Every finding on record at Generations Center of Spencer

Based on facility policy review, medical record review, facility document review, and interview, the facility failed to timely report allegations of abuse to the state survey agency within the required timeframe for 6 of 6 incidents of abuse that were reviewed, which affected Residents #31, #40, #57, #18, #29, and #36. However, due to the Administrator's misunderstanding of the reporting requirements for abuse, the failure had the potential to affect all residents residing in the facility. The findings included: Review of a facility policy titled, Abuse, Neglect and Exploitation, dated 01/20/2026, indicated, The purpose of this policy is guide in the protection of residents in the prevention of abuse, neglect, exploitation, and misappropriation of resident property. The policy revealed, VII. Reporting/Response included, A. The facility will have written procedures that include, which included, 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. [exempli gratia, for example],law enforcement when applicable) within specified timeframes, which included, a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. 1. Review of an admission Record indicated the facility admitted Resident #31 on 04/08/2021. According to the admission Record, the resident had a medical history that included diagnoses of dementia with behavioral disturbances, schizoaffective disorder-bipolar type, agoraphobia with panic disorder (an anxiety disorder involving fear and avoiding places or situations that might cause panic and feeling of being trapped, helpless or embarrassed), anxiety disorder, post-traumatic stress disorder (PTSD), and borderline intellectual functioning. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2026, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) assessment score of 13, which indicated the resident had intact cognition. Review of Resident #31's Care Plan Report, included focus area initiated 02/19/2023 and revised 04/09/2026, that indicated the resident had traumatic experiences in their history (self-harm, sexual abuse) that put them at risk for daily challenges with their mood, behavior, safety, activities, and communication. Interventions directed staff to allow the resident to verbalize their feelings, offer support, monitor the resident for changes in their mood, behavior, and socialization (initiated 02/19/2023). Review of a Tennessee Health Facilities Commission form, dated 04/09/2026 and completed by the Administrator, indicated the facility reported an allegation of Sexual Abuse to the state survey agency, involving Resident #31, which occurred on 04/08/2026. The report indicated that Resident #31 reported to Certified Nursing Assistant (CNA) #2 that their roommate's family member touched their breast on 04/08/2026. The report indicated that facility staff became aware of the incident on 04/08/2026 at 11:30 PM. Per the report, the Abuse Coordinator was notified on 04/08/2026 at 11:41 PM by CNA #2. The report indicated that it was submitted to the state survey agency on 04/09/2026 at 10:17 AM, more than 10 hours after staff became aware of the allegation. On 05/13/2026 at 7:58 PM and 05/14/2026 2:08 PM, an attempt was made to contact CNA #2 without success and a voicemail was left. During an interview on 05/15/2026 at 1:02 PM, the Director of Nursing (DON) stated that all staff were expected to report any allegation of abuse or neglect immediately to the Administrator or the Social Services Director (SSD). The DON stated that all allegations of abuse or neglect were expected to be reported to the state survey agency within two hours of learning about the allegation. The DON stated the allegation involving Resident #31 was not reported to the state survey agency within the required two-hour timeframe because of the facility staff's interpretation of the guidelines and regulations. During an interview on 05/13/2026 at 2:48 PM, the Administrator, who was the Abuse Coordinator, stated that when staff see or hear an allegation of abuse or neglect, they were to immediately report to her. The Administrator stated that she was responsible for reporting to the state survey agency if there was an allegation of abuse or neglect. She stated that if there was any harm, they were to report to the state survey agency within two hours, and if there was no harm, the allegation was reported to the state survey agency within 24 hours. The Administrator stated she was notified about the allegation involving Resident #31 on 04/08/2026 in the afternoon. She stated that staff told her the resident was not tearful, felt safe, and did not display any signs and symptoms of being afraid. She stated that early the following morning, the resident was assessed again for any type of psychosocial trauma. The Administrator stated that since there was not any harm, she thought she had 24 hours to report the allegation of abuse to the state survey agency. 2. Review of an admission Record indicated the facility admitted Resident #40 on 09/19/2025. According to the admission Record, the resident had a medical history that included diagnoses of severe dementia with psychotic disturbances, major depressive disorder, and anxiety disorder. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/25/2026, revealed Resident #40 had a BIMS assessment score of 3, which indicated the resident had severe cognitive impairment. Review of Resident #40's Care Plan Report included focus area initiated 09/19/2025, that indicated the resident had multiple mental health diagnoses that included anxiety, major depressive disorder, and history of cannabis dependency, that caused the resident daily challenges with their mood, behavior, socialization, activities, and daily care. Interventions directed staff to approach the resident in a calm unhurried manner, use positive cheerful dialogue when assisting the resident to maintain and promote positive self-esteem (initiated 09/19/2025), and during episodes of confusion/increased anxiety, attempt to redirect the resident to something positive (initiated 09/19/2025). Review of an admission Record revealed the facility admitted Resident #9 on 04/09/2024. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder, and unspecified dementia. Review of an annual MDS, with an ARD of 04/20/2026, revealed Resident #9 had a BIMS assessment score of 6, which indicated the resident had severe cognitive impairment. Review of Resident #9's Care Plan Report included a focus statement initiated 04/23/2024 and revised 03/11/2026, that indicated the resident made sexually inappropriate comments towards staff during provision of care. Interventions indicated that a mental health nurse practitioner visited the resident at least every three months and as needed (initiated 04/23/2024). Review of a Tennessee Health Facilities Commission form, dated 3/11/2026 and completed by the Administrator, indicated the facility reported an allegation of Sexual Abuse to the state survey agency, involving Resident #40, which occurred on 03/06/2026 at approximately 4:20 PM. The report indicated that facility staff became aware of the incident on 03/06/2026 at 4:30 PM. Per the report, the Abuse Coordinator was notified on 03/10/2026 at 12:00 PM, four days later, by the Social Services Director (SSD). The report indicated that another resident reported that they witnessed Resident #9 place their hand on Resident #40's breast and start to rub in the dining room on 03/06/2026. The report indicated that the contact was made on the outside of Resident #40's clothing. The report indicated that it was submitted to the state survey agency on 03/11/2026 at 11:37 AM, five days after staff became aware of the allegation. During an interview on 05/13/2026 at 2:48 PM, the Administrator, who was the Abuse Coordinator, stated when staff see or hear an allegation of abuse or neglect, they were to immediately report to her. The Administrator stated that she was responsible for reporting to the state survey agency if there was an allegation of abuse or neglect. She stated that if there was any harm, they were to report to the state survey agency within two hours, and if there was no harm, the allegation was reported to the state survey agency within 24 hours. During an interview on 05/15/2026 at 1:02 PM, the Director of Nursing (DON) stated that all staff were expected to report any allegation of abuse or neglect immediately to the Administrator or the SSD. The DON stated that all allegations of abuse or neglect were expected to be reported to the state survey agency within two hours of learning about the allegation. The DON stated the allegation involving Resident #40 and Resident #9 was not reported to the state survey agency within the required two-hour timeframe because they were under the impression that they had 24 hours to report it once the Abuse Coordinator was notified and there was not any type of harm. During an interview on 05/15/2026 at 1:26 PM, the Administrator stated that staff were expected to immediately report any allegation of abuse or neglect to her or their supervisor. The Administrator stated they did not report the incident involving Resident #40 and Resident #9 within the two-hour timeframe due to their interpretation of the guidelines and regulations. She stated that she thought if there was no harm, then it needed to be reported to the state survey agency within 24 hours. 