documented on the treatment administration record.

Based on interview and document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 2 of 5 residents (R8, R28) reviewed for unnecessary medications.Findings include:R28's face sheet received on 4/23/26, included diagnoses of wedge compression fracture of lumbar vertebrae, hypertension, dependence on renal dialysis, hyperlipidemia (high levels of fat in the blood), depression, diabetes, congestive heart failure (heart not able to pump enough blood) and anemia. R28's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated her brief interview for mental status (BIMS) was 99, indicating the cognitive interview was not able to be completed. R28 had clear speech, could understand and be understood. Behaviors included rejection of care and verbal behaviors directed towards others. R28 was dependent upon staff for activities of daily living (ADLs) and didn't walk. R28's orders included 28 medications. R28's care plan identified diagnoses and problem areas with goals and interventions. Record review indicated monthly pharmacy reviews had been conducted from 6/13/25 through 4/21/26. Pharmacist recommendations were indicated for the following nine months: 6/13/25, 8/11/25, 10/13/25, 11/10/25, 12/5/25, plus waiting for response to previous recommendation, 1/10/26, 2/6/26, 3/9/26, plus waiting for response to previous recommendation, and 4/21/26. Requested copies of pharmacy recommendation with provider responses for each of the months. Of the nine months, only one recommendation with a provider response was provided for 10/13/25. R8's face sheet provided on 4/23/26, included diagnoses of Alzheimer's disease and dementia.R8's annual MDS assessment dated [DATE], indicated serve cognitive impairment, unclear speech, rarely/never understood and rarely/never understands. R8 was dependent upon staff for ADLs and did not walk. R8 was receiving hospice care.R8's orders included eight medications. R8's care plan identified diagnoses and problem areas with goals and interventions. Record review indicated monthly pharmacy reviews had been conducted from 6/13/25 through 4/21/26. Pharmacist recommendations were indicated for the following four months: 6/13/25, 9/11/25, 12/5/25, and 3/9/26. Requested copies of pharmacy recommendation with provider responses for each of the months and none were received. During an interview on 4/22/26 at 12:20 p.m., the regional clinical consultant (RCC)-D stated she did not believe they would find any more recommendations with provider responses than what had already been provided. The process was the responsibility of the interim director of nursing (DON). During a telephone interview on 4/22/26 at 12:30 p.m., the consultant pharmacist (CP)-E stated getting pharmacy recommendations with a provider response back from the facility was an ongoing issue. CP-E stated she had brought it up at QAPI (quality assurance and performance improvement) meetings and the medical director was aware. CP-E stated there had been a significant number of staff changes which likely contributed to the lack of sustained improvement. CP-E stated the interim DON informed her he would develop a process and create a binder, but CP-E had not seen that happen. During an interview on 4/23/26 at 11:36 p.m., the interim DON stated pharmacy sent the recommendations to him and he put them in the provider folder at the desk for providers to review and sign. He believed the providers gave the recommendations to the nurses when complete and, The nurses took care of them. After that, the interim DON stated the forms were scanned into the electronic medical record (EMR). The interim DON admitted he did not follow through to ensure the recommendations were address by providers, implemented, and the completed forms scanned into the EMR. Regarding R28's recommendations with provider responses, the interim DON stated he had looked for those and couldn't find them. During a telephone interview on 4/23/26 at 11:38 a.m., the medical director (MD)-C stated pharmacy recommendation reports had been talked about at QAPI and in May 2025, the facility had created a new process to ensure compliance but it had not been sustained as a result of transitions in nursing leadership. Facility Medication Regime Policy dated 2024, indicated the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist and included a review of the resident's medical chart. The pharmacist communicated any irregularities to the facility in the following ways: 1) Verbal communication to the attending physician, Director of Nursing, and/or staff of any urgent needs. 2) Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on interview and document review, the facility failed to ensure medications were coded accurately on the Minimum Data Set (MDS) assessments for 2 of 5 residents (R11 and R29) reviewed for unnecessary medications.Findings include:R11's face sheet printed 4/22/26, indicated diagnoses of type two diabetes with complications, alcohol abuse, and weakness.R11's quarterly MDS dated [DATE], indicated intact cognition, no rejection of care, use of wheelchair, independent with dressing and hygiene, and section N identified R11 took an anticoagulant.R11's physician's orders printed 4/22/26, did not include an anticoagulant but did include and order for aspirin oral capsule 81mg by mouth one time a day.R11's care plan revised 4/16/26, did not include mention of an anticoagulant medication.R29's face sheet printed 4/22/26, indicated diagnoses of chronic respiratory failure, repeated falls, and systolic heart failure.R29's quarterly MDS dated [DATE], indicated intact cognition, rejection of care one to three days, use of wheelchair, partial assistance with hygiene, substantial assistance with lower body dressing, and section N identified R29 took an anticoagulant.R29's physician's orders printed 4/22/26, included an order for aspirin oral tablet delayed release 81mg by mouth one time a day, but did not include an order for an anticoagulant medication.R29's care plan revised 4/7/26, did not include mention of an anticoagulant medication.During interview on 4/21/26 at 9:29 a.m., registered nurse (RN)-A stated she thought the aspiri taken by both R11 and R29 could be counted as an anticoagulant medication on the MDS assessment. RN-A stated she would clarify with the person who trained her. After clarification, RN-A stated aspirin should be coded as an antiplatelet medication, not an anticoagulant medication. RN-A further stated the MDS was coded incorrectly and she would submit corrections.During interview on 4/22/25 at 2:08 p.m., interim director of nursing stated he would expect the MDS to be coded correctly based on the resident assessment instrument (RAI) directions to ensure accurate representation of resident needs.Facility Conducting an Accurate Resident Assessment policy dated 1/2026, stated accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status using the appropriate RAI instructions.

Based on observation, interview and document review, the facility failed to report elevated blood glucose levels per provider order for 1 of 1 residents (R5) reviewed for insulin. In addition, the facility failed to calibrate blood glucose monitors according to manufacturer instructions for 1 of 1 residents (R5) reviewed for insulin. Further, the facility failed to ensure monitoring of skin wounds for 1 of 1 resident (R22) reviewed for non-pressure skin conditions. Findings include: ELEVATED BLOOD GLUCOSE AND CALIBRATION OF MONITOR R5's face sheet received on 4/22/26, included diagnoses of diabetes with hyperglycemia (elevated blood sugar). R5's annual Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R5 was independent with most activities of daily living, did not walk and could propel wheelchair independently. R5's provider order dated 7/31/25, indicated blood sugar checks two times a day. Order dated 6/21/21, indicated staff were to notify provider if BS (blood sugar) was <70 or >400. R5's care plan dated 8/16/21, indicated R5 had diabetes and his blood sugars would remain within normal limits through next review. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of R5's electronic medical record (EMR) indicated in March and April 2026, two of R5's fingerstick blood sugars had been in excess of 400 mg (milligram)/dl (deciliter) without documentation that a provider had been notified. On 3/31/26 at 9:00 a.m., blood sugar had been 536 mg/dl On 4/3/26 at 4:40 p.m., blood sugar had been 421 mg/dl A provider note dated 3/17/26, (prior to documentation of the elevated blood sugars) indicated R5 had presented for evaluation of type 2 diabetes. Recent A1c (blood test that measures average blood sugar levels over the past two or three months) was 8.8% (normal = 5.7%). Minor adjustments to diabetes medications had been made and R5 would continue to be monitored closely. During an interview on 4/23/26 at 10:30 a.m., regional clinical consultant (RCC)-D looked in R5's EMR and verified the two blood sugars greater than 400 mg/dl. RCC-D also verified there had not been an order for a sliding scale (where insulin dosages were adjusted based on blood sugar levels), nor had there been documentation nursing staff notified a provider of the blood sugars greater than 400 mg/dl. RCC-D stated she would have expected nursing staff to follow provider orders, inform the provider of the elevated blood sugars and potentially receive new orders. Further, RCC-D was informed nursing staff did not know if glucometers were being calibrated per manufacturer instructions, something that would be considered with abnormally high blood sugars checks. RCC-D stated she would expect glucometers to be calibrated and would check on it. At 10:41 a.m., RCC-D stated she could not see evidence glucometers where being calibrated. During an interview on 4/23/26 at 10:45 a.m., trained medication aide (TMA)-A stated she did not know anything about glucometer calibration. During an interview on 4/23/26 at 12:10 a.m., licensed practical nurse (LPN)-B who had earlier stated she did not think glucometers were calibrated, obtained R5's glucometer from the medication cart and the brand was Arkray Assure Platinum. Together with LPN-B, looked in medication room for evidence glucometers had been calibrated. LPN-B found unopened boxes of control solutions with expiration dates of 2027, but no binder or other documentation that indicated calibration was being done. During a telephone interview on 4/23/26 at 3:13 p.m., licensed practical nurse (LPN)-A recalled R5's blood sugar greater than 500 mg/dl at the end of March. LPN-A admitted she did not call the provider to notify him, but may have sent the provider an electronic message, however, could not say for certain. LPN-A acknowledged the importance of following provider orders and notifying a provider with a significantly elevated blood sugar to allow the provider to make medication adjustments if necessary. During a telephone interview on 4/23/26 at 3:48 p.m., advanced practice registered nurse (APRN)-F did not recall being informed of R5's elevated blood sugars greater than 400 mg/dl in March and April. APRN-F stated the reason it was good to be notified for anything over 400 mg/dl was so action could be taken, such as a one-time dose of insulin. Informed there had been an order to inform the provider of blood sugars great than 400 mg/dl – he was not aware of that and stated he would expect nursing staff to follow provider orders and/or facility policy. Facility Blood Glucose Monitoring policy dated 2023, indicated the facility would perform blood glucose monitoring as per physician's orders and report critical test results to the physician timely. Calibration checks on glucometers must be performed __________ (this space was left blank) as per manufacturer's instructions. Manufacturer Instructions: The Quality Assurance/Quality Control Reference Manual with revised date of 10/24, found on website (Assure Platinum Blood Glucose Meter - ARKRAY USA, Inc.) for the Arkray Assure Platinum glucometer, indicated, the user should check meter and test strips using Assure Dose Control Solutions (Normal-Level 1 and High-Level 2) to confirm the meter and test strips are working properly, or to check if testing correctly. Assure Dose Control Solutions contain known amounts of glucose and are used to check that the meter and the test strips are working properly. The test strip bottles have Assure Dose Control Solution ranges printed on the labels. Compare the result displayed on the meter to the Assure Dose Control Solution range printed on the test strip bottle. Before using a new meter or a new bottle of test strips, conduct a control solution test following the procedure with two different levels of control solutions (Normal-Level 1 and High-Level 2). USE CONTROL SOLUTION To test technique. Before testing with the meter for the first time. When opening a new bottle of test strips. When suspecting the meter or test strips may not be functioning properly. If the test results appear to be abnormally high or low or are not consistent with clinical symptoms. When the meter has been dropped or stored below 32ºF (0ºC) or above 122ºF (50ºC). The test strip bottle has been left open or has been exposed to light, temperatures below 39 degrees F (4 degrees C) or above 86 degrees F (30 degrees C), or humidity levels above 80%. Each time the batteries are changed. NON-PRESSURE SKIN CONDITION R22's face sheet printed 4/22/26, indicated diagnoses of mild cognitive impairment, weakness, mood disorder, and excoriation skin-picking disorder. R22's annual MDS assessment dated [DATE], indicated intact cognition, no behaviors or rejection of care, use of wheelchair, dependent for personal hygiene and dressing, and no pressure ulcers, open lesions, or wounds. R22's physician's order dated 3/8/25, indicated weekly skin review on bath day every Sunday. R22's care plan printed 4/22/26, indicated potential for impairment to skin integrity related to obesity with goal of maintaining intact skin by review date. Apply medications as directed when ordered for skin treatments. Keep skin clean and dry. Use lotion on dry skin. Do not use wet wipes. During observation and interview on 4/20/26 at 3:11 p.m., R22 was awake in her bed. R22 had four small scabs (0.1cm to 0.4cm) and 3 scabs (0.3cm to 0.6cm) on her left arm. R22 had one larger scab (0.7cm) on her right arm that she was actively picking open. R22 stated nurses did not check on her scabs, put medication on them, or ask her what they were from. R22 stated she always had scabs. R22's weekly bath audits dated 4/5/26 and 4/12/26, indicated no skin alterations or open areas, other than wound to coccyx. During interview on 4/22/26 at 11:59 a.m., TMA-B stated she was aware of R22's skin-picking and her multiple scabs. TMA-B stated she thought they used to monitor the scabs and document it on the treatment record, but they no longer did that. TMA-B stated they used to use a cream on her scabs but she didn't see that ordered anymore either. TMA-B stated those areas would normally be documented and monitored on weekly bath audits but she did not see them documented for R22. During interview on 4/22/26 at 12:07 p.m., LPN-C stated R22 had a bath on 4/19/26, and she didn't see that R22's scabs were documented or assessed at that time. LPN-C stated she did not see any monitoring or treatment for R22's scabs on her physician's orders. During interview on 4/22/26 at 12:32 p.m., interim director of nursing (DON) stated he was aware of R22's skin-picking diagnosis but was not sure if they were monitoring or treating her scabs. DON stated he didn't think they were doing anything for the scabs. DON stated if R22 had wounds from skin-picking he would expect them to be monitored for signs of infection and worsening to prevent future injury or illness for R22. Facility Skin Assessment policy printed 4/22/26, indicated a full body skin assessment will be conducted by a licensed or registered nurse upon admission/readmission, daily for three, and weekly thereafter. Documentation of skin assessment: document observation, types of wounds, other information as indicated.

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day for 5 of 7 days reviewed. This had the potential to affect all 34 residents living in the facility.Findings include:Review of nursing schedule in the last 30 days identified no registered nurse (RN) had been scheduled on 3/15/26, 3/16/26, and 4/5/26.On 4/22/26 at 11:54 a.m., the administrator stated the facility had obtained a waiver for RN coverage and the facility was currently working on filling the RN positions and actively recruiting RN staff and offering incentives. During the interview the administrator stated the facility was using agency nursing staff to fill the RN coverage, was actively hiring RN's, was aware not all days had a scheduled RN, and confirmed the facility had a waiver. The administrator stated finding RN's in a rural area was difficult and the facility was competing with other facilities such as homecare, hospice, and hospitals.