3. Review of an admission Record revealed the facility admitted Resident #57 on 11/13/2019. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, dementia, anxiety disorder, and atrial fibrillation. Review of an annual MDS, with an Assessment Reference Date (ARD) of 01/08/2026, revealed Resident #57 had a BIMS assessment score of 11, which indicated the resident had moderate cognitive impairment. Review of Resident #57's Care Plan Report included a focus area initiated 08/30/2024, that indicated that due to the resident's diagnosis of dementia, the resident was at risk for daily challenges with their memory, communication, confusion, and daily activities. Interventions directed staff to approach the resident in a calm manner and to use cheerful dialogue when assisting them (initiated 08/30/2024), Review of a Tennessee Health Facilities Commission form, dated 12/12/2025 and completed by the Administrator, indicated the facility reported an allegation of Physical Abuse to the state survey agency, involving Resident #57. The report indicated that the Abuse Coordinator was notified of the allegation on 12/11/2025 at 2:27 PM. The report indicated that it was submitted to the state survey agency on 12/12/2025 at 10:54 AM, more than 20 hours after the Abuse Coordinator was notified. During an interview on 05/13/2026 at 3:01 PM, the Administrator, who was the Abuse Coordinator, stated that Resident #57's abuse allegation was reported to her by Adult Protective Services. The Administrator stated that there was no harm to the resident, so she thought she had 24 hours to report the allegation to the state survey agency. During an interview on 05/15/2026 at 1:02 PM, the DON stated that all staff were expected to report any allegation of abuse or neglect immediately to the Administrator or the SSD. The DON stated that all allegations of abuse or neglect were expected to be reported to the state survey agency within two hours of learning about the allegation. During an interview on 05/15/2026 at 1:26 PM, the Administrator stated that staff were expected to immediately report any allegation of abuse or neglect to her or their supervisor. She stated that she thought if there was no harm, then it needed to be reported to the state survey agency within 24 hours. 4. Review of an admission Record revealed the facility admitted Resident #18 on 04/02/2026. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder and unspecified intellectual disabilities. Review of an admission MDS, with an Assessment Reference Date (ARD) of 04/13/2026, revealed Resident #18 had a BIMS assessment score of 5, which indicated the resident had severe cognitive impairment. Review of Resident #18's Care Plan Report included a problem statement initiated 04/03/2026, that indicated the resident exhibited restlessness and agitation, which caused challenges with the resident's mood, behavior, socialization, and daily care. Interventions directed staff to approach the resident in a calm, unhurried manner, and use cheerful dialogue when assisting the resident to maintain and promote a positive self-esteem (initiated 04/03/2026). Review of an admission Record revealed the facility admitted Resident #49 on 09/13/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia and anxiety disorder. Review of a quarterly MDS, with an ARD of 03/24/2026, revealed Resident #49 had a BIMS assessment score of 13, which indicated the resident had intact cognition. Review of Resident #49's Care Plan Report included a problem statement revised 05/05/2026, that indicated the resident had multiple mental health diagnoses, which caused daily challenges with their mood, behavior, socialization, activities, and daily care. Interventions directed staff to monitor the resident for changes in their mood/behavior and report to the mental health nurse practitioner (initiated 05/05/2025). Review of a Tennessee Health Facilities Commission form, dated 04/06/2026 and completed by the Administrator, indicated that the facility reported an allegation of Mental Abuse involving Resident #18 and Resident #49, to the state survey agency. The report revealed that on 04/05/2026 at approximately 5:00 PM, Resident #18 yelled at Resident #49, stating, If I had a knife [sic] I would cut you. The report listed four staff names as witnesses to the incident. The report indicated that the Abuse Coordinator was notified of the incident on 04/05/2026 at approximately 8:28 PM. The report indicated that it was submitted to the state survey agency on 04/06/2026 at 2:10 PM, more than 20 hours after the 5:00 PM incident. During an interview on 05/15/2026 at 1:26 PM, the Administrator, who was the Abuse Coordinator, stated that staff were expected to immediately report any allegation of abuse or neglect to her or their supervisor. She stated that she thought if there was no harm, then it needed to be reported to the state survey agency within 24 hours. 5. Review of an admission Record revealed the facility admitted Resident #29 on 04/21/2021. According to the admission Record, the resident had a medical history that included diagnoses of vascular dementia, major depressive disorder, high risk heterosexual behavior, and expressive language disorder. Review of a quarterly MDS, with an Assessment Reference Date (ARD) of 01/27/2026, revealed Resident #29 had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. Review of Resident #29's Care Plan Report included a problem statement initiated 07/31/2024 and revised 03/19/2026, that indicated that the resident was inappropriate, physically and verbally, to staff during provision of care at times. Interventions indicated that social services staff were to visit the resident as needed to discuss any concerns or needs the resident had (initiated 07/31/2024). Review of a Tennessee Health Facilities Commission form, dated 03/17/2026 and completed by the Administrator, indicated that the facility reported an allegation of Physical Abuse involving Resident #29 to the state survey agency. The report indicated that on 03/16/2026 at approximately 1:00 PM, Resident #29 grabbed Certified Nursing Assistant (CNA) #1's buttocks and the CNA in turn slapped Resident #29 on the buttocks, stating the resident could not [expletive] grab her like that. The report indicated that CNA #4 witnessed the incident. Per the report, the CNA reported the incident on 03/17/2026 at approximately 6:25 PM, more than five hours after the incident. The report indicated that it was submitted to the state survey agency on 03/17/2026 at 11:20 AM, more than 20 hours after the incident. Review of an email from the Tennessee Health Facilities Commission, dated 03/17/2026 at 11:22 AM, revealed confirmation that the state survey agency received the report. Review of a Follow-up Investigation Report indicated that CNA #4 did not immediately report the incident involving CNA #1 and Resident #29 because the resident was not harmed and was laughing, but she thought about the events and reported it to the Administrator on 03/17/2026. During an interview on 05/13/2026 at 11:25 AM, CNA #4 stated that during the incident with Resident #29, she was with another CNA whose name she could not remember. She stated that she and the other CNA rolled the resident when the resident grabbed the other CNA's buttocks. She stated that the other CNA smacked Resident #29 on the hip and said the resident could not touch her like that. CNA #4 stated that Resident #29 was laughing and did not seem distraught. She stated that she reported it the following day and said the delay was her fault. She stated that she did not think about it at the time because the resident grabbed the other CNA first. During an interview on 05/15/2026 at 1:02 PM, the DON stated that all staff were expected to report any allegation of abuse or neglect immediately to the Administrator or the SSD. The DON stated that all allegations of abuse or neglect were expected to be reported to the state survey agency within two hours of learning about the allegation. During an interview on 05/15/2026 at 1:26 PM, the Administrator, who was the Abuse Coordinator, stated that staff were expected to immediately report any allegation of abuse or neglect to her or their supervisor. She stated that she thought if there was no harm, then it needed to be reported to the state survey agency within 24 hours. 