Based on record review and interviews, the facility failed to ensure all required data were included on the nurse staffing information posted daily. This had the potential to affect all 35 residents residing in the facility and their visitors who may wish to view the information. Findings include: The Facility's PBJ Staffing report 1705D dated quarter 1 2025 October 1st-December 31st, indicated the facility had triggered the following staffing concerns: 1. One star staffing rating. 2. Excessively low weekend staffing. 3. No RN hours. The staff schedule and posting documentation dated from October 2024 through May 2025, was reviewed and the following dates failed to include any or all of the following requirements for the daily staff posting: 1. Facility name. 2. Current date. 3. Facility Census. 4. Total number and actual hours worked by licensed staff. 5. Total number of licensed staff, and their designation or title. October 2024: 10/5/24, 10/12/24,10/13/24, 10/15/24,10/19/24, 10/20/24, 10/24/24, 10/28/24 December 2024: 12/19/24, 12/31/24 February 2025: 2/6/25, 2/17/25, 2/23/25, 2/24/25 March 2025: 3/2/25, 3/3/25, 3/9/25, 3/1025, 3/16/25, 3/17/25, 3/23/25, 3/24/25, 3/3025, 3/31/25 April 2025: 4/6/25, 4/7/25, 4/13/25, 4/14/25, 4/16/25 through 4/30/25. May 2025: 5/1/25 through 5/16/25, and 5/18/25 through 5/28/25. On 5/28/25 at 9:59 a.m., the administrator and the health unit coordinator (HUC) stated the HUC prepared the staff posting and the night nurses were responsible for listing any staff changes, and posting it in the morning. The administrator and the HUC stated they believed the posting was required to have the name of the facility, census, name of staff, the shift they worked, and the hours they worked. The administrator and the HUC confirmed the above listed staff postings were missing some or all of the required information. The administrator stated the importance of posting all of the correct information, so the facility and residents were aware of how many staff were working. A staff posting policy was requested and none was provided.

Based on observation, interview and document review the facility failed to ensure dishwasher temperatures were within the manufactures minimum temperatures to ensure resident dishes were sanitized. In addition, the facility failed to ensure temperatures were monitored in 4 of 4 refrigerators and 2 of 2 freezers reviewed for the kitchen. This had the potential to affect all 35 residents who resided in the facility. Findings include: On 5/18/25 at 1:50 p.m., during the initial walk through of the kitchen the dishwashing machine was being used by a nursing assistant (NA)-A, the machine was labeled a [NAME] Temp star Dishwasher with temperature requirements as follows: wash temperature 150 degrees Fahrenheit (F), and rinse temperature of 180 degrees F. The actual temperatures observed were as follows: 1. 2:02 p.m., wash -165 degrees F, rinse -170 degrees F 2. 2:03 p.m., wash -164 degrees F, rinse -168 degrees F 3. 2:04 p.m., wash -165 degrees F, rinse -170 degrees F 4. 2:05 p.m., wash -154 degrees F, rinse -160 degrees F NA-A confirmed the temperatures for the rinse were not reaching the required 180 degrees F, and stated they were responsible for checking the machines temperatures were within range each mealtime or at least three times a day. NA-A confirmed they had conducted the temperature check when they arrived to work, and it had been working correctly. However, had not noticed the low temperatures until they were pointed out by surveyor. NA-A then notified their supervisor unprompted, and stated they would use paper material until the machine could be repaired. On 5/18/25 at 2:08 p.m. the certified dietary manager (CDM) arrived onsite and confirmed the dishwasher was not reaching the required temperatures and stated maintenance had been updated and confirmed they would be using paper products until the issue had been resolved, which was confirmed by observation at the next meal time. The [NAME] Warewashing Systems: Tempstar series installation, operation, and service manual last revised 11/30/15, indicated the facility's machine was a Tempstar S Steam Heated Model with the follow minimum temperature requirements: 1. Wash temperature (minimum): 150 degrees F 2. Rinse temperature (minimum): 180 degrees F On 5/21/25 at 1:12 p.m., the maintenance director (M)-A stated the machine had maintenance conducted on 4/30/25 and had been in working order since then. The refrigerator and freezer temperature logs were reviewed from March through May for the 2 freezers, and 4 refrigerators in the kitchen. The logs information showed the following: 1. Small Freezer: a. March: 15/62 opportunities were documented. b. April: 40/60 opportunities were documented. c. May: 21/44 opportunities were documented. 2. Big Freezer a. March: 14/62 opportunities were documented. b. April: 36/60 opportunities were documented. c. May: 20/44 opportunities were documented. 3. Refrigerator Number 2: a. March: 12/62 opportunities were documented. b. April: 38/60 opportunities were documented. c. May: 23/44 opportunities were documented. 4. Refrigerator Number 3: a. March: 13/62 opportunities were documented. b. April: 41/60 opportunities were documented. c. May: 21/44 opportunities were documented. 5. Refrigerator Number 4: a. March: a March log was requested for refrigerator number 4; however, none was provided. b. April: 41/60 opportunities were documented. c. May: 21/44 opportunities were documented. 6. Refrigerator Number 5: a. March: 13/62 opportunities were documented. b. April: 42/60 opportunities were documented. c. May: 23/44 opportunities were documented. On 5/22/25 at 10:03 a.m., the CDM stated their expectation was for the dishwasher wash cycle to meet 150 degrees F and the rinse cycle to meet 180 degrees F, and it was important to ensure the dishwasher was functioning properly, so all of the items were sanitized properly. Furthermore, the CDM confirmed the four refrigerator logs, and two freezer logs were missing information. The CDM stated the cooks were typically responsible for completing them, and they were expected to be done in the morning and the evening, and it was important to store food appropriately and keep the food safe. On 5/22/25 at 10:05 a.m., the administrator stated they expected the dishwasher to be meeting manufacturers temperature requirements, and it was important to ensure the safety of the residents and proper sanitation of the dishes. Furthermore, they expected the refrigerator and freezer temperature logs to be completed daily, and it was important to ensure the safety of the food they are giving the residents. The facility Dishwashing Machine Use policy revised march of 2010, indicated dishwashing machines that use hot water to sanitize must maintain the following wash solution temperatures: 150 degrees F and dishwashing machines that use hot water sanitation rinse may not be more than 194 degrees F or less than 180 degrees F. The facility Refrigerators and Freezers policy last revised 2014, indicated food service supervisors or designated employee will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.

I'm not sure if this is correct, I used other surveyors tags as guidiance, and their tag from last year. Let me know if you want me to change anything. Based on interview and document review the facility failed to ensure a registered nurse (RN) was scheduled for at least 8 consecutive hours a day, seven days a week. This had the potential to affect at 35 residents who reside in the facility. Findings include: The Facility's PBJ Staffing report 1705D dated quarter 1 2025 October 1st-Decemeber 31st, indicated the facility had triggered the following staffing concerns: 1. One star staffing rating. 2. Excessively low weekend staffing. 3. No RN hours. Review of the facility's license staff schedule for May 10th, 2025, and May 24th, 2025, confirmed they was no consecutive eight hours of RN coverage in the facility. The Daily Timecards Log dated 5/6/25 -5/10/25, listed punch in and outs times for licensed employees from 5/6/25 -5/10/25, and 5/23/25-5/26/25. These logs confirmed there was no RN coverage on 5/10/25, and 5/24/25. On 5/28/25 at 9:59a.m., the administrator and health unit coordinator (HUC) stated both were responsible for and completed the schedule. They attempt to conduct block scheduling when possible and have been struggling with call ins for scheduled shifts. On an average day they aim to have one charge nurse, 2-trained medication administrators (TMA), 2-3 nursing assistants, and on nights 1-2 nurses, and 1-2 aides. The administrator and HUC confirmed they attempt to check and verify they have RN coverage by reviewing the schedule and time cards, however they confirmed sometimes it did not happen. The Administration confirmed they did not have consecutive RN coverage on 5/10/25 and 5/24/25. Furthermore, the administrator stated it was important to have RN coverage in the facility because it was a requirement of skilled nursing. A Staffing policy was requested, and none was provided.

Based on interview, observation, and document review the facility failed to thoroughly investigate falls, establish adequate fall prevention interventions, and follow care planned fall interventions for 2 of 3 residents (R1 and R5) reviewed for falls. This resulted in actual harm when R1 fell and required a visit to the emergency department resulting in a fractured left tenth rib. Findings include: R1's Face Sheet dated 9/30/24, indicated R1 had hemiplegia affecting her right dominant side, dementia, disorientation, and muscle weakness. R1's Fall Risk assessment dated [DATE], indicated R1 was a high risk for falls. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, had two or more falls without injury, and needed limited assistance with transfers, toilet use, and bed mobility. R1's care plan undated, indicated R1 was at high risk for falls and to ensure R1 was wearing appropriate footwear: non-skid socks or tennis shoes when ambulating or mobilizing in wheelchair. Other interventions included to educate R1 not to stand without assistance, anticipate needs, ensure call light was within reach, encourage call light usage, prompt response to all requests for assistance, and therapy would evaluate and treat as ordered. R1's unwitnessed fall document dated 12/20/24, indicated R1 was found on the floor next to her wheelchair due to trying to self-transfer to the bathroom. No interventions were identified on the document. R1's witnessed fall document dated 2/4/25, indicated R1 had fallen trying to stand from wheelchair alone. No interventions were identified on the document. R1's unwitnessed fall document dated 2/27/25, indicated R1 had fallen from her wheelchair when trying to stand alone. Intervention indicated R1 was re-educated not to stand up alone. R1's progress note dated 3/22/25 at 6:34 a.m., indicated R1 had fallen as she was trying to use the bathroom at 5:15 a.m., with no injury noted. R1's progress note dated 3/22/25 at 10:00 a.m., indicated R1 was crying in pain at her left lower rib and left hip area. R1 was sent to the emergency department for evaluation. R1's progress note dated 3/22/25 at 1:43 p.m., indicated R1 had a nondisplaced tenth left rib fracture. R1's investigation report undated, indicated R1 would have a call don't fall sign placed in room, care plan would be updated, and staff would be educated on call light times and anticipating the needs of residents who are at risk for falls. R1's care sheet undated, lacked any fall interventions. R1's medical record lacked IDT review, root cause analysis, or appropriate fall interventions after each fall. R5's Face Sheet dated 1/17/23, indicated R1 has Alzheimer's disease, dementia, mild neurocognitive disorder, and muscle weakness. R5's fall risk assessment dated [DATE], indicated R1 was at high risk for falls. R5's significant change MDS dated [DATE], indicated R5's memory was not assessed, had 2 or more falls with no injury, and one fall with minor injury. R1 needed extensive assistance with toileting. R5's care plan dated 1/17/23, indicated R1 was at moderate risk for falls. Interventions included anticipate residents needs, currently on hospice to manage end of life care, wear appropriate footwear such as rubber soled skid- free shoes, slippers, or non skid socks when ambulating. R5's unwitnessed fall document dated 3/9/35, indicated R1 missed his chair when attempting to sit down and fell . No interventions were identified on the document. R5's witnessed fall document dated 3/19/25, indicated R1 slid out of his wheelchair and was on the floor. No interventions were identified on the document. R5's fall with suspected head injury document dated 3/29/25 at 12:00 a.m., indicated R1 was found on the floor next to his bed with bowel movement in his brief. Had an injury to the top of his scalp. No interventions were identified on the document. R5's unwitnessed fall dated 3/29/25 at 2:40 a.m., R1 was found on the floor next to his bed. No interventions were identified on the document. R5's care sheet undated, lacked any fall interventions. R5's medical record lacked IDT review, root cause analysis, or appropriate fall interventions after each fall. During an observation on 4/2/25 at 11:18 a.m., R1 did not have a call don't fall sign in her room. During an observation on 4/3/25 at 8:29 a.m., R1 was in the common area with blue star socks on that did not have grip on the bottoms of them and no shoes on. During an interview on 4/3/25 at 8:40 a.m., nursing assistant (NA)-A stated residents fall interventions would be on the resident care sheets or care plans. NA-A stated she was not aware of what the current interventions were for R1 or R5. On 4/3/25 at 9:10 a.m., NA-B stated fall interventions for R1 and R5 were on the care sheet NA-B keeps in her pocket. NA-B stated currently there were no fall interventions in place for R1 or R5 according to the care sheets. NA-B stated she was not aware of any fall intervention in place for R1 or R5 at this time. On 4/3/25 at 9:15 a.m., licensed practical nurse (LPN)-A stated she assisted R1 and R5 with cares the morning of 4/3/25 but had not looked at their care plans to see what fall interventions are currently in place. LPN-A stated she put socks on R1 and thought they were gripper socks but was not aware they are not. LPN-A stated R1 should have had gripper socks or shoes on. LPN-A stated there was a process issue with who was responsible for producing interventions after a residents fall. LPN-A stated the director of nursing (DON) and interdisciplinary team (IDT) are the ones who would assign the interventions and put them in the care plans. LPN-A stated she was not sure why interventions had not been put into place after residents had fallen. On 4/3/25 at 10:10 a.m., registered nurse-(RN)-A stated the DON used to be the one who put fall interventions in the care plans, but she was not sure who would be responsible for that now. R1 was expected to have shoes or gripper socks on when she was in her wheelchair. RN-A stated she was not sure why fall interventions were not being put into place or care planned. On 4/3/25 at 10:29 a.m., the DON stated RN-A was expected to update the care plans with fall interventions for R1 and R5. Staff were expected to look at the care plans to find fall interventions. DON stated she was not sure why fall interventions were not being put into place after every fall, but she expected this to be completed. DON stated there were no fall interventions care planned for R1 or R5's falls. On 4/3/25 at 12:20 p.m., the medical director (MD)-A stated he was concerned there were no interventions care planned for R1 and R5 after their falls. MD-A stated he would have expected interventions to be put into place right after the fall. If R1 had interventions in place after prior falls the potential for falls could have been decreased and could have helped prevent her fracture. The facility should have followed the facility policy in regard to falls. The facility Fall Prevention Program policy reviewed 8/2024, indicated when a resident experienced a fall the facility would review and update the care plan as needed and document all assessments and actions. Interventions would be monitored for effectiveness.