6. Review of an admission Record revealed the facility admitted Resident #36 on 07/20/2022. According to the admission Record, the resident had a medical history that included diagnoses of generalized anxiety, heart failure, and type 2 diabetes. Review of a quarterly MDS, with an Assessment Reference Date (ARD) of 12/08/2025, revealed Resident #36 had a BIMS assessment score of 15, which indicated the resident had intact cognition. Review of Resident #36's Care Plan Report included a focus area initiated 04/08/2026, that indicated Resident #36 had dementia and experienced daily challenges with communication, episodes of confusion, and daily activities. Interventions directed staff to approach the resident in a calm, unhurried manner (initiated 04/08/2026) and use positive cheerful dialogue when assisting the resident (initiated 04/08/2026). Review of an admission Record revealed the facility admitted Resident #67 on 12/27/2022. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, bipolar type; and hypertension. Review of a quarterly MDS, with an ARD of 03/09/2026, revealed Resident #67 had a BIMS assessment score of 10, which indicated the resident had moderate cognitive impairment. Review of Resident #67's Care Plan Report included a focus area initiated 09/03/2024, that indicated Resident #67 had schizoaffective disorder and anxiety disorder that caused daily changes in the resident's mood, behavior, and socialization. Interventions directed staff to attempt to re-direct the resident to do something positive during episodes of increased anxiety and hallucinations (initiated 09/03/2024). Review of a Tennessee Health Facilities Commission report, dated 12/19/2025, indicated the facility reported an allegation of verbal abuse involving a resident-to-resident interaction between Resident #36 and Resident #67 to the state survey agency. The report revealed the facility staff became aware of the incident on 12/19/2025 at approximately 12:00 PM. Per the report, the Mental Health Nurse Practitioner (MHNP) entered a progress note on 12/18/2025 at 11:14 AM indicating that on 12/16/2025, staff reported that Resident #67 screamed at their roommate, Resident #36, while in their room. The report indicated that it was submitted to the state survey agency on 12/19/2025 at 4:39 PM. Review of a facility document titled, Resident Abuse Investigation Report Form indicated that on 12/13/2025 between 6:00 PM and 7:00 PM, Licensed Practical Nurse (LPN) #10 and Certified Nursing Assistant (CNA) #14 heard Resident #67 yelling at their roommate, alleging that their roommate had taken $5.00. Review of a handwritten statement signed by LPN #10, dated 12/13/2025 revealed that LPN #10 noted that Resident #67 yelled at their roommate, Resident #36, accusing them of stealing. The statement indicated that LPN #10 reported the incident to Administration, the SSD, and the MHNP. During an interview on 05/12/2026 at 11:27 AM, the Administrator stated that she thought the incident between Resident #36 and Resident #67 took place on 12/13/2025 but she was not sure. She stated that she became aware of the incident on 12/19/2025. She stated that LPN #10 said in a statement that she told administration, meaning the DON, the SSD, and the Mental Health Nurse Practitioner (MHNP). She stated that the DON and SSD both said they did not know, but the MHNP did mention it in a note. During an interview on 05/12/2026 at 10:16 AM, the Medical Records Nurse stated that LPN #10 and CNA #14 witnessed the verbal abuse between Resident #36 and Resident #67 and reported it to the MHNP but not their supervisors. During an interview on 05/12/2026 at 4:50 PM, LPN #10 stated that on 12/13/2025 at approximately 7:00 PM, she was with CNA #14 when they answered a call light and Resident #36 accused Resident #67 of taking $5.00 and she assisted in de-escalating the situation. She stated that she notified the DON by text at the time and left a written note under the SSD's door and left a note for the MHNP. During an interview on 05/13/2026 at 8:03 AM, the SSD stated abuse allegations should be reported immediately. She stated that she did not recall receiving a note from LPN #10 about the 12/13/2025 incident. She stated she became aware of the incident on 12/19/2025. During an interview on 05/13/2026 at 8:12 AM, the DON stated she did not recall receiving a text message from LPN #10 on 12/13/2025. She stated that she first became aware of the 12/13/2025 incident on 12/18/2025 or 12/19/2025, after being informed by the Medical Records Nurse. During an interview on 05/15/2026 at 1:02 PM, the DON stated that all staff were expected to report any allegation of abuse or neglect immediately to the Administrator or the SSD. The DON stated that all allegations of abuse or neglect were expected to be reported to the state survey agency within two hours of learning about the allegation. During an interview on 05/15/2026 at 1:26 PM, the Administrator stated that staff were expected to immediately report any allegation of abuse or neglect to her or their supervisor. She stated that she thought if there was no harm, then it needed to be reported to the state survey agency within 24 hours.

Based on facility policy review, medical record review, observation, Humalog KwikPen insulin manufacturer instruction review, and interview, the facility failed to ensure an error rate of 5 percent (%) or less during a medication administration observation. There were 2 errors out of 31 opportunities, which resulted in a medication error rate of 6.45% affecting 2 (Resident #44 and Resident #7) of 5 residents observed for medication administration. The findings included: Review of a facility policy titled, Liberalized Medication Administration Policy, effective 11/01/2019, indicated, Medications which are ordered by the physician for a specific time will be given as such. All other medications will be given as ordered per the resident's desires and daily schedules. Review of an admission Record revealed the facility admitted Resident #44 on 04/03/2024. According to the admission Record, the resident had a medical history that included a diagnosis of epilepsy (seizure disorder). Review of Resident #44's Order Summary Report, with active orders as of 05/12/2026, included an order dated 05/05/2026 for levetiracetam oral solution 100 milligrams (mg) per milliliter (ml) with instructions to give 7.5 ml by mouth two times a day for epilepsy. During an observation of medication administration on 05/12/2026 at 7:50 AM, Registered Nurse (RN) #6 prepared and administered 10 ml of the levetiracetam 100 mg per ml to Resident #44 instead of 7.5 ml as ordered. Review of an undated Instructions for Use Humalog KwikPen insulin lispro injection instruction manual, revealed the section titled, Priming your Humalog KwikPen, included, Prime before each injection. Priming ensures the Pen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin. The manual continued, Step 5: Turn the Dose Knob to select 2 units. Step 6: Hold your Pen with the Needle pointing up. Tap the Cartridge holder gently to collect air bubbles at the top. Step 7: Hold your Pen with the Needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. A stream of insulin should be seen from the needle. The manual continued, Step 8: Turn the Dose Knob to select the number of units you need to inject. The Dose Indicator should line up with your dose. Review of an admission Record indicated the facility admitted Resident #7 on 03/18/2024. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. Review of Resident #7's Order Summary Report, with active orders as of 05/12/2026, included an order dated 07/21/2025 for Insulin Lispro (rapid-acting insulin) subcutaneous solution pen-injector 100 unit per ml, with instructions to inject per sliding scale (dose of insulin based upon the blood glucose level). During an observation of medication administration on 05/12/2026 at 11:17 AM, RN #7 prepared Resident #7's Insulin Lispro KwikPen. RN #7 turned the dose selector to 4 units, then turned to administer the insulin to the resident. The surveyor stopped RN #7 and asked if the pen was primed, and the RN stated they did not have to prime the pen. During an interview on 05/12/2026 at 11:28 AM, RN #7 stated it had been a while since she was trained on the insulin pen but could refer to the policy and procedure manual. RN #7 stated the importance of priming the insulin pen was because it was not the correct dose without priming the pen. During an interview on 05/14/2026 at 2:38 PM, the Director of Nursing (DON) stated she expected the nurses to administer medications by the medication administration record and to follow the physician orders. The DON stated Resident #44's physician order was for 7.5 ml of levetiracetam oral solution 100 mg per ml two times a day, and the resident should not have received 10 ml. The DON stated RN #7 should have primed the Insulin pen. The DON said she expected the medication error rate to be less than 5%. During an interview on 05/14/2026 at 2:51 PM, the Administrator stated she expected the physician orders to be followed and the medication error rate to be less than 5%.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on facility policy review, medical record review, facility document review, and interview, the facility failed to protect the resident's right to be free from verbal abuse by another resident for 1 (Resident #49) of 9 residents reviewed for abuse. Specifically, on 04/03/2026 and on 04/05/2026, staff overheard Resident #18 verbally threaten Resident #49. The findings included: Review of a facility policy titled, Abuse Prevention Program, dated 01/20/2026, indicated, The residents of [facility name] have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Abuse is prohibited. Review of a facility policy titled, Abuse, Neglect and Exploitation, dated 01/20/2026, indicated, The purpose of this policy is guide in the protection of residents in the prevention of abuse, neglect, exploitation, and misappropriation of resident property. The policy further indicated, .B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body 3. Physical injury of a resident, of unknown source 4. Resident reports of theft of property, or missing property 5. Verbal abuse of a resident overheard. Review of an admission Record revealed the facility admitted Resident #18 on 04/02/2026. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder and unspecified intellectual disabilities. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/13/2026, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) assessment score of 5, which indicated the resident had severe cognitive impairment. Review of Resident #18's Care Plan Report included a problem statement initiated 04/03/2026, that indicated the resident exhibited restlessness and agitation, which caused challenges with mood, behavior, socialization, and daily care. Interventions directed staff to approach the resident in a clam unhurried manner and use cheerful dialogue when assisting the resident, to maintain and promote a positive self-esteem (initiated 04/03/2026), and one-to-one staff observation for safety (initiated 04/05/2026). Review of an admission Record revealed the facility admitted Resident #49 on 09/13/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia and anxiety disorder. Review of a quarterly MDS, with an ARD of 03/24/2026, revealed Resident #49 had a BIMS score of 13, which indicated the resident had intact cognition. Review of Resident #49's Care Plan Report included a problem statement, revised 04/06/2026, that indicated the resident had multiple mental health diagnoses, which caused daily challenges with their mood, behavior, socialization, activities, and daily care. The Care Plan Report indicated the resident had recently made statements about emotional distress related to interactions with peers. Interventions included increased support by social services and activities staff (initiated 04/05/2026) and Licensed Clinical Social Worker (LCSW) to increase visits with the resident and staff to encourage the resident to attend visits. Review of a Tennessee Health Facilities Commission form, dated 04/06/2026 and completed by the Administrator, indicated that the facility reported an allegation of Mental Abuse involving Resident #18 and Resident #49, to the state survey agency. The report indicated that on 04/03/2026 at approximately 12:30 PM, Resident #49 told Resident #18 that they could not skip the line when waiting to go to a smoke break. While at the gazebo during the smoke break, Resident #18 told Resident #49 that if they had a butcher knife, they would cut Resident #49's throat. On 04/05/2026, at approximately 5:00 PM, Resident #18 yelled at Resident #49, stating, If I had a knife I would cut you. Per the form, Resident #49 indicated they felt safe in the facility, but was fearful of Resident #18. Review of a Follow-up Investigation Report, dated 04/10/2026, and signed by the Administrator, revealed that on 04/03/2026 a verbal altercation occurred at the gazebo area between Resident #18 and Resident #49. The report further indicated that on 04/05/2026 at approximately 5:20 PM, at the evening meal, Resident #18 became agitated and verbally aggressive toward Resident #49 and made threatening comments to Resident #49. Per the report, Resident #18 stated they were going to knock [Resident #49's] [expletive] head off. Resident #18 also said if they had a butcher knife, they would cut Resident #49's throat. Per the report, Resident #49 verbalized being upset immediately following the event, but reported no feelings of fear, anxiety, distress, depression, or humiliation. The report indicated Resident #49 had no changes in behaviors following the event. Review of a facility typed document titled, On 04/06/2026 at 9:30 am. [Resident #49] interview, signed and dated by Resident #49 on 04/06/2026, revealed that on Friday (04/03/2026) during the 12:30 smoke break, Resident #18 told Resident #49 that if they had a butcher knife, they would cut Resident #49's throat. Per the document, Resident #49 indicated they felt threatened. The document also revealed that on Sunday 04/05/2026 at approximately 5:20 PM, they were just finishing supper and Resident #49 was talking to another resident when suddenly, Resident #18 jumped up and stated, If I had a knife, I would cut you. Per the document, Resident #49 indicated they felt like they had been abused. Review of Certified Nursing Assistant (CNA) #16's signed witness statement, dated 04/06/2026, revealed that on 04/05/2026, while staff were passing out drinks, Resident #18 jumped from their table and yelled at Resident #49, stating they were going to knock [Resident #49's] [expletive] block off. Per the witness statement, CNA #11 and CNA #16 explained to Resident #18 that was not appropriate, and Resident #18 apologized and there were no further incidents until dinner was almost done. The witness statement revealed, at that time, Resident #49 was talking to another resident, when Resident #18 jumped up, and yelled that they were going to beat the [expletive] out of Resident #49. Review of CNA #11's signed, undated witness statement revealed that on 04/05/2026, Resident #49 was talking to another resident when Resident #18 threatened to cut Resident #49's throat. The statement revealed that a second time, while Resident #49 was talking to another resident, Resident #18 jumped from their chair and started calling Resident #49 names and saying he/she was going to kill Resident #49. During an interview on 05/12/2026 at 2:06 PM, CNA #16 revealed she witnessed the incident between Resident #18 and Resident #49 in the dining room. She stated there were two incidents that day. First, when staff passed out drinks before dinner, Resident #18 jumped up and cursed at Resident #49, stating [he/she] was going to knock [Resident #49's] [expletive] head off. CNA #16 said she told Resident #18 that behavior was not appropriate, and Resident #18 apologized and sat down. As dinner was finishing, Resident #49 was talking to another resident. Resident #18 believed Resident #49 was speaking ugly to them, and Resident #18 started cursing at Resident #49, stating they were going to beat the [expletive] out of Resident #49. During an interview on 05/13/2026 at 10:37 AM, CNA #11 said they recalled the incident with Resident #18 and Resident #49 and confirmed her witness statement was consistent with what she recalled. During an interview on 05/13/2026 at 10:58 AM, Janitor #17 revealed he witnessed the incident between Resident #18 and Resident #49 in the dining room. Janitor #17 stated Resident #18 was verbally abusive to Resident #49 and threatened to kill Resident #49. He stated Resident #49 was very upset. During an interview on 05/14/2026 at 8:29 AM, Resident #49 said they recalled the incident when Resident #18 said they were going to cut Resident #49's throat. Resident #49 said it was all settled, and the two residents got along currently. Review of the Follow-up Investigation Report, dated 04/10/2026, and signed by the Administrator, indicated the facility implemented the following corrective actions beginning on 04/05/2026: The Social Service Director (SSD) came on-site to provide support on 04/05/2026; Medication and mental health services review were completed by the MHNP on 04/07/2026; Resident #18 was placed on one-on-one staff supervision when out of the room to support transition into their new community and provide direction and calming as needed on 04/05/2026; Care plan reviewed and updated by the interdisciplinary team (IDT) committee on 04/06/2026; Private room was provided for Resident #18 on 04/05/2026 to support adjustment and calming and Preadmission Screening and Resident Review (PASRR) was completed on 04/09/2026; Peer