Based on interview and document review the facility failed to provide a physician ordered pureed diet for 1 of 1 resident (R3) with a history of dysphasia. This resulted in actual harm for R3 as he R3 choked, was unable to be revived and died as a result. The survey resulted in an immediate jeopardy (IJ) that began on [DATE] at 8:30 p.m., when the facility failed to provide the appropriate physician ordered altered texture diet (pureed). R3 was served a whole Uncrustable brand peanut butter and grape jelly sandwich on wheat bread. R3 began choking and became unresponsive. The licensed nurse performed the [MEDICATION(S)] maneuver until EMS arrived. EMS also attempted to revive R3, but were unsuccessful, R3 died . The director of nursing (DON) was notified of the IJ on [DATE] at 4:08 p.m., which was identified at a scope and severity of J-ISOLATED. The facility had implemented immediate corrective action by [DATE] to prevent recurrence, therefore the IJ was issued at PAST NON-COMPLIANCE. Findings include: Review of the [DATE], report to the State Agency (SA) identified R3 was given an Uncrustable brand sandwich. Staff had reported they sat next to R3 and watched R3 eat the sandwich without problems. Staff assisted R3 back to his room and at that time, R3 collapsed. The charge nurse was immediately contacted and started the [MEDICATION(S)] maneuver on R3. Staff reported some food was removed from R3's mouth, however R3 was unable to be revived. EMS was called and identified R3 as unable to be resuscitated. R3 was pronounced dead. R3's [DATE], physician hospital discharge orders identified R3 was to resume prior dietary restrictions and swallowing protocols. R3 required dentures and 1 staff limited assistance for eating. R3's discharge ordered diet was International Dysphagia Standardization Initiative (IDDSI) 4 carbohydrate consistent, pureed texture, moderately thick liquids. R3's Order Summary Report reviewed identified R3's diet order had been entered into point click care (PCC) (electronic medical record) on [DATE], which identified R3's diet as Co Cho NAS (consistent carbohydrate or controlled carbohydrate, no added sodium) diet, of pureed texture and thickened liquid of honey consistency. R3's [DATE], admission Minimum Data Set (MDS) assessment identified R3 was admitted on [DATE] from the hospital. R3 had severe cognitive impairment, required 2 staff assistance for cares, was able to eat with staff supervision. R3 had diagnoses of Type 2 diabetes mellitus, and a history of pneumonitis due to inhalation of food and vomit, dysphasia and malignant neoplasm of unspecified part of bronchus or lung. Review of the [DATE], facility investigation summary identified R3 had been given the wrong physician diet by nursing assistant (NA)-A causing R3 to choke. The correct diet for R3 was found to be properly communicated to the staff as well as NA-A. Although attempts to perform the [MEDICATION(S)] maneuver and EMS notified, R3 ultimately passed away. Retraining on safe eating and the importance of providing accurate diets was completed with all staff. All residents diets were reviewed for accuracy along with a review of the communication system was performed. Facility interview with NA-A who responded I thought he would be ok, I didn't think it would be a problem. NA-A reported he had obtained the sandwich from the kitchen and was unsure of what R3's diet was. The investigation also identified other staff on duty at time were able to state what R3's diet texture was and where to find the diet R3 was to receive. Review of [DATE], email from social service designee (SSD) to facility leadership identified a subject was Welcome New Admit. The information provided in the email included R3's name, date of birth, admitted and time, room, physician, original hospital admitted , hospital, diagnosis, COVID-19 vaccination status, orientation, transfer, service, PASRR , discharge goal, and diet which was identified as an IDDSI 3, using moderately thick liquids needs. R3 was noted to require some personal help with feeding, someone to ensure he does not choke . has no teeth. Review of current, undated, International Dysphagia Standardization Initiative (IDDSI) chart, used by the facility for people who have feeding, chewing or swallowing problems identified the levels as: Food level 3=Liquidized as food that can be eaten with a spoon or drunk from a cup it cannot be eaten with a fork because it drips through the fork prongs, has a smooth texture and no lumps, fibers, husk, bits of shell or skin particles of gristle or bone. Level 4=Pureed. Drink level 3= moderately thick (Honey-Thick Liquids). R3's [DATE], Hospital History report identified R3 had history of aspiration pneumonia. R3 had worked with speech therapy who recommended an IDDSI 3- liquidized food, no bread, no straws, and medications were to be given in pureed form. R3's [DATE], Nutritional Assessment identified R3's diet as a carbohydrate consistent, with pureed consistency, and it noted staff were to sit with R3 to assure he did not choke. Observation and interview on [DATE] at 2:29 p.m., with NA-B while NA-B was passing the afternoon snack cart identified on the snack cart was a blue book of diets. NA-B identified the book had a list of all the residents diets and information sheets about textures of each diet listed. She further confirmed the book had been on the snack cart prior to the incident with R3 for a reference. NA-B also stated there was now a list of each resident diets located on each wing in the staff charting station. She stated that there was always a snack cart located in the therapy room for after hours so if a resident was hungry, there were snacks to provide to them. Interview on [DATE] at 2:30 p.m., with trained medication aide (TMA)-A confirmed after R3 had the choking incident all staff had to take the computerized safe eating training. Management reviewed all the resident diets with staff and went over the chart that described the different types of diets. The dietary manager (DM) placed extra copies of the list of each resident's diet in a book on each wing. TMA-A revealed during meal times the dietary staff were responsible for dishing up the correct diet. Nursing was to double check the diet prior to being served. If something did not look right, staff were to stop and question the cook. Interview on [DATE] at 2:44 p.m. with TMA-B identified there was a list of residents and their diets also located in the dining room and on the snack cart. She revealed those diets were now also posted in the staff charting stations on each wing. She confirmed staff had completed training about resident diets, types of diets, and where to find diets on PCC beginning immediately after the incident. Interview on [DATE] at 9:01 a.m., with dietary manager (DM) identified prior to a new admission arriving, social services would send out a welcome email that identified information staff would need to know, including the resident's diet. After the resident arrived, that information was reviewed to make sure no changes were identified. If so, it was immediately updated. The DM reported she double checked the diet orders upon admission, as well as the nurse. The nurse provided the kitchen with a resident's diet slip which she posted in the kitchen. It was also found in the kitchen communication book. She revealed that there was a blue communication book on the snack cart that identified each residents diet at the time of the incident which was correct for R3. Kitchen staff would set up the snack carts and make sure there were items on it for each kind of diet required. Snacks were delivered to the residents around 2:30 p.m. and 7:00 p.m. each day. She revealed R3's correct diet was on the welcome email, in the blue book on the snack cart, on a dietary card, and on PCC prior to R3's choking incident. She confirmed she went around to each staff after the incident and made sure they knew how to find each resident's diet on PCC. Interview on [DATE] at 9:31 a.m., with registered nurse (RN)-A identified he was the nurse on duty that evening. Staff called him over the radio and he immediately went to R3's room to find R3 unconscious and slumped over. NA-A reported to RN-A that he had feed R3 in the dining room area and then assisted R3 back to his room. Once in his room, he slumped over. RN-A stated he initiated the [MEDICATION(S)] maneuver while another staff called 911. He continued providing the [MEDICATION(S)] until emergency services (EMS) arrived. He stated he was able to get some food out of R3's mouth however, by the time EMS arrived R3 had no pulse. He identified NA-A had given R3 the wrong diet. Following the incident, all staff had to complete training on diets including himself as contracted staff working in the facility. Interview on [DATE] at 11:08 a.m., with SSD identified she had been notified the evening of the incident and came into the facility. She along with the IDON interviewed NA-A, RN-A, and NA-C. Interview with NA-A confirmed he had provided R3 with the Uncrustable whole peanut butter and jelly sandwich and sat with R3 the entire time he was eating. After R3 was done NA-A assisted him back to his room and it was then when R3 slumped over. NA-A reported he called the charge nurse who did the [MEDICATION(S)] maneuver and a chunk of food came out. The SSD revealed it was her understanding through interviews with staff, R3 had been hungry prior to the incident, so NA-A went to the kitchen to get him a sandwich. NA-A reported denying knowing R3's ordered diet and fed him the whole sandwich. Resident's diets are identified prior to admission, are placed on diet cards, and noted in PCC. The facility normally received information prior to admission that identified the ordered diet, but staff always confirmed diets when the resident was admitted as sometimes orders were known to have been recently changed. The IDON notified the SSD NA-A was suspended during the investigation. Interview on [DATE] at 11:24 a.m., with nurse practitioner (NP)-A identified she had met R3 the Thursday prior to the incident. NP-A revealed she had been notified of the incident and had been told that R3 had been given a whole peanut butter and jelly sandwich. The NP noted that was the wrong diet. R3 started to choke after he was brought back to his room. The licensed nurse was summoned to the room and started the [MEDICATION(S)] maneuver and continued until the EMS arrived. The [MEDICATION(S)] maneuver was unsuccessful and R3 was unable to be resuscitated. NP-A revealed in her professional opinion, if R3 had been given the correct diet consistency of pureed texture he would not have choked. She confirmed that R3's diet at the time of admission was a pureed diet. She revealed she was advised by the facility, NA-A never really answered why he gave [R3] the sandwich, other than he thought it would be okay from her understanding. R3's diet information was available. NA-A should have confirmed R3's ordered diet before giving R3 a snack item. Staff had been retrained, including herself, on all the resident diets, where to find the diet information for residents, and different types of diets. She confirmed the facility had tools in place already and the staff had just not followed the process. Interview on [DATE] at 11:54 with the interim director of nursing (IDON) identified she had been called by the registered nurse (RN)-A that there had been an incident and 911 had been called following R3 choking. RN-A had reported to her that he had done the [MEDICATION(S)] maneuver after R3 had been given an Uncrustable sandwich by NA-A and subsequently choked. She had instructed RN-A to keep NA-A away from all residents until she arrived to interview him. Upon interview, NA-A revealed e had gone directly into the kitchen to obtain the sandwich that was provided to R3 which was not standard protocol. Staff were to obtain dietary items from the snack carts provided. NA-A should have known R3's diet as the diet was clearly communicated to all staff in the Welcome letter, on the diet slip, on the tray cards, and by a book located at each nurse aide kiosk. There was also a resident diet book on the snack cart. NA-A was suspended and told he would be contacted for additional information at a later time. All staff were retrained on diets. The dietary manager also went to all staff to ensure they knew how to access resident's diet on PCC. All staff also competed the online training for safe eating. The IDON revealed NA-A had recently taken the nurse aide course and would have received education on special diets during that CNA course. She noted, had R3 received the correct diet, he most likely would not have choked. She stated this was a terrible accident and she did not know why NA-A thought it would be okay to give him a whole sandwich. Interview on [DATE] at 1:00 p.m., medical director (MD) identified he was notified staff had given the wrong diet to R3. The expectation would be that if staff were unsure of a residents diet, they were to verify the diet before providing food for consumption. The MD revealed R3 cause of death likely resulted from choking. He confirmed R3's diet was to be pureed texture and receiving a diet that was not prescribed to him would have increased his risk for choking. Interview on [DATE] at 11:43 with NA-A confirmed R3 had been given the whole peanut butter and jelly sandwich during evening snack time. NA-A revealed he knew R3's diet was an IDDSI 3 as it was listed on the Welcome letter that came out when R3 was admitted . He denied knowing where to find a residents diet other than on the sheet that came out when they came. NA-A reported he knew a IDDSI 3 diet was for soft food as there was a sheet that showed normally he worked nights and did not do much with diets. He reported he sat with R3 while he ate, then took him back to his room and that was when he slumped over. RN-A was summoned immediately and started the [MEDICATION(S)] maneuver. He confirmed RN-A did the [MEDICATION(S)] maneuver until the EMS arrived. NA-A denied ever seeing a book with resident diets on the snack cart. NA-A did report normally residents have pictures next to their name on their door if they have thickened liquids or something but [R3] did not have any sign on his door. Review of [DATE], Admission Criteria policy identified prior to admission the facility was to provide a physician ordered diet for immediate resident care. Review of [DATE], Therapeutic Diets policy identified resident diets would be prescribed by the residents provider. If a mechanically altered diet was ordered it would include the type of texture modification. Compatible snacks for therapeutic diets will be provided. The immediate jeopardy (IJ) that began on [DATE] at 8:30 p.m., was removed by [DATE], prior to survey when it was verified by observation, interview, and document review, the facility took steps to remove the immediacy by ensuring education had been provided to all staff related to providing the correct diet to all residents. All staff were retrained to find each resident's diet order on point click care (PCC), how to read the meal ticket, and snack cart hard copy of the residents dining orders which included diet, texture, consistency of liquids, adaptive devices, allergies and preferences. Staff were also retrained on different types of diets, and reviewed existing policies. All staff took the online training for safe eating. The kitchen was now locked beginning after the incident during non-service times when no dietary staff were present to prevent unauthorized access. The dietary manager (DM) created an audit that was completed during meal service to ensure the potential for harm or IJ was not repeated due to lack of a check and balance system during the meal service prior to resident meal consumption.

Based on observation, interview and document review, facility failed to ensure the safety of 1 of 1 resident (R3) by failing to follow the care plan during a transfer. This resulted in actual harm for R3, whose fall resulted in a fractured left hip. The facility had implemented corrective action to prevent reoccurrence by 3/27/20, resulting in past non-compliance. Findings include: R3's admission record included [DIAGNOSES REDACTED]. R3's 2/4/20, admission Minimum Data Set (MDS) identified R3 was cognitively impaired, had impairment on one side of the body and did not walk. R3 required extensive assist of two staff for bed mobility, and was fully dependent on two staff for transfers. R3's 4/6/20, Significant Change MDS identified R3 had improved mental cognition to no cognitive impairment, but still could not walk, required extensive assist of two staff for bed mobility, and was fully dependent on two staff for transfers. R3's 1/30/20, care plan, active at the time of R3's fall, identified R3 required assistance with Activities of Daily Living (ADL's) related to stroke and [MEDICAL CONDITION]. R3 required assist of two staff for bed mobility and total assistance of two staff for transfers using a mechanical lift. Review of the State Agency (SA) report filed 3/27/20, identified R3 had a fallen that day resulting in a fractured left hip. The report identified the nurse was called into R3's room by nursing assistant (NA) and a trained medication assistant (TMA). The nurse found R3 laying on left side on floor next to bed. R3 was getting ready to be transferred so the floor mat next to bed was removed. R3 was sitting up at the side of the bed. R3 had identified she stood up trying to reach for something and fell . The NA was in the room and had turned with her back to R3 to grab R3's wheelchair. The nurse completed a head to toe assessment on R3 after the fall, not noting any redness, swelling, or bruising to R3's left side. R3 rated her pain at 9 on scale of 1-10. The nurse applied Biofreeze to R3's left hip area for pain. R3 continued to complain of severe pain and swelling was later noted. R3 was sent by non-emergent ambulance at around 3:30 p.m. that day for further follow-up. Facility staff received phone call from hospital stating R3 had a left [MEDICAL CONDITION] and had been transferred for surgery. Review of the facility investigation of the fall identified R3 was a two person assist with bed mobility, and mechanical hoyer lift for transfers. Nursing assistant (NA)-A identified she sat R3 up in bed, turned her back to her and grabbed the wheelchair. R3 attempted to stand up by herself and fell . NA-A identified the fall mat was not in place as NA-A was planning on transferring R3 and was waiting for assistance from another person as she had planned to transfer R3 with a gait belt and two staff. Through staff interviews, the facility determined R3 would at times refuse to use the lift. Action taken to prevent reoccurrence to R3 included R3's transfer and bed mobility was reassessed and confirmed R3 had required two staff for bed mobility and total assistant with a mechanical lift. Action taken to prevent reoccurrence to other residents included the director of nursing (DON) or designee, along with therapy would review each resident's care plan to ensure current and update as needed. Further identified that on-going attendance by therapy staff at daily meeting will be mandatory to address any changes for residents. Nursing staff and therapy staff will be educated to the process. Through facility interviews it was identified NA-A was unaware R3 required a mechanical lift or where to find the NA Kardex care plan for resident's care needs. NA-A identified she knew how to care for R3 by word of mouth. Review of investigation information found NA-A received counseling and re-education related to not following the care plan. Review of R3's progress note dated 3/27/20 at 1:39 p.m., identified the nurse was called into R3's room to find R3 on floor on her left side. R3 informed the nurse that R3 was sat up by NA-A and then she turned her back to her and R3 was talking to her when she became distracted and stood up and fell . R3 reported to nurse she hit her head and left hip. Note identified nurse assessed R3 and educated staff that R3 is a two person transfer and should not have been sitting at edge of bed. Note identified nurse had educated other staff about resident also. Progress note dated 3/27/20 identified as late entry for 12:15 p.m., identified the emergency room (ER) was called for possible [MEDICAL CONDITION] from fall. Resident had reported a lot of pain and would like to be seen. Facility nurse had not identified any swelling or redness at this time. ER nurse directed the facility to watch area and call back if swelling or increased pain noted. Progress note dated 3/27/20 at 3:38 p.m., identified R3 left for ER at 3:05 p.m., for an x-ray of left hip as R3 was noted to have swelling and severe pain in left hip. Progress note on 3/27/20 at 6:31 p.m., identified hospital nurse called and reported R3 had a fractured left hip and would be admitted . Observation on 8/4/20 at 8:44 a.m., R3 was observed to be transferred correctly with a mechanical lift by two staff from her wheelchair into her bed. There were no concerns identified during the transfer. Interview on 8/6/20 at 2:41 p.m., with assistant director of nursing (ADON) confirmed NA-A did not follow R3's care plan. As a result, R3 suffered a fall with a fracture. Following R3's fall, there was re-training provided to all staff on the importance of following each resident's care plan. R3 had no further falls since 3/27/20. All residents care plans had been reviewed for accuracy Interview on 8/10/20 at 9:56 a.m., with registered nurse (RN)-A identified she was the charge nurse on duty at time of R3's fall. NA-A came to get her after R3 fell to assess R3. NA-A reported she sat R3 up on edge of bed and turned to get the wheelchair when R3 fell . R3 required a total mechanical lift with two staff assistance. NA-A also reported she never had intentions of transferring R3 alone and was just getting ready for the second staff to arrive. When the nurses update a care plan, it automatically goes to the NA Kardex on the computer. All nursing assistants complete a return demonstration of skills while training on the floor with other staff. The ADON managed education and NA's were shown the Kardex. It was each nurses responsibility to ensure staff were monitored and the care plans were followed. Interview on 8/10/20 at 12:40 p.m., with the DON identified staff have cheat sheets along with the NA Kardex they can reference for residents care needs. The DON would expect staff to follow the care plan and implement interventions as identified when providing care. If a resident would refuse care or interventions, she would expect staff to update the charge nurse and explain to the resident the reason for the intervention. The facility had multiple departments review the care plan for each resident and ensure implementation of the care plan. The DON was not employed at facility at time of the fall, investigation, or retraining of staff at the time R3 had fallen, but ensured present facility processes were ongoing and followed to prevent falls. Interview on 8/11/20 at 10:24 a.m., with medical director (MD) identified he is notified of falls on a quarterly basis unless there was injury. MD had been notified of R3's fall. MD would expect staff at the facility to implement the identified care plan that was put in place for each resident. Interview on 8/11/20 at 12:16 p.m., with administrator (A) verified the facility investigation found staff had not followed R3's care plan which resulted in her [MEDICAL CONDITION]. The A expected all staff to followed each resident's care plan and interventions to ensure safe transfers. The facility has routinely scheduled meetings to discuss falls and re-educate staff as needed as well as audit care provided. Review of the undated, Assessing Falls and Their Causes policy identified the purpose of the policy was to identify the cause of a fall. If a resident had a fall, staff were to assess the resident's vital signs and check for injury, providing first-aid as appropriate. Staff were to perform a post-fall assessment, identify complications from the fall, implement interventions to prevent further falls, document information, and notify all appropriate personal. To correct the deficiency, the facility had conducted a root cause analysis of R3's fall, specific corrective action training was provided to the NA involved, all other residents' care plans were reviewed for accuracy, and all remaining staff were re-educated by 3/27/20.

Based on interview and document review, the facility failed to provide an comprehensive assessment and monitoring of their physical condition following a surgical procedure for 1 of 1 resident (R1) whom had a surgical procedure. As a result of this, R1 died unexpectedly at the facility the same day she returned from the procedure causing actual harm. Findings include: R1's [DATE], quarterly Minimum Data Set (MDS) assessment identified [DIAGNOSES REDACTED]. R1's cognition was intact, and she was independent with activities of daily living (ADLs), except for eating which required supervision. R1's nursing progress notes identified R1 had been admitted to the facility in (MONTH) (YEAR), with the biliary drain in place. R1 had requested the physician remove her biliary drain related to complaints of pain. R1 had requested to have the drain removed resulting in the scheduled procedure which took place on [DATE]. R1 had left the faciity on [DATE], at 6:53 a.m. for a medical procedure in Rochester Minnesota. The notes indicated R1 returned [DATE], by medical transport van at 1:21 a.m. and complained of terrible pain. The Medication Administration Record [REDACTED]. R1's [DATE], post operative (post-op) discharge instructions given to the R1 at the time of hospital discharge identified facility staff were to call R1's surgeon if: 1. R1 experienced a temperature over 100.4 degrees Fahrenheit 2. Foul smelling pus-like drainage, 3. Increased abdominal pain, 4. Wound swelling, bleeding, redness form the incision sites, 5. Nausea or vomiting, 6. Pain not relieved by medication, 7. Frequent, painful, or inability to urinate. Wound and dressing care: The wound was packed post operatively. Change the packing daily until the tract heals. Check the incision and surrounding area daily for any redness, swelling discoloration, heavy drainage or separation of the skin. 8. Start taking [MEDICATION NAME] 50 milligrams (mg) tablet ([MEDICATION NAME]); Change: [MEDICATION NAME] 800 mg ([MEDICATION NAME])-another medication with the same name was removed. Continue taking this medication, and follow the direction you see here. Stop taking: [MEDICATION NAME] 500 mg capsule (TYLENOL). Further review of the discharge summary identified the last set of vitals signs (VS) recorded on [DATE] were at 7:10 p.m., prior to discharge. 1. Pulse rate- 86 (A normal is 60 to 100 beats per minute); 2. Respiratory rate (RR) 23 breaths per min (bpm) (The normal RR is 12 to 20). 3. Blood Pressure (BP) ,[DATE] millimeters of mercury (mm/hg) (normal is ,[DATE] mm/hg). 4. Oxygen saturation (SpO2) was 88%, (Normal is 95 to 100 %). The facility progress notes on: (1) [DATE], indicated R1 had 4 dressings on her abdomen that needed to stay in place for 48 hours. Nursing staff identified they had reviewed hospital discharge orders. R1 was not to shower for 2 days and was not to strain for a bowel movement. R1 had 8 pills upon her return, and had taken one en-route back to the facility. R1 had complained of bad indigestion upon her return and [MEDICATION NAME] (an antacid) and MOM (milk of magnesia- a laxative) had also been given. (2) [DATE] at 9:01 a.m., R1 was administered [MEDICATION NAME] (narcotic pain medication) and identified her pain as a 3 of 10, (,[DATE] pain scale, identifying 1 as minimal and 10 being excruciating pain) but did not identify where the pain was located. There was no assessment of R1's physical condition, pain, or vital signs to monitor R1's after her surgical procedure, even though R1 returned from the hospital 8 hours 23 minutes earlier. A late entry progress note dated [DATE], at 7:49 p.m. identified at approximately 5:00 p.m., R1 was found not breathing, and had no pulse. Staff initiated resuscitative measures and EMS (emergency medical services) was activated. Interview and review of the [DATE], sheriff's report with the sheriff on [DATE] at 10:11 a.m., identified R1 was deceased upon his arrival approximately at 6:00 p.m. on [DATE]. At: 1.) 1:00 a.m. on [DATE], R1 returned to the facility. 2.) 8:27 a.m. R1 received her morning medications passed by licensed practical nurse (LPN)-A. 3.) 9:15 a.m., R1 got up from bed and went out to smoke and advised the nurse aide (NA)-A she had vomited all her 8:27 a.m. medications and requested more pain medication. there was no documentation to support NA-A had notified nursing staff of R1's vomiting. 4.) 12:00 p.m., R1 had refused her noon meal. 5.) 1:00 p.m., R1 was witnessed going outside to smoke by RN-A. 6.) 4:00 p.m. LPN-A indicated she looked into R1's room, which was dark. LPN-A thought she was sleeping. 7.) R1 had not gone to the dining room for her 5:00 p.m. supper meal. The dietary manager had mentioned this to RN-A. RN-A then proceeded to R1's room to check on her condition. 7.) 5:01 p.m. RN-A entered R1's room and found R1 not breathing and pulseless, a large large amount of a dark red blood-like substance on her bedding and pillow. An emesis basin was observed by RN-A at the bedside and contained what she believed to be dark red blood. EMS was immediately activated and resuscitative measures initiated. 8.) 5:45 p.m., staff documented the time of death, following contact with the medical examiner and authorization to release R1's body to the funeral home. 9.) 7:19 p.m., staff had made contact with family members to alert them to R1's passing. Review of the [DATE], faxed communication to the medical director on [DATE], identified CPR had been performed on R1 with no effect. On [DATE], the medical director faxed back communication stating unfortunate. Any autopsy to be done? Post-op complication concerns? There was no indication the faciltiy had investigated events leading up to R1's death to determine what occurred. During an interview and document review, with the director of nursing (DON) and facility administrator on [DATE] at 5:04 p.m., identified prior to R1's surgical procedure, she had been alert, oriented and able to direct her own care. Their understanding was R1's appointment was to remove a drain in her abdomen. The administrator and DON were unaware R1 had a cholecystectomy in addition to an abdominal drain removal. Both were unaware of details of the surgical procedure R1 had on [DATE]. Their expectation was nursing staff should have performed a comprehensive physical assessment upon arrival back to the facility and routine post-op monitoring. There was no indication a physical assessment was completed or communication with the physician when R1 was vomiting and increased pain. The dietary manager (DM) was interviewed on [DATE], at 11:08 a.m. and stated she had noticed R1 was not in the dining room and asked RN-A if R1 was coming to the dining room for supper. RN-A stated she was going to go to R1's room to check on her. The DM heard staff yelling for help. Upon arrival at R1's room, R1 had been placed on the floor by staff and cardiopulmonary resuscitation (CPR) was performed. The ambulance was called. RN-A utilized the automated emergency defibrillator (AED) in an attempt to further resuscitate R1. The AED advised no shock was indicated. CPR continued until emergency medical services (EMS) arrived and took over resuscitative measures. Following 3 unsuccessful attempts to revive R1, EMS contacted the medical director and received the order to discontinue resuscitative measures at 5:45 p.m. RN-A was interviewed on [DATE], at 11:47 a.m. and confirmed she had been working on [DATE], from 6:00 a.m. - 6:00 p.m. RN-A confirmed she had received report on [DATE], and had been informed R1 had arrived back from her medical apt at 1:00 a.m. on [DATE]. LPN-A who was on duty when R1 returned, but there was no mention of any assessment being completed or monitoring in place. RN-A also verified she had not completed a post operative assessment or checked VS. R1's usual pattern was to not get up for breakfast, and come out of her room for her morning medications around 9:30 - 10:00 a.m. and following that, go outside to smoke. Since this was the usual routine for R1, she didn't question when R1 didn't come for breakfast. R1 had been notified R1 complained of pain, but made no attempt to perform a comprehensive assessment post-operatively. RN-A was advised by TMA-A that R1 didn't come out for her noon meal and had stated she wasn't hungry. Staff observed R1 going out to smoke at 1:00 p.m. R1 had been observed lying in bed, watching TV after returning to her room after smoking. R1 had a history of [REDACTED]. RN-A indicated when she was notified by the DM R1 hadn't come for her supper meal, she went to check on her. R1's lights were off in her room. R1 was lying on her right side, facing the door. R1 didn't respond to RN-A, so she walked over to the bed and noticed something dark on R1's blanket and pillow. RN-A turned on the light, and observed R1's face with a dark blood-like substance around her nose, cheeks, mouth, and large amounts on both the pillow and bedding. R1 was pale, her lips were dark and she was neither breathing nor had a heartbeat. R1's advanced directive was for resuscitative measures so she called for help and initiated CPR. EMS was activated and the AED was obtained and utilized per instructions. No shock was advised and CPR continued. EMS arrived and took over CPR. The paramedic on the scene contacted the medical director and received orders to discontinue resuscitative attempts. The sheriff's department was contacted by EMS personal and responded to the scene. Family members were contacted after multiple attempts in addition to the primary provider. The sheriff arrived on scene, conducted his investigation and contacted the medical examiner who authorized release of R1's body to the funeral home. The director of nursing (DON) was notified of the occurrence and indicated she would notify the facility administrator. TMA-A was interviewed on [DATE], at 12:24 p.m. and confirmed she had also been working on [DATE]. She indicated she was providing medication pass on her shift and R1 had turned on her call light on around 8:30 a.m. and requested her morning medications and pain medication. (R1 did not indicate where she was having pain), but was observed cringing when she moved, and required assistance to sit up in bed. TMA-A indicated R1 usually got up without assistance and came to the medication cart to request/receive her medication. TMA-A indicated she knew this was not R1's usual pattern of behavior but didn't provide any additional investigation. R1 requested 2 narcotic pain medication. TMA-A explained to R1 that she could not have both per RN-A's direction. RN-A had not followed up to identify why R1 wanted additional medication. R1 then took the offered medication and laid back down in bed. TMA-A indicated approximately ,[DATE] to ,[DATE] of an hour later, R1 got out of bed and transported herself outside to smoke. R1 informed TMA-A she had thrown up and was requesting additional narcotic pain medication. TMA-A had advised RN-A of R1's vomiting and request for additional medication. RN-A denied the medication request. TMA-A was unaware if RN-A had gone to R1 to perform an assessment. She indicated she had checked on R1 through her doorway periodically during the day. She saw R1 lying in bed with the lights off and window curtains drawn. TMA-A made no attempt to rouse or physically check R1 due to her hx of not wanting to be bothered while sleeping. Around 4:00 p.m. TMA-A had looked in through R1's doorway. R1 was in bed, facing the door, and appeared to be sleeping. TMA-A indicated it was shortly after 5:00 p.m., RN-A went into R1's room, discovered R1 was unresponsive and called for help. TMA-B was interviewed on [DATE], at 1:17 p.m. and also confirmed she had worked on [DATE]. TMA-B indicated she was not aware of a problem with R1 until she was summoned to come and assist during the emergency. Upon her arrival in the room, she observed R1 lying in bed, with blood on her face, nose and mouth. R1's skin color was blue, and she was not breathing. CPR was initiated and EMS was notified. R1's surgeon was interviewed on [DATE], at 12:30 p.m. and confirmed he had performed a laparoscopic cholecystectomy, and drain removal on [DATE], at 1:57 p.m. The surgeon stated the procedure was uncomplicated, however, there had been a small tear to the liver made during the operation, but was controlled with electro-cautery. R1 had received screening in the clinic that same day, prior to her procedure and had no identified concerns. The surgeon also verified there had been no concern with the resident's intubation (tube to assist in breathing during general anesthesia). R1 had not left the hospital to transfer back to the facility until later in the evening. The surgeon had not been called at any time regarding R1's post-op condition from her arrival at the facility until after R1 had died . His expectation was staff were to have followed discharge instructions as ordered. He was surprised an autopsy had not been requested due to the unexplained cause of death. Although R1 had a medical procedure on [DATE] and returned to the faciltiy on [DATE] at 1:21 a.m., there was no indication the facility completed a physical assessment, vital signs, or pain monitoring to determine if any medical interventions needed to be implemented even though R1 identified she had terrible pain and was vomiting. The facility made no attempts to contact the physician, and follow R1's discharge instructions even though the instructed directed staff to call if there was vomiting and increased pain. As a result R1's became unresponsive on [DATE] at 5:00 p.m., 12 hours and 21 minutes after she returned from the hospital and died . There was no policy or professional standards of practice reference provided related to post-op monitoring or comprehensive assessment guidelines for staff to follow for any resident post-operatively if there were concerns or questions.