support group was provided on 04/09/2026 to reestablish positive communication between the two residents; Council meeting was held to initiate change in waiting areas for supervised smoking activities on 04/07/2026 and staff education initiated 04/07/2026 through 04/10/2026 to provide education on change; A medical chart review was conducted by the Director of Nursing (DON) on 04/04/2026 for both residents. The Report indicated the plan for oversight of implementation of the corrective action included: SSD was to orient new residents that smoke to the smoking procedures, including times, staff support, and waiting areas; admission of a resident policy reviewed and updated by Quality Assurance and Assessment (QAA) committee on 04/09/2026 to include PASRR review; admission review team educated on admission of a Resident policy update on 04/09/2026; QAA committee would review 100% of admissions for the next 90 days to promote orientation process and review of medical records pre-admission. The Report indicated the following steps taken to address systems that were identified that required correction: admission of a Resident Policy reviewed and updated by QAA committee on 04/09/2026 to include PASRR review; admission review team educated on admission of a Resident policy update on 04/09/2026; QAA committee will review 100% of admissions for the next 90 days to promote orientation process and review of medical records pre-admission. During an interview on 05/14/2026 at 3:07 PM, the Administrator stated immediate interventions put into place after the incident included: staff assisted Resident #18 to the resident's room and remained with the resident for emotional support, the SSD came to the facility to assist, a medication and mental health service review was conducted, one-on-one staff monitoring was put into place for Resident #18, smoke break concerns were discussed in resident council, staff training was completed, and a quality assurance meeting was held on 04/09/2026. After review and verification of the facility's corrective actions, to include the facility's investigation, facility audits, staff education, and interviews with staff, the survey team determined the facility implemented the above corrective actions beginning on 04/05/2026 and conducted ongoing education and monitoring; therefore, past noncompliance was cited.

Based on facility policy review, medical record review, and interview, the facility failed to immediately implement protective measures following an allegation of resident-to-resident verbal abuse involving 2 residents (Resident #67 and Resident #36) of 9 residents sampled for abuse. Specifically, on 12/13/2025, Resident #67 screamed at their roommate (Resident #36) and the facility failed to implement protective measures until management became aware of the incident on 12/19/2025. The findings included: Review of a facility policy titled, Abuse, Neglect and Exploitation Procedures, dated 01/20/2026, indicated, .The purpose of this policy is guide in the protection of residents in the prevention of abuse, neglect, exploitation, and misappropriation of resident property . The policy revealed, VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: included, .C. Increased supervision of the alleged victim and residents .D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences changes as a result of an incident of abuse . Review of an admission Record revealed the facility admitted Resident #67 on 12/27/2022. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, bipolar type, and hypertension. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2026, revealed Resident #67 had a Brief Interview for Mental Status (BIMS) assessment score of 10, which indicated the resident had moderate cognitive impairment. Review of Resident # 67's Care Plan Report included a focus area initiated 09/03/2024, that indicated Resident #67 had schizoaffective disorder and anxiety disorder that caused daily changes in the resident's mood, behavior, and socialization. Interventions directed staff to attempt to re-direct the resident to do something positive during episodes of increased anxiety and hallucinations (initiated 09/03/2024). Review of an admission Record revealed the facility admitted Resident #36 on 07/20/2022. According to the admission Record, the resident had a medical history that included diagnoses of generalized anxiety, heart failure, and type 2 diabetes. Review of a quarterly MDS, with an Assessment Reference Date (ARD) of 12/08/2025, revealed Resident #36 had a BIMS assessment score of 15, which indicated the resident had intact cognition. Review of Resident #36's Care Plan Report included a focus area initiated 04/08/2026, that indicated Resident #36 had dementia and experienced daily challenges with communication, episodes of confusion, and daily activities. Interventions directed staff to approach the resident in a calm, unhurried manner (initiated 04/08/2026) and use positive cheerful dialogue when assisting the resident (initiated 04/08/2026). Review of a Tennessee Health Facilities Commission report, dated 12/19/2025, indicated the facility reported an allegation of verbal abuse involving a resident-to-resident interaction between Resident #36 and Resident #67 to the state survey agency. The report revealed the facility staff became aware of the incident on 12/19/2025 at approximately 12:00 PM. Per the report, the Mental Health Nurse Practitioner (MHNP) entered a progress note on 12/18/2025 at 11:14 AM indicating that on 12/16/2025, staff reported that Resident #67 screamed at their roommate, Resident #36, while in their room. The report indicated that it was submitted to the state survey agency on 12/19/2025 at 4:39 PM. Review of a facility document titled, Resident Abuse Investigation Report Form indicated that on 12/13/2025 between 6:00 PM and 7:00 PM, Licensed Practical Nurse (LPN) #10 and Certified Nursing Assistant (CNA) #14 heard Resident #67 yelling at their roommate, alleging that their roommate had taken $5.00. Review of a handwritten statement signed by LPN #10, dated 12/13/2025 revealed that LPN #10 noted that Resident #67 yelled at their roommate, Resident #36, accusing them of stealing. The statement indicated that LPN #10 reported the incident to Administration, the Social Services Director (SSD), and the MHNP. During an interview on 05/12/2026 at 4:50 PM, LPN #10 stated that on 12/13/2025 at approximately 7:00 PM, she was with CNA #14 when they answered a call light and Resident #36 accused Resident #67 of taking $5.00 and she assisted in de-escalating the situation. She stated that she notified the Director of Nursing (DON) by text at the time and left a written note under the SSD's door and left a note for the MHNP. LPN #10 said she did not separate the residents, put interventions into place, update the care plan, or document the incident. During an interview on 05/12/2026 at 1:56 PM, CNA #15 confirmed she worked on 12/16/2025, 12/17/2025, and 12/18/2025. She stated she was unaware of the incident between Resident #36 and Resident #67 at that time and only became aware when asked to write a statement. CNA #15 said had she been aware, she would have attempted to keep the residents separated and would have increased monitoring since the two residents shared a room. During an interview on 05/15/2026 at 8:17 AM, Registered Nurse (RN) #7 confirmed she worked on 12/14/2025, 12/17/2025, and 12/18/2025 and said she was unaware of the incident between Resident #36 and Resident #67. She stated there were no nursing notes or interventions documented. She stated had she known, she would have separated the residents immediately or at least left the door open to their shared room. During an interview on 05/13/2026 at 8:12 AM, the DON stated the residents should have been separated and interventions implemented. She confirmed there was no documentation of interventions and that she could not identify any actions taken between 12/13/2025 and 12/19/2025 to prevent recurrence. During a follow-up interview on 05/15/2026 at 10:47 AM, the DON stated staff should have separated Resident #36 and Resident #67 immediately when the incident occurred. During an interview on 05/12/2026 at 11:27 AM, the Administrator stated she became aware of the 12/13/2025 altercation on 12/19/2025. She stated there were no progress notes or documented interventions, and she could not identify any actions taken to protect Resident #36 between 12/13/2025 and 12/19/2025. During a follow-up interview on 05/15/2026 at 1:25 PM, the Administrator stated that the residents' care plans should have been reviewed, and interventions should have been put in place to prevent recurrence. The Administrator stated the residents remained in their shared room, and the expectation was for staff to offer a room change at the time of the incident, and to implement and document safety interventions.

Based on facility policy review, observation and interview, the facility failed to contain garbage and refuse in a water sealed dumpster for 2 of 2 garbage dumpsters and failed to maintain the garbage storage area in a safe and sanitary condition. The findings include: Review of the facility's undated policy, Waste Disposal Procedure, revealed .All infectious and regulated waste destined for disposal shall be placed in closable leak-proof containers .All garbage, trash, and other non-infectious waste shall be stored and disposed of in a manner that shall not permit the transmission of disease, create a nuisance, provide a breeding place for insects and rodents . During an observation and interview on 10/7/2024 at 12:00 PM, with the Dietary Manager, showed the facility had 2 dumpsters for garbage, waste and refuse disposal. The observation revealed 2 of 2 dumpsters were surrounded by scattered garbage on all four sides which included multiple used exam gloves, multiple broken plastic cups of various sizes, and multiple pieces of cardboard and paper of various sizes. Further observation revealed multiple garbage bags in 2 of 2 dumpsters with visible sunlight entering from the bottom of the dumpster in 2 of 2 dumpsters. Dumpster 1 was observed to have a horizontal crack surrounded with rust on the bottom of the back side of the dumpster facing away from the building. Dumpster 2 had a waste drain on the back side of the dumpster facing away from the building without a dumpster plug in place. The Dietary Manager stated Dumpster 1 and Dumpster 2 were used to dispose of garbage, waste, and refuse. The Dietary manager confirmed Dumpster 1 and Dumpster 2 were not leak-proof containers and confirmed the garbage area was not maintained in a safe and sanitary condition.

Based on facility policy review, medical record review, facility investigation review and interview, the facility failed to complete a thorough investigation of falls for 2 residents (Resident #67 and #323) of 3 residents reviewed for falls. The findings include: Review of the facility's undated policy titled, ACCIDENTS AND INCIDENTS-INVESTIGATING AND REPORTING PROCEDURES, revealed .The following data as applicable, shall be included on the report of incident/accident form .the circumstances surrounding the accident or incident .names .and their accounts of the accident or incident .Any corrective action taken .Follow-up information .other pertinent data as necessary or required . Medical record review revealed Resident #67 was admitted to the facility on [DATE], with diagnoses including Schizoaffective Disorder, Cerebrovascular Disease, Epilepsy, Disorders of Brain, and Closed Fractures of the 3rd and 4th Fingers on the Left Hand. Review of the current comprehensive care plan for Resident #67, revealed the resident had .poor safety awareness .multiple falls .required extensive assistance with transfers .gait .unsteady .poor balance .overestimate .ability and continue to attempt to transfer myself this puts .at risk for falls/injuries . Interventions included .call light .available .answered promptly .fall mat right side of bed .safety reminders .encourage proper footwear .Provide .assistance as needed .wheelchair for locomotion .keep .available and in good repair .Monitor .environment for safety. Make changes as needed .report to MD [Medical Doctor] .ensure .area .is clutter free, well lit .free of spills .Seatbelt with alarm in wheelchair .[all initiated on 4/23/2024] .1:1 supervision while in any other chair beside my wheelchair .[initiated on 8/7/2024] .[non-slip material] to wheelchair .assist .to recline .chair, except during mealtime, it is more comfortable for me .relieves .pressure on my back .buttocks when I am up to my chair .keep bed in lowest position .[initiated on 8/23/2024] . Review of the facility's fall packet dated 8/7/2024 at 5:30 PM, revealed Resident #67 was observed in the dining room sitting in the floor on the bottom. The staff member present reported she heard oh shoot and observed Resident #67 sitting on the floor. The resident had been transferred from a wheelchair to a regular dining room chair at the start of dinner. Resident #67 denied any pain or injury. The packet revealed staff were educated that Resident #67 was to remain in the wheelchair with a seatbelt and safety alarm on when out of bed, but if the resident was removed from the wheelchair and placed in a regular chair, staff were to remain with the resident. The fall packet did not reveal any witness statements, did not identify who the staff person was in the dining room, at the time of the fall, and did not identify who the staff person was that moved Resident #67 from the wheelchair to a regular dining room chair. Review of the facility's fall packet dated 8/23/2024, 16 days following the 8/7/2024 fall, revealed Resident #67 was observed on the floor. The resident reported he was attempting to stand up to use the bathroom and his lower back was hurting from sitting in the wheelchair. The resident denied pain or injury. Resident #67 was toileted; a non-slip material was added to the seat of the wheelchair and the resident was assisted back to the wheelchair. The back of the wheelchair was reclined slightly for comfort. Continued review of the fall packet did not reveal who found Resident #67 in the floor or the last time the resident was observed or toileted. 50480 Medical record review revealed Resident #323 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Congestive Heart Failure, Vascular Dementia, Depression, Peripheral Vascular Insufficiency, and Lack of Coordination. Review of the current comprehensive care plan for Resident #323 revealed the following interventions were listed prior to 6/16/2024: ensure the resident's area was clutter free, well-lit and free of spills for safety; ensure the call light was available and answered promptly; give frequent reminders to use the call light for assistance; observe the resident's environment for safety and make changes as needed and report to the Medical Doctor (MD). Use a wheel chair for locomotion, keep it available and in good repair. The care plan revealed the resident had geri chair (a specialized reclining chair); was provided frequent safety reminders by staff; encouraged the use of proper footwear; provided assistance as needed; and monitored by staff for changes in balance. The following interventions were added to the comprehensive care plan: bed in lowest position at all times .I have an electric bed and I do raise it myself . (7/14/2024); provide visual reminders to lock wheelchair brakes prior to repositioning (7/28/2024); a non-slip material to wheelchair seat (8/13/2024); anti-thrust cushion to wheelchair seat (8/21/2024). Review of the facility's fall packet dated 6/16/2024, revealed Resident #323 had an unwitnessed fall while attempting to transfer self in bathroom. No injuries were noted. The falls packet revealed .CNA [certified nursing assistant-unknown] entered bathroom to check on him .staff educated to assist resident with toileting needs and to not leave resident unattended during toileting . The immediate interventions included staff and resident education and neurological (neuro) checks of the resident per the facility's policy. The fall packet did not include the identity of the staff member who alerted the nurse of the fall or included how long the resident had been left in the bathroom unattended. Review of the facility's fall packet dated 6/21/2024, 5 days after the 6/16/2024 fall, revealed Resident #323 had an unwitnessed fall. The falls packet revealed .Called to resident's room by housekeeping .resident observed on his left side in the floor .pad in wc [wheelchair] halfway out and floor was wet .resident stated he slid out of wc .added nonskid material to wheelchair . The falls packet determined the cause of the wet floor was urine. Review of the fall packet revealed Resident #323 suffered a couple of scratches to the left side of head, a scratch to the left ear, and had a reddened area to his back. The immediate interventions included neuro checks and to add a non-slip socks or proper foot ware. The falls packet did not include the statements of witnesses, who discovered the resident or alerted the nurse, last observation of the resident, or when the resident was last toileted. Review of the facility's fall packet dated 7/14/2024, revealed Resident #323 had an unwitnessed fall .CNA responded .resident .sitting on the floor .Resident stated was trying to turn over myself, but I slid out of bed .Resident educated about the importance of waiting for assistance . Continued review showed no injuries were noted. The immediate interventions included staff and resident education and ensure the bed was in the lowest position (placed on the care