Based on observation, interview and document review, the facility failed to review and revise behavioral health care plans that were ineffective, and failed to obtain necessary services for the behavioral health care needs of 1 of 11 residents (R1, R2 and R3) reviewed, who repeatedly demonstrated sexual, physical and verbal behaviors causing distress to himself and others. This resulted in actual physical and psychosocial harm for R1. R1's behaviors contributed to his poor compliance with his medication and care regimen that negatively impacted his physical health and caused him to experience repeated episodes of distress and anger evidenced by cursing, hitting, threatening others, and throwing physical objects having the potential to cause injury to himself and others. In addition the facility failed to provide an environment and atmosphere that was conducive to mental and psychosocial well-being for 2 of 11 residents (R2 and R3) who were repeatedly exposed to R1's behaviors. Findings include: R1's admission progress note dated (MONTH) 11, (YEAR), indicated R1's admission [DIAGNOSES REDACTED]. R1's physician's diet order dated (MONTH) 11, (YEAR), indicated R1 was to receive a consistent carbohydrate diet. R1's admission psychiatric note dated (MONTH) 21, (YEAR), indicated R1 refused his insulin at times with elevated blood sugars as a result. There were no documented medication changes to address his refusal of insulin. R1's care plan revised (MONTH) 27, (YEAR), indicated for personal hygiene assistance R1 required supervision to wash face and hands, comb hair, shave whiskers as needed, complete peri cares with each incontinence episode. R1's care plan revised (MONTH) 17, (YEAR), indicated for dressing assistance R1 required extensive assistance of one staff to pull up/down pants, pull shirt over head, guide arms through clothing openings, don/doff socks and shoes, button buttons, zip zippers. R1's care plan revised (MONTH) 21, (YEAR), indicated R1's toileting schedule instructed staff to assist R1 every two hours and as needed to promote skin integrity as he needs assistance with toileting task, staff to assist with peri care after each incontinence episode. R1's physician fax dated (MONTH) 12, (YEAR), indicated staff informed the physician about R1's increase in sexual comments and touching of himself and others. When staff approached R1, he put his hands down his pants and then exposed himself. R1 made sexual comments towards staff and tried to touch staff inappropriately and then giggled and smiled at times throwing pills and saying suck my dick, [***] you [***] . R1 attempted to inappropriately touch staff with all medication passes. The physician's response was to continue to re-direct. R1's significant change Minimum Data Set (MDS) dated (MONTH) 13, (YEAR), indicated R1 was cognitively intact and there were no behaviors identified. R1's progress note dated (MONTH) 15, (YEAR), indicated during the supper meal R1 yelled at staff, You [***] ing cunt, suck my dick and suck it dry. You ugly [***] ing face. R1 told other residents multiple times to suck my dick dry. Staff attempted to redirect and R1 repeatedly stated [***] you [***] . Staff tried redirecting again and R1 continued cursing at staff. R1's physician fax dated (MONTH) 20, (YEAR), indicated staff informed the physician R1 continued to refuse medication four times on the evening shift. R1's Medication Administration Record [REDACTED]. R1 had an ordered to check his blood sugar four times a day, and he refused it thirty-three times. There is no documentation indicating medication changes to address the refused medications and monitoring. R1's psychiatric note dated (MONTH) 23, (YEAR), indicated R1's [MEDICATION NAME] was increased due to R1's increase in sexual aggression and impulsivity. R1's progress note dated (MONTH) 30, (YEAR), indicated R1 told staff he wanted to grab their crotch. R1's progress note dated (MONTH) 1 and 2, (YEAR), indicated in the west dining room with staff present R1 reached over and touched R2's breasts and R2 pushed R1's hand away and said no while R1 continued to try and touch R2. Staff removed R1 from the area. R1's progress notes indicated R1 made explicit sexual comments to staff and that he attempted to grab staff during cares. Due to an increase in R1's behaviors, staff were advised two staff should be present when working with R1, but there no modifications to the plan of care to reflect this advisement. R1's physician fax dated (MONTH) 2, (YEAR), indicated the physician ordered [MEDICATION NAME] every day for inappropriate sexual behaviors. R1's progress note dated (MONTH) 3, (YEAR), indicated R1 watched R2 leave the dining room and head down the hallway in a wheelchair. R1 proceeded to walk up behind R2 and grab R2's wheelchair, and then R1 grabbed R2's right breast. R2 yelled out and when staff intervened, R1 yelled at staff you can suck my cock and R1 went to his room. Staff went to R1's room to address the inappropriate behavior, and R1 told staff suck my dick many times and to get the [***] out. Staff asked R1 if he planned to touch R2 again and R1 stated sure. R1's progress note dated (MONTH) 4, (YEAR), indicated R1 ate his meal in his room as an intervention to keep other residents safe due to R1's increased sexually inappropriate behaviors in public spaces throughout the facility. However, R1's progress notes also reflect R1 ate breakfast and lunch in the dining room and staff had to redirect him back to his room due to inappropriate behaviors. The care team determined R1 required an inpatient stay and R1's progress note dated (MONTH) 6, (YEAR), indicate R1 was transferred to an inpatient behavioral unit. R2's admission record indicated R2 was admitted to the facility on (MONTH) 20, (YEAR), and was diagnosed with [REDACTED]. R2's care plan dated (MONTH) 21, (YEAR), indicated R2 was at risk for elopement related to history of elopement and anger with placement at the facility. R2 was given a room on the west wing on the secured unit in the facility. Staff interventions included redirect from doors, and evaluate effect of cognitive impairment on resident's ability to understand. R2's safety was at risk and there is potential for abuse due to decreased cognitive and physical ability. Staff interventions to keep R2 safe included not placing R2 near others who disturb her and removing R2 from potentially dangerous situations. R2's progress notes dated (MONTH) (YEAR), indicated R1 reached over and touched her breasts. R2 pushed R1's hand away and said, No. Staff removed R2 from the dining room and noted no injuries. R2's progress notes indicated R2 was moved to a room on the east wing on the non-secured unit temporarily as a safety precaution to keep R1 away from her. Following this incident, R2's progress notes indicated R2 was agitated and swearing at staff because they would not give her cigarettes or let her go outside as R2 was an elopement risk. R2 had not smoked since her admission on (MONTH) 20, (YEAR). R2 was frequently redirected and placed on fifteen-minute checks. R2's care plan intervention for at risk for elopement was revised with the addition of a wanderguard placement on R2's wrist. R2's progress notes indicated R2 was anxious and not sleeping well. R2 was later moved to a different room on the east wing non-secured unit, due to R2's behaviors of asking her roommate to do many things for her and the roommate was not able to sleep through the night. R2's progress notes dated (MONTH) 8, (YEAR), indicated R2 put on extra clothes to go outside, repeatedly asked to go outside, and asked for cigarettes. Staff observed R2 go out the front door and the alarm did not sound. R2 told staff she removed her wanderguard and flushed it down the toilet. Staff moved R2 back to the secured unit, since R1 was hospitalized and not on the unit. R1's progress note dated (MONTH) 5, (YEAR), indicated staff contacted an inpatient behavioral unit and staff were waiting to hear if R1 would be accepted for inpatient treatment. R1's progress notes dated (MONTH) (YEAR), indicated staff were pursuing placement at an all-male facility for R1 when discharged from the inpatient behavioral unit; however, the notes indicate R1 unable to be transferred and was discharged back to the facility. According to R1's progress note dated (MONTH) 24, (YEAR), at 11:33 a.m., inpatient staff stated R1's behaviors improved with no inappropriate touching, and he cooperated with blood sugar checks and took his medications while treated at the inpatient facility. R1's progress note dated (MONTH) 24, (YEAR), at 12:30 p.m., indicated R1 returned to the facility and was moved to a room on the open unit. R1 cooperated with staff when they applied a wander guard bracelet and took his vitals and weight. Within three days of returning to the facility, the (MONTH) (YEAR) progress notes indicate R1 stopped toileting himself, was incontinent of bowel and bladder, and was resistive to cares. R1's progress note dated (MONTH) 29, (YEAR), at 5:20 p.m., indicated R1's refused his medications, insulin and blood sugar checks. R1 attempted to take items off the medication cart and when staff redirected him, R1 yelled, swore and called staff names. During breakfast, R1 threw his toast across the dining room upsetting other residents. R1 hit out at staff when staff attempted to redirect R1. R1 repeatedly refused cares and toileting throughout the day. R1 was incontinent of urine and had dried feces on himself while lying in bed saturated in urine. R1 refused cares, raised his fists in the air and threatened to hit staff. When staff changed R1's bedding and his clothing, R1 raised his fist and hit staff in the stomach and head butted the staff in the chest. Later that same evening, the progress notes indicated R1 entered the dining room with no clothes on and his brief down around his ankles. A female resident was present. Staff attempted to redirect R1 and he yelled and screamed at staff to give him food. R1 raised his fists in the air and stated he would knock staff's [***] ing teeth out of their face. R1 continued to yell and scream at staff as staff escorted R1 back to his room. R1 refused to get dressed. R1's progress note dated (MONTH) 30, (YEAR), indicated while R1 ate lunch in the dining room, took juice and food from a resident, and then threw a cookie at the resident. While staff redirected R1 back to his room, R1 yelled, [***] you and put his fists in the air as if he was going to strike staff. R1 returned to his room and slammed the door. R1's MAR indicated [REDACTED]. R1 had an order to check his blood sugar four times a day, and he refused it thirteen times. R1's progress notes dated (MONTH) 1 and 2, (YEAR), indicated R1 ate in the dining room after he yelled, swore at staff, shoved a table, and upset a resident by taking the resident's food. R1's progress notes dated (MONTH) 3, (YEAR), indicated R1 laid in a urine saturated bed and refused to shower. Later, R1 came to the nurses' station and stated, I[***]my pants. As staff directed R1 to his room to change him, R1 raised his hand to staff and stated, Oh suck my dick. The progress notes indicated R1 took his morning insulin, and then refused all medications, blood sugar checks, and insulin the rest of the day. R1's progress note dated (MONTH) 4, (YEAR), indicated R1 was incontinent of bowel and allowed staff to complete cares and change bedding. R1 took his medication, but refused to have his blood sugar checked. R1 received a bottle of pop and candy bar for compliance. R1's progress note dated (MONTH) 5, (YEAR), at 6:10 a.m. indicated R1 called out from his room and staff found R1 on the floor in his room. R1 was assisted back to bed and given ice for right wrist pain. R1 told staff he had slipped when walking back from the bathroom. Staff found him sitting on the floor between his bed and bedside tray table. R1 later complained of pain on the top of his right hand by his fourth and fifth fingers where staff noted a small bruise. When R1 fell , he was wearing stockings and no shoes. Staff put gripper stockings on R1. R1's progress notes dated (MONTH) 5 to 8, (YEAR), indicated R1 at some meals in the dining and, at one point, grabbed another resident's milk. R1 allowed staff to assist with some cares, but, at times, refused blood sugar checks and medications, including insulin. R1's progress notes dated (MONTH) 14, (YEAR), at 8:46 a.m., indicated R1 ate breakfast in the dining room, but refused clothing change and medications. When staff approached again by staff, R1 allowed his clothing to be changed and he took his medications. At lunch, R1 refused to come to the dining room and told a nursing assistant (NA) to get the [***] out of his room. The nurse approached R1 again and he came out to the dining room and took all medications. The progress notes indicated a team of staff reviewed R1's response to interventions staff had implemented following his inpatient hospitalization . Staff reported R1 continued with behaviors of verbal inappropriate comments; however, staff also reported R1 does not yell at staff, is easier to work with when setting up clothing for him for cares, and staff can redirect R1 when behaviors occur. Staff decided to put an alternative placement on hold and continue to monitor R1's behaviors at the facility. Later that day for the evening meal, R1 sat in the dining room while soiled and refused to change his clothing. R1's progress notes dated (MONTH) 16, (YEAR), indicated R1 was in bed saturated in urine when staff approached to get R1 up for breakfast. R1 cooperated with cares, took all medications including insulin, and ate breakfast in the dining room. R1 ate his noon meal in the dining room, took all medications, and took meatloaf off his tablemate's tray. R1 ate his evening meal in the dining room and sat across from his tablemate instead of beside him. R1 refused toileting prior to meal, and took medications. The progress notes at 9:40 p.m. indicated R1 refused all care during the shift. R1's progress notes dated (MONTH) 17, (YEAR), indicated R1 ate all meals in the dining room. For the noon meal, R1 was directed to the chair across from his tablemate. R1 was served his meal first and after he ate his meat, he requested more before the kitchen staff had finished serving other residents. R1 stood up, reached over the table, and tried to take his tablemate's food. R1 and the tablemate yelled and screamed at each other. R1 threatened to beat his tablemate's ass. Staff intervened and R1 yelled and screamed calling staff a [***] ing [***] and to suck his dick. R1 continued to swear and yell at staff until staff were able to direct R1 back to his room. Throughout the day, R1 refused numerous medications, including insulin. R1 was observed with urine soiled clothes and repeatedly refused to allow staff to perform any cares. R1's physician fax dated (MONTH) 18, (YEAR), indicated R1 refuses supplements and continues to refuse medications at times, and in the past week R1 refused medications seven times. The physician's orders [REDACTED]. R1's care plan focus for shower or bathing initiated (MONTH) 18, (YEAR), indicated R1 prefers showers but will routinely refuse them if he is not enticed a treat of preference. If R1 refuses to shower, interventions direct staff to reattempt and ask him again as he does enjoy his nut roll, and let him know ahead of time prior to the shower occurring that is he takes a shower then he will be able to receive a small salted nut roll candy once he has finished the task. R1's progress notes dated from (MONTH) 18 to 27, (YEAR), indicated R1 routinely refused to