plan 7/14/2024). The fall investigation did not include a statement from the CNA who responded to the resident. Review of the facility's fall packet dated 8/14/2024, revealed Resident #323 had an unwitnessed fall from his wheelchair while seated outside in a secured gated resident courtyard area. The fall packet revealed another resident had entered the code to the door of the courtyard to allow Resident #323 exit from the door into the secured courtyard. Resident #323 was sent to the hospital for evaluation and treatments related to the resident's increased confusion and multiple skin injuries. The review revealed the resident returned to the facility with an incidental finding on a chest x-ray of pneumonia and was started on antibiotics. A medication review was performed 8/16/2024 with a reduction of Trazadone (a medication used for depression). The fall investigation packet did not include who observed the resident outside in the courtyard, details surrounding the fall or how long the resident had been outside. During an interview on 10/22/2024 at 2:00 PM, the Director of Nursing (DON) stated the root cause of Resident #323's fall on 8/14/2024 was the resident fell asleep in his wheelchair while sitting outside on the secured (gated) courtyard area and fell out of his chair which resulted in injuries (laceration and abrasion to left forehead, abrasions to 3rd/4th finger on right hand, abrasion to both knees, abrasion to right arm, and laceration to 2nd/3rd toe on left foot). The DON stated Resident #323 was sent to hospital for an evaluation, was diagnosed with Pneumonia, and was started on antibiotics. The DON stated the investigation conducted after the fall on 8/14/2024, revealed Resident #323 had been permitted to sit outside in the secured area with staff check-ins. The DON stated the resident loved to sit outdoors and at the time of the fall was cognitively intact. The DON stated prior to the fall occurrence on 8/14/2024, the protocol was for the staff to assist Resident #323 outside to sit and periodically check in with the resident. The DON further stated upon physician notification of the fall on 8/14/2024, the facility was given additional orders and interventions for hourly checks of the resident, laboratory orders, and a medication review. During an interview on 10/22/2024 at 7:05 PM, Licensed Practical Nurse (LPN) R stated she was the nurse assigned to Resident #323 on 8/14/2024. LPN stated she had just started her shift and was getting Resident #323's medication ready for administration when she observed Resident #323 at approximately 6:30 PM-6:45 PM self-propelling his wheelchair down the hallway. LPN R stated she instructed the resident not to go too far because she would be getting his medications ready for him to take. LPN R stated the resident acknowledged her and continued down the hall. LPN R stated shortly after talking with the resident, she was alerted by a staff member (unknown as she heard a yell) to come to the resident's courtyard area. LPN R stated when she arrived to the courtyard at approximately 7:15 PM, Resident #323 was about 6-12 feet from the doorway, his wheelchair was in the upright position, and the resident was lying on the ground, on his left side. LPN R stated the resident had multiple skin tears, abrasion injuries, and was disoriented. LPN R stated the resident was sent to the ER. LPN R further stated the physician was notified and upon the resident's return from the ER, the physician ordered hourly checks, laboratory orders, and a medication review. LPN R stated she met with the staff and it determined the root cause of Resident #323's fall on 8/14/2024 was that he fell asleep in his wheelchair while sitting outside and fell out of the wheelchair. LPN R stated the resident loved to sit outdoors and usually sat outside in the evenings with the other residents. During an interview on 10/22/2024 at 7:25 PM, CNA Q stated she was assigned to provide care for Resident #323 on 8/14/2024. CNA Q stated she was completing rounds on her hall when she went into Resident #323's room to see if he wanted to go to the bathroom. CNA Q stated when the resident was not in the room, she went to the gated courtyard area to check on him. CNA stated Resident #323 frequently went to the courtyard in the evenings and knew if the resident was not in his room that is where he would be located. CNA Q stated at approximately 6:55-7:05 PM, she went to the gated area and observed Resident #323 sitting in his wheelchair talking to another resident. CNA Q stated she spoke to the resident and he stated he was ok and wanted to come back inside the facility around 7:30 PM to get ready for bed. CNA stated at 7:15 PM she heard a yell down the hall that a resident had fell in the courtyard area and help was needed. CNA Q stated when she got to the courtyard, Resident #323 was close to the doorway, the wheelchair was in the upright position, and the resident was lying on the ground, on his left side. CNA Q stated the nurse assessed the resident and the resident was sent to the ER. Review of the facility's fall packet dated 8/21/2024, revealed Resident #323 had an unwitnessed fall while attempting to get out of the wheelchair to ambulate without assistance, with no injuries noted. Review of the packet revealed the intervention was to add an anti-thrust wedge cushion to the wheelchair seat. The fall packet did not include the statements of witnesses, who discovered the resident, or who had alerted the nurse. Review of the facility's fall packet dated 8/25/2024, 4 days after the previous fall, revealed Resident #323 had an unwitnessed fall and reported he rolled out of bed. The resident suffered a hematoma and laceration to the bridge of his nose. The interventions included to add a grab bar to the left side of the bed, bed bolsters (added to care plan 8/26/2024), and a fall mat to the left side of the bed (added to care plan 8/25/2024). The falls packet did not include the statements of witnesses or the resident, who discovered the resident, or who had alerted the nurse. Review of the medical record for Resident #323 revealed the resident had no further falls after 8/25/2024. During an interview on 10/9/2024 at 10:34 AM, the Falls Coordinator revealed when a fall incident occurred the nursing staff had an incident/accident (fall) packet to complete. The Falls Coordinator reviewed the packet, documented a summary, and added additional fall interventions, if necessary. The Minimum Data Set (MDS) Nurse added the interventions to the residents' care plans, if they had not already been added by the nurse completing the fall packet. The Falls Coordinator stated the falls packet did not always include a witness statement from the staff working.they are not a required portion [witness statements] of the fall packet . During an interview on 10/9/2023 at 5:25 PM, the Falls Coordinator confirmed the fall investigations for Residents #67 and #323 was not complete and a root cause analysis for the falls was not conducted for Resident #67. During an interview on 10/23/2024 at 8:30 AM, the Administrator stated the gated, secure, courtyard area was designated for the residents and promoted a homelike environment. The Administrator stated prior to Resident #323's fall on 8/14/2024, residents were permitted to sit outside at their leisure with staff approval and staff frequent monitored the residents. The Administrator stated the residents had to have a BIMS of 9 or greater to sit outside with staff approval. The Administrator stated after Resident #323's fall on 8/14/2024, the door code was changed, and signage was placed for staff to not share the code, and to not assist residents outside without approval. The Administrator stated residents were permiteed to go outside as desired but now had to be accompanied by a staff member regardless of their BIMS score. The Administrator further stated the activities department had incorporated more activities for outdoors to aid in the residents' desire to go outside. During an interview on 10/23/2024 at 8:45 AM, Falls Coordinator stated when a fall occurred the floor nurses will call her to go over the fall incident. The Falls Coordinator stated she typically would go over with the nurses the details of the fall to determine the root cause and discuss interventions to be implemented. The Falls Coordinator stated she guided the nurses through the fall documentation which needed to completed for the incident report. The Falls Coordinator stated the next business day she (or designee if she is off work) reviewed the fall occurrence, evaluated the interventions, and the details of fall during the clinical meeting. The Falls Coordinator confirmed not all components of the falls packet investigation had been completed for Residents #67 and #323.