change his soiled clothing and ate meals with soiled clothing in the dining room with other residents. At one point, R1 tried to take food off other residents' plates. R1 routinely refused medications, blood sugar checks, and cares, including his insulin and medication to treat his red, irritated skin. R1's progress note dated (MONTH) 20, (YEAR), indicated R1 was compliant with taking his medication and blood sugar checks. R1 was given a candy bar and glass of milk. R1's progress notes dated (MONTH) 28 to 29, (YEAR), indicated R1 ate most meals in the dining room and independently ate his choice of food. R1 refused all medications, blood sugar checks and insulin throughout the day. R1 walked out to the dining room without a shirt on and when staff redirected him back to his room to get a shirt, R1 swore at staff calling them [***] es and to get the hell out of here. R1 continue to call staff [***] es as he walked down the hallway. R1 was resistive to cares. R1's MAR indicated [REDACTED]. R1 had an order to check his blood sugar four times a day, and he refused these checks twenty-one times. R1's progress note dated (MONTH) 29, (YEAR), at 1:35 p.m., indicated R1 was very disruptive by yelling and swearing at others during lunch in the dining room. R1 tried to take food from other residents and hit and yelled at staff to shut the [***] up cunts and [***] es. R1 attempted to get up and go after staff and another resident with a butter knife. Staff attempts to redirect the resident were unsuccessful so 911 was called and the sheriff and ambulance were dispatched to the facility. R1 was given an injection by the ambulance crew due to R1's resistive behaviors towards the sheriff and ambulance crew. R1 was transferred to the emergency room , and then hospitalized at an inpatient psychiatric unit. R1's progress note dated (MONTH) 30, (YEAR), indicated hospital staff called to report R1 was pleasant and compliant, and they were looking into medication adjustments. R1's progress note dated (MONTH) 31, (YEAR), indicated R1 would be moved to a room with a bathroom to himself to alleviate behaviors between R1 and other residents. R1's progress notes dated (MONTH) 2, (YEAR), indicated R1 returned to the facility with a new [DIAGNOSES REDACTED]. R1 ate noon and evening meals in the dining room and was compliant with medications, blood sugar checks and insulin. R1's progress notes dated (MONTH) 3 to 6, (YEAR), indicated R1 had episodes of incontinence with bowel and bladder. After multiple attempts, R1 would allow staff to complete cares and change his bedding, but R1 would refuse to change his soiled clothing. At one point, he urinated on the bathroom floor while staff attempted to assist him. He began refusing his medications, insulin, blood sugar checks, and some meals. R1's behaviors escalated with him yelling cursing, and hitting at staff. R1's progress note dated (MONTH) 5, (YEAR), at 6:38 p.m., R1 met with the nurse practitioner (NP) and voiced no concerns. Staff informed the NP of R1's medication refusals. The NP planned to consult with the hospital's psychiatrist from R1's inpatient psychiatric stay for insight into his treatment plan. R1's quarterly MDS dated (MONTH) 7, (YEAR), indicated R1 had moderate cognitive impairment, and required the physical assistance of two staff for toilet use and personal hygiene. The only behavior identified was rejection of care that occurred one to three days. R1's progress notes dated (MONTH) 8 to 11, (YEAR), indicated R1 cooperated with some cares, but continued to refuse medications, blood sugar checks, and insulin. R1's progress notes dated (MONTH) 12, (YEAR), indicated the NP had talked to the psychiatrist from R1's inpatient psychiatric stay, and R1 had been compliant with all medications while hospitalized . Staff informed the NP of R1's continued refusal to take medications, and the NP requested that the facility psychiatrist see R1 to discuss intramuscular (IM) medications versus daily medications. R1's care plan revised (MONTH) 12, (YEAR), indicated R1's toileting schedule instructed staff to assist R1 every two hours and as needed to promote skin integrity as he needs assistance with toileting task, staff to assist with peri care after each incontinent episode, wears brief. For personal hygiene assistance R1 required supervision to wash face and hands, comb hair, shave whiskers as needed, complete peri cares with each incontinent episode, and for dressing assistance R1 required extensive assistance of one staff to pull up/down pants, pull shirt over head, guide arms through clothing openings, don/doff socks and shoes, button buttons, zip zippers. R1's progress notes dated (MONTH) 12 to 14, (YEAR), indicated R1 ate his meals in his room due to behaviors but was later allowed to eat in the dining room with other residents. R1 toileted himself, but was occasionally incontinent. Staff assisted with personal hygiene as R1 allowed. R1 was compliant with some cares, but continued to refuse medication, blood sugar checks, and insulin. R1's care plan initiated on (MONTH) 14, (YEAR), indicated R1 has a history of using knives inappropriately, and that R1 will not be given a knife unless staff are there to assist him. R1's physician's fax dated (MONTH) 15, (YEAR), indicated R1 continued to refuse medication and insulin at times, and the physician instructed staff to continue to encourage, add bedtime blood sugar check, and follow up with the psychiatrist. R1's progress notes dated (MONTH) 15, (YEAR), indicated R1 took all medications including insulin. R1 agreed with the treatment goal of consistent medication compliance and positive behaviors. R1's progress notes dated (MONTH) 16 to 18, (YEAR), indicated R1 cooperated with cares, toileted self with less incontinence, and took most of his medications. R1's progress notes dated (MONTH) 17, (YEAR), at 7:47 a.m., 10:58 a.m., and 4:36 p.m., indicated there were no test strips available to check R1's blood sugar, so staff were unable to administer R1's prescribed [MEDICATION NAME] insulin. R1's progress notes dated (MONTH) 18, (YEAR), at 7:52 a.m. and 11:17 a.m., indicated there were no test strips available to check R1's blood sugar, so staff were unable to administer R1's prescribed [MEDICATION NAME] insulin. R1's progress notes dated (MONTH) 19, (YEAR), indicated R1 cooperated with cares, but felt nauseated and did not eat breakfast so his insulin was held. The psychiatrist saw R1 per the primary physician's request regarding injectable medication. R1 offered no complaints or concerns. The psychiatrist made no medication changes, as R1 had no psychiatric [DIAGNOSES REDACTED]. R1's psychiatric note indicated R1 was non-compliant with cares at times, but did not get aggressive. R1's progress notes dated (MONTH) 20 to 21, (YEAR), indicated R1 cooperated with some cares, but refused some medications and blood sugar checks. He did not eat some meals due to nausea. R1's progress note dated (MONTH) 22, (YEAR), indicated R1 was incontinent of urine and initially resisted staff assistance, but then allowed staff to give him a shower. After the shower, staff gave R1 a glass of chocolate milk and he laid down in his room Housekeeping reported to the nurse R1 had emesis of chocolate milk in his room. R1 refused blood sugar checks and all medications, including insulin. While eating an afternoon snack in the dining room, the progress note indicates R1 had a clear emesis and refused a blood sugar check. R1's progress notes dated (MONTH) 23 to 24, (YEAR), indicated while eating breakfast in the dining room, R1 tried to grab another resident's food. Staff redirected R1 and gave him additional food. R1 refused meals, blood sugar checks, and doses of his medications, including insulin. R1's progress note dated (MONTH) 24, (YEAR), indicated R1 refused to allow staff to toilet him. He was incontinent all shift. R1's physician's fax dated (MONTH) 24, (YEAR), indicated R1 continued to refuse medications, blood sugar checks and insulin. R1 was also refusing meals. The physician indicated the social worker would work on an inpatient stay for R1 at a geriatric psychiatric unit or get recommendations for care. R1's progress notes dated (MONTH) 25 to 28, (YEAR), indicated R1 ate most meals in the dining room and had snacks in his room. R1 ate some meals in his room due to his behaviors, and, at times, he refused meals. R1 refused most medications, blood sugar checks and insulin. R1 refused to use the toilet when staff attempted to assist as indicated on his care plan. R1's refusals of medication and care were reviewed with NP. The NP recommended an inpatient stay at a geriatric psychiatric facility. The recommendation was given to the facility social worker. R1's progress note dated (MONTH) 28, (YEAR), indicated R1 could be independent with cares, but that he chose not to be so R1 needed assistance with changing incontinence clothing and cleansing afterwards. R1 refused cares often, but had been cooperative with letting staff check his blood sugars and administer his medications. R1 communicated needs if he was thirsty or hungry, but did not communicate when he was incontinent of bowel and bladder. R1's progress note dated (MONTH) 30, (YEAR), indicated R1 ate meals in the dining room and that he had snacks in his room. R1 required total assistance of two staff for personal hygiene. R1 refused medications, blood sugar checks, and insulin. R1's MAR indicated [REDACTED]. R1 refused his insulin fifteen times in the morning, fifteen times at noon, and eighteen times in the afternoon. R1 had blood sugar checks ordered four times a day, and he refused these checks forty-seven times. R1's progress note dated (MONTH) 1, (YEAR), indicated R1 refused his meals but he had snacks in his room. R1 refused medications, blood sugar checks, and insulin. R1's progress note dated (MONTH) 2, (YEAR), indicated the NP saw R1 on a routine nursing home visit. Staff reviewed R1's continued refusals of medications and treatment with the NP, administrator and director of nursing (DON). They discussed if comfort cares would be appropriate due to R1's continued refusals. The NP requested staff consult with R1's power of attorney (POA) regarding comfort cares and the plan of care. The NP did note it was ok for staff to reward R1 for compliance with cares even if those rewards violated R1's ordered diet. R1's progress notes dated (MONTH) 2 to 3, (YEAR), indicated R1 refused to come out of his room for meals, but he did eat lunch and had snacks in his room. R1 was initially cooperative with cares, but subsequently became resistive and combative with cares, which included R1 yelling, swearing, and kicking at staff. R1 allowed staff to check his blood sugar and administer some doses of insulin, however, R1 refused most of his medications. At one point, staff offered R1 a candy bar. R1's progress note dated (MONTH) 3, (YEAR), at 6:21 p.m., indicated R1's guardian was contacted and a care conference scheduled, due to R1's current decline in health, well-being, and activities of daily living (ADL's) due to continued refusal to take medication or receive help with cares. R1's progress notes dated (MONTH) 4 to 6, (YEAR), indicated R1 refused some meals, but he had snacks in his room. R1 intermittently refused to allow staff to assist him with personal cares. At one point, R1 hit staff on the hand when he did not want his blood sugar tested . R1 was incontinent of bowel and bladder and laid in a wet bed and clothes due his refusals to allow staff to change him. R1 refused medications, blood sugar checks, and insulin. R1's care plan revised (MONTH) 5, (YEAR), indicated R1's nutrition focus of a diet alteration related to diabetes indicated staff had educated R1 on nutrient restrictions in relation to medical condition, educated on risks of not following diet restrictions, provided a snack basket in his room with snacks according to my preferences, allow him to request to eat meals in his room, his diet will be followed as ordered, his food/beverage preferences will be obtained and updated as needed, and his labs, meal consumption and weight will be monitored. R1's diabetes focus of alteration in blood glucose due to insulin dependent diabetes mellitus indicated staff will administer insulin as ordered in the morning instead of bedtime, administer medications as ordered, and observe for high blood sugar symptoms-increased thirst, increased hunger, and increased urinary output. R1's ineffective health maintenance due to his deficient knowledge regarding care of his diabetic condition indicated staff educate and assist him in choosing a healthy lifestyle, explain the risks and benefits of his treatment regimen, and refer him to his physician if he would experience a worsening of his health contrition after treatment has been administered. R1's risk for injury due to [DIAGNOSES REDACTED] or [MEDICAL CONDITION] related to failure to comply with medication regimen instructed staff to offer my diabetic medications, try offering me a pop and candy bar with my medication as this is what I do like as a reward, and explain the risks and benefits to me if I would refuse diabetic medications. R1's noncompliance related to his healthcare plan instructed staff to allow him to verbalize feelings about the situation, evaluate his understanding of the disease process, barriers to compliance, lifestyle perception of non-compliance, and offer him rewards with compliance of medical regimen. He likes pop and candy bars. R1's progress notes dated (MONTH) 7, (YEAR), indicated R1 continued to refuse cares by staff; however, he did let staff change him on last rounds. Staff were instructed to tell R1 what to do and to not ask him to do things. Staff were directed to approach R1 so R1 would not be rushed and could process what staff are asking him to do. The progress notes indicated R1 could be continent of bowel and bladder if he chooses; however, most of the time R1 is incontinent and needs bed linen and clothing changed. R1 refused all medications, blood sugar checks, and insulin. After supper and while in bed, R1 threw his stool all over the floor. R1's progress notes dated (MONTH) 8, (YEAR), indicated R1 cooperated with cares after he dug out his own stool and threw it on the floor. R1 allowed staff to change him when he was wet. R1 refused his medications, but allowed staff to check his blood sugar. The progress notes indicated R1 could feed himself, but R1 had not eaten for a long time. Staff had given R1 supplement drinks. Staff had to anticipate R1's needs, as he could not communicate them to staff. While eating breakfast in the dining room, R1 took food off another resident's plate. R1 then walked over to another resident to take his food. When staff redirected R1, he hollered, [***] you, all you [***] es, and then walked to his room. The progress notes indicated R1 required supervision during meals to not take other residents' food. R1's progress note dated (MONTH) 9, (YEAR), at 1:28 a.m., indicated R1 cooperated with cares, allowed staff to check his blood sugar, ate all meals, and requested more food before bed. R1 took his medications after staff placed a reward of soda and a candy bar down for him. Later that day, R1 refused breakfast and most doses of medication, blood sugar checks, and insulin. R1's progress notes dated (MONTH) 10, (YEAR), indicated R1 ate breakfast in the dining room, and that he took food from tablemates. R1 had been served an extra breakfast. When staff attempted to redirect R1, he hit staff and hollered, Suck my dick, you cunt [***] es. After two different staff tried to approach R1, the third staff was able to redirect R1 back to his room. The progress notes indicated R1 told staff he would take his medications, but refused when the medications were brought t

Based on interview and document review, the facility failed to review and revise behavior interventions to ensure residents were provided a safe environment and protected from resident to resident abuse for 5 of 14 residents (R2, R3, R4, R7, and R8) reviewed when R1 became agitated and was verbally, physically and sexually aggressive when he cursed, threatened, hit, slapped, and touched residents. R1's behaviors had the potential to affect all 12 resident residing on the east wing. In addition, the facility failed to ensure effective behavioral health care interventions were implemented to enable staff to provide cares and manage physical health for 1 of 1 residents (R1) reviewed when R1 refused cares, medications, blood sugar checks and insulin. R1 was neglected when he laid in urine soaked clothes in a urine soaked bed with flies on him for 3 days in a row, and experienced elevated blood sugars up to 587. Findings include: R1's admission progress note dated (MONTH) 11, (YEAR), indicated R1's admission [DIAGNOSES REDACTED]. R1's care plan revised (MONTH) 27, (YEAR), indicated for personal hygiene assistance R1 required supervision to wash face and hands, comb hair, shave whiskers as needed, complete peri cares with each incontinent episode R1's care plan revised (MONTH) 17, (YEAR), indicated for dressing assistance R1 required extensive assistance of one staff to pull up/down pants, pull shirt over head, guide arms through clothing openings, don/doff socks and shoes, button buttons, zip zippers. R1's care plan revised (MONTH) 21, (YEAR), indicated R1's toileting schedule instructed staff to assist R1 every two hours and as needed to promote skin integrity as he needs assistance with toileting task, staff to assist with peri care after each incontinent episode, wears brief. R1's physician fax dated (MONTH) 12, (YEAR), indicated staff informed the physician about R1's increase in sexual comments and touching. R1 stuck his hands down his pants. When staff approach R1 he will put his hands down his pants and then expose himself. R1 makes sexual comments towards staff and tries to touch staff inappropriately and then giggles and smiles at times throwing pills and making vulgar statements to staff. R1 attempts to inappropriately touch staff with all medication passes. The physician's response was to continue to re-direct. R1's significant change Minimum Data Set (MDS) dated (MONTH) 13, (YEAR), indicated R1 was cognitively intact and there were no behaviors identified. R1's progress note dated (MONTH) 15, (YEAR), indicated during the supper meal R1 swore at staff and made multiple vulgar comments to residents and staff. Staff attempted to redirect and R1 continued to swear. Staff tried redirecting again and asked R1 to go to his room and R1 made another vulgar statement. R1 was served supper in his room. R1's physician fax dated (MONTH) 20, (YEAR), indicated staff informed the physician R1 continued to refuse medication four times on the evening shift. There were no new orders. R1's psychiatric note dated (MONTH) 23, (YEAR), indicated R1's [MEDICATION NAME] was increased due to R1's increase in sexual aggression and impulsivity. R1's progress note dated (MONTH) 30, (YEAR), indicated R1 told staff he wanted to grab their crotch. R1's Medication Administration Record [REDACTED]. R1 refused his insulin two times in the morning, three times at noon, ten times in the afternoon, and twenty-five times in the evening. R1 had an ordered to check his blood sugar four times a day and he refused it thirty-three times. R1's progress note dated (MONTH) 1, (YEAR), indicated in the west dining room with staff present R1 reached over and touched R2's breasts and R2 pushed R1's hand away and said no while R1 continued to try and touch R2. Staff removed R1 from the area. R1's progress note dated (MONTH) 2, (YEAR), indicated during medication pass R1 sat on the edge of his bed with his pants down and hands on his genitalia and asked staff to help him with this. R1's progress note dated (MONTH) 2, (YEAR), indicated staff had a lunch tray set up in R1's room and when staff redirected R1 to his room he tried grabbing staff and asked them to do a sexual act. Due to an increase in R1's behaviors staff advised having two staff present when working with R1. R1's progress note dated (MONTH) 3, (YEAR), indicated R1 watched R2 leave the dining room and head down the hallway in a wheelchair. R1 proceeded to walk up behind R2 and grab R2's wheelchair, and then R1 grabbed R2's right breast. R2 yelled out and when staff intervened R1 yelled a vulgar statement to staff and then R1 went to his room. Staff went to R1's room to address the inappropriate behavior, and R1 made repeated sexual statements and told staff he planned to touch R2 again. The care team determined R1 required an inpatient stay and placement options were researched. R1's progress note dated (MONTH) 4, (YEAR), at 11:03 a.m., indicated R1 would be getting room trays for all meals as an intervention to keep other residents safe due to R1's increased sexual inappropriate behaviors in public spaces throughout the facility. R1's progress note dated (MONTH) 4, (YEAR), at 12:13 p.m., indicated R1 required redirection from the dining room back to his room during the breakfast and lunch meal due to inappropriate behaviors and managements decision to have R1 eat his meals in his room. When redirected R1 made vulgar statements and repeatedly put up his middle finger at staff while walking back to his room. R2's admission record indicated R2 was admitted to the facility on (MONTH) 20, (YEAR), and was diagnosed with [REDACTED]. R2 was given a room on the west wing on the secured unit in the facility. R2's care plan dated (MONTH) 21, (YEAR), indicated R2 was at risk for elopement related to history of elopement and anger with placement at the facility. Staff interventions included redirect from doors, and evaluate effect of cognitive impairment on resident's ability to understand. R2's safety was at risk and there is potential for abuse due to decreased cognitive and physical ability. Staff interventions to keep R2 safe included not placing R2 near others who disturb her and removing R2 from potentially dangerous situations. R2's focus on environment indicated R2 was still adjusting to her new surroundings and would like help getting comfortable in her new home. Staff interventions to assist R2 become comfortable included helping R2 maintain her preferences every day. R2's admission MDS dated (MONTH) 27, (YEAR), indicated R3 was moderately cognitively impaired. R2's progress note dated (MONTH) 1, (YEAR), at 7:35 p.m., indicated R1 reached over and touched her breasts. R2 pushed R1's hand away and said, No. Staff removed R2 from the dining room and noted no injuries. R2's progress note dated (MONTH) 4, (YEAR), at 10:58; indicated R2 had been moved to a room on the east wing on the non-secured unit temporarily as a safety precaution to keep R1 away from her. A wanderguard was placed on R2's wrist due to her history as an elopement risk. R2's progress note dated (MONTH) 4, (YEAR), at 12:25 p.m., indicated R2 asked for cigarettes and was agitated and swearing at staff because they would not give her cigarettes or let her go outside as R2 was an elopement risk. R2 had not smoked since her admission on (MONTH) 20, (YEAR). Fifteen-minute checks were initiated. R2's progress note dated (MONTH) 4, (YEAR), at 5:53 p.m., indicated R2 asked residents for cigarettes, asked others to let her outside and for the door code. R2 was redirected frequently and on fifteen-minute checks. Others were reminded of the smoking policy and to use caution when entering or exiting the facility. R2's progress note dated (MONTH) 4, (YEAR), at 9:32 p.m., indicated R2 continued to ask for cigarettes, to go outside and for the door code. R2 was redirected frequently and remains on fifteen-minute checks. R1's progress note dated (MONTH) 5, (YEAR), indicated staff contacted an inpatient behavioral unit and staff were waiting to hear if R1 would be accepted for inpatient treatment. R2's care plan intervention for at risk for elopement was revised on (MONTH) 5, (YEAR), with the addition of a wanderguard placement on R2's wrist. R2's progress note dated (MONTH) 5, (YEAR), at 2:03 p.m., indicated staff observed R2 slide from her wheelchair to the floor on her butt. R2 stated she was dreaming a snake was on her and she reached for the doorknob and tried to stand. Staff noted no injuries. R2's progress note dated (MONTH) 6, (YEAR), at 6:18 p.m., indicated R2 was moved to a different room on the east wing non-secured unit, due to R2's behaviors of asking her roommate to do many things for her and the roommate was not able to sleep through the night. R1's progress note dated (MONTH) 6, (YEAR), indicated R1 was transferred to an inpatient behavioral unit. R2's progress note dated (MONTH) 7, (YEAR), at 1:44 p.m.; indicated R2 was anxious and not sleeping well. R2's progress note dated (MONTH) 8, (YEAR), 2:17 p.m., indicated R2 put on extra clothes to go outside, repeatedly asked to go outside, and asked for cigarettes. Staff observed R2 go out the front door and the alarm did not sound. Staff's checks of the wanderguard placement and functioning were completed this morning and midday. R2 told staff she removed her wanderguard and flushed it down the toilet. Staff moved R2 back to the secured unit, since R1 was hospitalized and not on the unit. R1's progress note dated (MONTH) 24, (YEAR), at 11:33 a.m.; indicated the inpatient behavioral unit discharged R1 back to the facility. Inpatient staff stated R1's behaviors improved, he had no inappropriate touching, and he cooperated with blood sugar checks and took his medications. R1's progress notes dated (MONTH) 25, (YEAR), indicated R1 refused medication and attempted to take items off the medication cart. When staff redirected R1 he swore and called staff names. R1's progress note dated (MONTH) 26, (YEAR), indicated R1 was eating in the dining room, taking his medications and insulin, and toileting himself. In the morning, R1 was loud and sneezing at the dining room table and at lunch R1 took food off other residents' plates. R1's progress note dated (MONTH) 27, (YEAR), at 3:33 p.m., indicated R1 stopped toileting himself and was incontinent of bowel and bladder. Staff assisted R1 with all his cares and gave him a bath; however, R1 was resistive or refused cares at times. R1 refused medication on the first attempt, but did take them on the second attempt. R1 has plaque psoriasis on scalp, neck, torso, back, arms, legs and feet. R1's progress note dated (MONTH) 29, (YEAR), at 5:20 p.m., indicated R1's refused his medications, insulin and blood sugar checks. R1 attempted to take items off the medication cart and when staff redirected him, R1 yelled, swore and called staff names. During breakfast, R1 ate part of his food and then threw his toast across the room upsetting other residents. R1 hit out at staff when staff attempted to redirect R1. R1 returned to his room, sat himself on the floor, and then laid down on the floor. Initially R1 refused to get up but on second attempt by staff, R1 got up and laid down in his bed. R1 repeatedly refused cares and toileting throughout the day. R1 at lunch and supper in his room. R1 yelled, swore and called staff names from his room. R1's progress note dated (MONTH) 29, (YEAR), at 8:40 p.m., indicated R1 refused all his evening medications and made vulgar statements to staff. R1 was incontinent of urine and had dried feces on himself while lying in bed that was saturated in urine. R1 refused cares, raised his fists in the air and threatened to hit staff. Staff were able to get R1 to stand up and when staff were changing the bedding and his clothing, R1 raised his fist and hit staff in the stomach and head butted the staff in the chest. R1 yelled, screamed and swore at staff while making vulgar statements. R1's progress note dated (MONTH) 29, (YEAR), at 11:31 p.m., a female resident was sitting in the dining room when R1 entered the dining ROM with no clothes on and his brief down around his ankles. Staff attempted to redirect and R1 yelled and screamed at staff to give him food. R1 raised his fists in the air and threatened to physically assault staff. R1 continue to yell and scream at staff as staff escorted R1 back to his room. R1 refused to get dressed. R1's care plan revised (MONTH) 30, (YEAR), indicated R1's toileting schedule instructed staff to assist R1 every two hours and as needed to promote skin integrity as he needs assistance with toileting task, staff to assist with peri care after each incontinent episode, wears brief. For personal hygiene assistance R1 required supervision to wash face and hands, comb hair, shave whiskers as needed, complete peri cares with each incontinent episode, and for dressing assistance R1 required extensive assistance of one staff to pull up/down pants, pull shirt over head, guide arms through clothing openings, don/doff socks and shoes, button buttons, zip zippers. R1's progress note dated (MONTH) 30, (YEAR), indicated while R1 ate lunch in the dining room, R1 took juice and food from the other resident at his table, and then R1 threw a cookie at the other resident. While staff redirected R1, back to his room R1 swore at staff and put his fists in the air as if he was going to strike staff. R1 returned to his room and slammed the door. R1's MAR indicated [REDACTED]. R1 refused his insulin three times in the morning, two times at noon, four times in the afternoon, and four times in the evening. R1 had an ordered to check his blood sugar four times a day and he refused it thirteen times. R1's progress note dated (MONTH) 1, (YEAR), indicated R1 ate lunch in the dining room after he yelled and swore at staff and shoved a table. R1's progress note dated (MONTH) 2, (YEAR), indicated during breakfast R1 was redirected to sit at a different table in the dining room, after R1 upset a resident by taking the resident's food. R1's progress notes dated (MONTH) 3, (YEAR), indicated in the evening R1 laid in urine saturated bed and refused to shower and later R1 came to the nurses' station and stated, I[***]my pants. As staff directed R1 to his room to change him, R1 raised his hand to staff and swore at them. R1's progress note dated (MONTH) 14, (YEAR), at 5:26 p.m., indicated R1 ate evening meal in the dining room while soiled due to refusal to change clothing. R1 refused medications. R1's progress notes dated (MONTH) 16, (YEAR), indicated R1 ate meals in the dining room, reached over and took meatloaf off R7's tray and refused cares all day. R1's progress note dated (MONTH) 17, (YEAR), at 12:25 p.m., indicated R1 was directed to the chair across from R7's for the noon meal. R1 was served his meal first and after he ate his meat, he requested more before the kitchen staff had finished serving other residents. R1 stood up, reached over the table, and tried to take R7's food. R1 and R7 yelled and screamed at each other and R1 threatened to beat R7's ass. Staff intervened and R1 yelled and made vulgar statements to staff. R1's chair moved up against the wall and he continued to swear and yell at staff until staff were able to direct R1 back to his room. R1's progress note dated (MONTH) 17, (YEAR), at 10:24 p.m., indicated R1 was in bed with urine soiled clothes and repeatedly refused to allow staff to perform any cares. R1's care plan focus for shower or bathing initiated (MONTH) 18, (YEAR), indicated R1 prefers showers but will routinely refuse them if he is not enticed a treat of preference. If R1 refuses to shower, interventions direct staff to reattempt and ask him again as he does enjoy his nut roll, and let him know ahead of time prior to the shower occurring that is he takes a shower then he will be able to receive a small salted nut roll candy once he has finished the task. R1's progress note dated (MONTH) 18, (YEAR), indicated R1 tried to take food off other residents' plates this morning and was redirected by staff. R1 refused medication to treat red, dry skin. R1's physician's fax dated (MONTH) 18, (YEAR), indicated R1 refuses supplements and continues to refuse medications at times, and in the past week R1 refused medications seven times. The physician's orders [REDACTED]. R1's progress notes dated (MONTH) 19, (YEAR), indicated R1 refused all cares during the shift and ate meals in the dining room. R1 refused [MEDICATION NAME] cream for his plaque psoriasis. R1 took his medications on the day shift but refused them on the evening shift. R1's progress notes dated (MONTH) 20, (YEAR), at 2:56 p.m., indicated R1 refused cares, blood sugar check, and medications including insulin during the shift. R1 ate meals in the dining room. R1's progress note dated (MONTH) 21, (YEAR), indicated R1's physician ordered an insulin adjustment, monitor blood sugars and to follow up in two weeks. R1's progress notes dated (MONTH) 23, 24, 25, (YEAR), indicated R1 refused all cares during the day shift and ate meals in the dining room. R1's progress notes dated (MONTH) 26, (YEAR), indicated during the day shift R1 was incontinent of urine and resistive when two staff provided cares. R1's progress notes dated (MONTH) 28, (YEAR), indicated R1 refused all medications, blood sugar checks and insulin throughout the day. R1 walked out to the dining room without a shirt on and when staff redirected him back to his room to get a shirt, R1 swore at staff calling them [***] es and to get the hell out of here. R1 continue to call staff [***] es as he walked down the hallway. R1's progress note dated (MONTH) 29, (YEAR), at 1:35 p.m., indicated R1 was very disruptive by yelling and swearing at others during lunch in the dining room. R1 tried to take food from R7 and other residents and hit and swore at staff. R1 attempted to get up and go after staff and another resident with a butter knife. Staff's attempts to redirect the resident were unsuccessful so 911 was called and the sheriff and ambulance were dispatched to the facility. R1 was given an injection by the ambulance crew due to R1's resistive behaviors towards the sheriff and ambulance crew. R1 was transferred to the emergency room , and then to the hospital inpatient psychiatric unit. R7's significant change MDS dated (MONTH) 21, (YEAR), indicated R7 was moderately cognitively impaired. R1's MAR indicated [REDACTED]. R1 refused his insulin three times in the morning, four times at noon, and six times in the afternoon. R1 had an ordered to check his blood sugar four times a day and he refused it twenty-one times. R1's progress note dated (MONTH) 2, (YEAR), indicated R1 returned to the facility. R1's progress notes dated (MONTH) 3, (YEAR), indicated R1 refused his medications and made vulgar comments to staff while sitting in the dining room. R1's progress notes dated (MONTH) 5, (YEAR), indicated R1 was incontinent of both bowel and bladder, and refused cares while yelling sexual statements to staff. A second staff assisted and R1 allowed staff to change his brief but not his clothing. R1 ate breakfast in the dining room and refused to take medication, blood sugar check and insulin. At noon R1 refused his medications and insulin. R1's progress note dated (MONTH) 5, (YEAR), at 6:38 p.m., indicated R1 ate evening meal in the dining room and he refused all medications including insulin. R1 met with the nurse practitioner (NP) and voiced no concerns. Staff informed the NP of R1's medication refusals, and NP will consult with the hospital's psychiatrist from R1's inpatient psychiatric stay for insight into his treatment plan. R1's progress notes dated (MONTH) 6, (YEAR), indicated R1 refused cares along with morning and evening medications, blood sugar checks and insulin. R1 did take medication at noon. Staff attempted to get hospice referral for R1; however, he is not a candidate at this time. R1's quarterly MDS dated (MONTH) 7, (YEAR), indicated R1 had moderate cognitive impairment, and required the physical assistance of two staff for toilet use and personal hygiene. The only behavior identified was rejection of care that occurred one to three days. R1's progress notes dated (MONTH) 8, (YEAR), indicated R1 refused cares including a shower, and refused all morning and noon medications, blood sugar checks and insulin. R1's care plan revised (MONTH) 12, (YEAR), indicated R1's toileting schedule instructed staff to assist R1 every two hours and as needed to promote skin integrity as he needs assistance with toileting task, staff to assist with peri care after each incontinent episode, wears brief. For personal hygiene assistance, R1 required supervision to wash face and hands, comb hair, shave whiskers as needed, and to complete peri cares with each incontinence episode. For dressing assistance, R1 required extensive assistance of one staff to pull up/down pants, pull shirt over head, guide arms through clothing openings, don/doff socks and shoes, button buttons, and zip zippers. R1's progress note dated (MONTH) 12, (YEAR), at 9:05 a.m., indicated the NP had talked to the psychiatrist from R1's inpatient psychiatric stay, and R1 had been compliant with all medications while hospitalized . Staff informed the NP of R1's continued refusal to take medications, and the NP requested the facility psychiatrist see R1 to discuss intramuscular (IM) medications versus daily medications. R1's progress note dated (MONTH) 13, (YEAR), at 2:25 a.m., indicated R1 ate meals in his room due to behaviors. R1's care plan initiated date (MONTH) 14, (YEAR), indicated R1 had a history of [REDACTED]. R1's physician's fax dated (MONTH) 15, (YEAR), indicated R1 continued to refuse medication and insulin at times, and the physician instructed staff to continue to encourage and follow up with the psychiatrist. R1's progress notes dated (MONTH) 17, and 18, (YEAR), indicated there were no test strips available to check R1's blood sugar, so staff were unable to administer [MEDICATION NAME] solution per sliding scale. R1's progress notes dated (MONTH) 19, (YEAR), indicated R1 cooperated with cares, but felt nauseated and did not eat breakfast so insulin was held. R1 denied any pain and vital signs were stable. R1 saw the psychiatrist for follow up per primary physician's request regarding injectable medication. R1 offered no complaints or concerns, and the psychiatrist made no medication changes, as R1 had no psychiatric [DIAGNOSES REDACTED]. R1's psychiatric note dated (MONTH) 19, (YEAR), indicated R1 at times was non-compliant with cares but did not get aggressive. There was no [MEDICAL CONDITION] and no medication changes. R1's physician's fax dated (MONTH) 24, (YEAR), indicated R1 continued to refuse medications, blood sugar checks and insulin. R1 also refused meals. The physician indicated the social worker was to work on an inpatient stay at a geriatric psychiatric unit or get recommendations for care. R1's progress note dated (MONTH) 25, (YEAR), at 1:53 p.m., indicated R1 continued to be non-compliant with taking medications, insulin and with cares. R1 refused to use the toilet when staff attempted to assist as indicated on his care plan. R1's refusals of medication and care were reviewed with the NP, and NP recommended an inpatient stay at a geriatric psychiatric facility. The recommendation was given to the facility social worker. R1's progress note dated (MONTH) 26, (YEAR), at 2:59 p.m., indicated R1 refused to eat meals but has snacks in his room. R1 ate breakfast and allowed staff to check blood sugar and administer insulin but refused morning and noon oral medication. R1 allowed staff to check blood sugar at noon but insulin was held due to not eating noon meal. R1's progress note dated (MONTH) 28, (YEAR), at 11:43 p.m., indicated R1 could be independent with cares but chose not to be, so R1 needed assistance with changing incontinence clothing and cleansing afterwards. R1 refused cares often, communicated needs if thirsty or hungry, but did not let staff know when he was incontinent of bowel and bladder and needed cares. R1's MAR indicated [REDACTED]. R1 refused his insulin fifteen times in the morning, fifteen times at noon, and eighteen times in the afternoon. R1 had an order to check his blood sugar four times a day. He refused it forty-seven times. R1's progress note dated (MONTH) 2, (YEAR), at 2:53 p.m., indicated R1 was seen by the NP on a routine nursing home visit. Staff reviewed R1's continued refusals of medications and treatment with the NP, administrator and director of nursing (DON). It was discussed if comfort cares would be appropriate due to R1's continued refusals. The NP requested staff consult with R1's power of attorney (POA) regarding comfort cares and plan of care. The NP did note it is ok to use a reward system for cares even if in violated R1's diet. R1's progress note dated (MONTH) 2, (YEAR), at 3:00 p.m., indicated in the morning R1 was incontinent of urine and refused to move or to allow staff to change him. R1 was swearing at staff and was resistive and combative with cares. Staff were finally able to change R1 and complete cares on him before lunch. R1's progress note dated (MONTH) 3, (YEAR), at 3:18 p.m.; indicated R1 had refused all morning cares, but did allow staff to change him before lunch. At this time, R1 has been incontinent and needs to be changed, however he has refused staff's repeated attempts to provide cares. R1's resistive while yelling,swearing and kicking out at staff. R1's progress note dated (MONTH) 3, (YEAR), at 5:21 p.m., indicated R1 refused supper and all medications. R1 refused to let staff assist with cares. R1's incontinent of urine, swearing at staff, and refusing to get changed. R1's progress note dated (MONTH) 5, (YEAR), at 4:19 p.m., indicated R1 hit staff in the hand when he did not want to have blood sugar tested . R1's progress note dated (MONTH) 5, (YEAR), at 11:15 p.m., indicated R1's usually incontinent of bowel and bladder. R1 lays in a wet bed and clothes refusing to allow staff to change him. R1 shakes his head no when staff offer to change him or for R1 to change himself. R1's care plan revised (MONTH) 5, (YEAR), indicated R1's nutrition focus of a diet alteration related to diabetes indicated staff had educated R1 on nutrient restrictions in relation to medical condition, educated on risks of not following diet restrictions, provided a snack basket in his room with snacks according to my preferences, allow him to request to eat meals in his room, his diet will be followed as ordered, his food/beverage preferences will be obtained and updated as needed, and his labs, meal consumption and weight will be monitored. R1's diabetes focus of alteration in blood glucose due to insulin dependent diabetes mellitus indicated staff will administer insulin as ordered in the morning instead of bedtime, administer medications as ordered, and observe for high blood sugar symptoms-increased thirst, increased hunger, and increased urinary output. R1's ineffective health maintenance due to his deficient knowledge regarding care of his diabetic condition indicated staff educate and assist him in choosing a healthy lifestyle, explain the risks and benefits of his treatment regimen, and refer him to his physician if he would experience a worsening of his health contrition after treatment has been administered. R1's risk for injury due to [DIAGNOSES REDACTED] or [MEDICAL CONDITION] related to failure to comply with medication regimen instructed staff to offer my diabetic medications, try offering me a pop and candy bar with my medication as this is what I do like as a reward, and explain the risks and benefits to me if I would refuse diabetic medications. R1's noncompliance related to his healthcare plan instructed staff to allow him to verbalize feelings about the situation, evaluate his understanding of the disease process, barriers to compliance, lifestyle perception of non-compliance, and offer him rewards with compliance of medical regimen. He likes pop and candy bars. R1's progress note dated (MONTH) 7, (YEAR), at 6:15 p.m., indicated after supper R1 was in bed when he dug himself out and threw the stool all over the floor. R1 was resistive during cares. R1's progress note dated (MONTH) 8, (YEAR), at 2:15 a.m., indicated R1 cooperated with cares after he dug himself out and had stool everywhere. R1 allowed staff to change him when he was wet. R1 refused his medications but allowed staff to check his blood sugar. R1 can feed himself but has not eaten for a long time. Staff has been giving him the in house supplement for drinks. Staff has to anticipate R1's needs, as he will not communicate them to staff. R1 denied any pain and had no behaviors towards staff or residents. R1's progress note dated (MONTH) 8, (YEAR), at 10:39 a.m., indicated R1 ate breakfast in the dining room, and during the meal, he reached over and took food off another resident's plate. R1 then stood up, walked over to another resident, and was going to take his food. When staff redirected R1, he swore at staff and then walked to his room. R1's progress note dated (MONTH) 10, (YEAR), at 3:01 p.m., indicated R1 ate breakfast in the dining room, and then stood up and took food from R7 and R8. Then R1 walked over to other residents' tables and tried to take their food. R1 had been served an extra breakfast. When staff attempted to redirect R1, he hit staff and made a vulgar comment. R8's admission MDS dated (MONTH) 22, (YEAR), indicated R8 was moderately cognitively impaired. R1's progress note dated (MONTH) 10, (YEAR), at 11:00 p.m., indicated R1 told staff he would take his medications, but refused when they were brought to him. R1 toilets self at times, but is mostly incontinent. R1 requires much encouragement and often refuses to allow staff to change his clothes, brief, and bed linen. R1's progress note dated (MONTH) 11, (YEAR), at 3:59 p.m., indicated R1's guardian attended a care conference to address R1's decline in ADL's, refusals of cares and refusals of medications. The guardian supported comfort cares for R1, and staff will arrange for hospice to evaluate and determine if R1 qualifies for comfort cares. The care plan was updated to comfort cares, and the guardian completed a new provider orders for life sustaining treatment (POLST) to utilize comfort care from this point on. R1's progress note dated (MONTH) 11, (YEAR), at 4:36 p.m., indicated R1 was incontinent of urine this morning and refused a shower. R1 attempted to sit at dining room table with wet clothes and no shirt on, and staff redirected R1 back to his room as he hollered at staff. R1 hollered, No can't you read my mind. R1 told staff to shut up while pushing and hitting at staff. R1 made vulgar statements to staff. R1's progress note dated (MONTH) 13, (YEAR), at 12:58 p.m., indicated that morning during breakfast in the dining room R1 hollered a vulgar statement to another resident. Then R1 hollered a vulgar statement to staff and called another resident a vulgar name. R1 tried to take other residents' food and was mocking other residents. R1 refused all medications and blood sugar check. During