Based on facility policy review, medical record review, observation and interview, the facility failed to implement a person centered care plan related to fall interventions for 1 resident (Resident #323) of 3 residents reviewed for falls. The findings incude: Review of the facility's undated policy titled, Comprehensive Care Plan Procedures, revealed .The comprehensive care plan will describe .services that are to be furnished to attain or maintain .highest practicable .wellbeing .Resident specific interventions that reflect the resident's needs .staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities initially and when changes are made . Review of the medical record revealed Resident #323 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Depression, and Lack of Coordination. Review of the facility's fall investigation for Resident #323 dated 7/28/2024, revealed the fall intervention was to place a sign in the resident's room to remind the resident to lock his wheelchair brakes. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #323 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had moderate cognitive impairment. Review of a comprehensive care plan for Resident #323 revised 9/18/2024, revealed .provide visual reminders to lock [the] wheelchair brakes . During an observation on 10/8/2024 at 1:00 PM, of Resident #323's room, no visual reminders were present to prompt the resident to lock his wheelchair brakes in the room or bathroom. During an observation on 10/9/2024 at 10:00 AM, of Resident #323's room and bathroom, there were no visual reminders present to remind him to lock his wheelchair brakes. During an interview on 10/9/2024 at 10:30 AM, the Falls Coordinator and Care Plan Coordinator stated a sign was placed in Resident #323's bathroom to remind the resident to lock his wheelchair brakes as a fall intervention for the fall that occurred on 7/28/2024. Further interview confirmed the sign was an active intervention on Resident #323's care plan. During an observation and interview in Resident #323's room and bathroom, on 10/9/2024 at 2:00 PM, with the Care Plan Coordinator, confirmed the visual reminder for the resident to lock his wheelchair brakes was not present.

Based on facility policy review, medical record review, observation and interview, the facility failed to revise the comprehensive care plan for 2 residents (Resident #25 and Resident #323) of 24 residents reviewed for care plans. The findings include: Review of the facility's undated policy titled, Comprehensive Care Plan Procedures, revealed .The comprehensive care plan will describe .resident specific interventions that reflect the resident's needs .comprehensive care plan will be reviewed and revised .after each comprehensive and quarterly MDS [Minimum Data Set] assessment . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Feeding Difficulty, Anxiety and Delusions. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had severe cognitive impairment. Review of a care plan dated 7/2/2024, for Resident #25 revealed .Med Pass [nutritional supplement to promote weight gain] 120 cc's (cubic centimeters) BID (twice a day) . Review of a physician's order for Resident #25 dated 9/19/2024, revealed . MED PASS 120CC TID (three times a day) . Review of the medication administration record (MAR) for Resident #25 dated 10/2024, revealed . MED PASS 120CC TID (three times a day) . During an interview on 10/23/2024 at 11:15 AM, the MDS Coordinator confirmed Resident #25's care plan was not revised to reflect the increase in Med Pass from BID to TID. Review of the medical record revealed Resident #323 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Dementia, Depression, and Lack of Coordination. Review of the facility's fall investigation for Resident #323 dated 7/14/2024, revealed the fall intervention was to add a grab bar to the resident's left side of the bed. Review of a MDS assessment dated [DATE], revealed Resident #323 scored a 9 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. Review of a comprehensive care plan for Resident #323 revised 9/18/2024, revealed the resident had a fall intervention for a grab bar to the resident's left side of the bed which was resolved on the care plan effective 9/18/2024. Further review of the comprehensive care plan revealed the resident had an active fall intervention for a geri chair (special wheelchair that reclines the resident's back and elevates the feet) which was revised on the care plan effective 7/29/2024. During an observation in Resident #323's room on 10/8/2024 at 1:00 PM, the resident was in his room, resting in bed with his eyes closed. The resident's bed had grab bars on the left and on the right side of the bed. Further observation of the resident's room revealed no geri chair was in the room or the resident's bathroom. During an observation in Resident #323's room on 10/9/2024 at 10:00 AM, the resident's bed had grab bars on the left and on the right side of the bed. Further observation of the resident's room revealed no geri chair was in the room or the resident's bathroom. During an interview on 10/9/2024 at 10:30 AM, the Falls Coordinator and Care Plan Coordinator stated the geri chair intervention was no longer a fall intervention and use of the geri chair was no longer indicated for Resident #323. The Falls Coordinator and the Care Plan Coordinator also stated Resident #323 had an active intervention for a grab bar on the left side of the bed. The Care Plan and the Falls Coordinator confirmed Resident #323's care plan was not updated to remove the geri chair as a fall intervention. During an observation and interview in Resident #323's room on 10/9/2024 at 2:00 PM, with the Care Plan Coordinator, showed grab bars present on both the left and right side of the bed. The Care Plan Coordinator stated the grab bars to the left and right side of the bed were an intervention and confirmed Resident #323's care plan was not revised to reflect the left and right grab bars placed on the resident's bed.

Based on facility policy review, medical record review and interview, the facility failed to maintain an accurate and complete medical record for 2 residents (Resident #19 and Resident #23) of 24 residents reviewed for medical records. The findings include: Review of the facility's policy, Medical Record, dated 10/10/2023, revealed .all services provided to the resident .any changes in the residents medical, physical .condition, shall be documented in the resident's medical record .The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition .The following information is to be documented .treatment or services performed .changes in residents condition .documentation will include .date and time treatment/procedure was provided .Notification of .physician .if indicated .signature and title of the individual documenting . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Dementia, Psychotic Disorder with Hallucinations, and Muscle Wasting. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #19 scored a 9 on the Brief Interview for Mental Status (BIMS) Assessment which indicated the resident had moderate cognitive impairment. Review of the medical record for Resident #19, revealed the resident had a 1 pound weight gain in one month and a 9 pound weight gain in 6 months. Review of a physician's order for Resident #19 dated 8/21/2024, revealed Med Pass (nutritional supplement used to promote weight gain) 120 milliliters (ml's) with medication administration twice a day (BID). Review of the Medication Administration Record (MAR) for Resident #19 dated 10/2024, revealed the MAR did not include the order for Med Pass 120ml's with medication administration BID. Review of a nursing progress note for Resident #19 dated 9/3/2024, revealed .residents [resident's] weight is stable, trending upward x [times] 3 months .currently ordered Med Pass 120ml PO [by mouth] BID .Nursing will continue to monitor appetite and intakes . Review of a dietary note for Resident #19 dated 9/4/2024 revealed, .residents weight is stable trending upward x months .discussed with the weight meeting committee .continue to monitor dietary manager will continue to monitor weight, intakes Review of a dietary note for Resident #19 dated 9/26/2024, revealed . resident's current weight is 133 lbs weight continues to slowly increase .receiving a regular diet with fortified foods and 120 ml med pass 2 times daily . Good acceptance reported .continue to monitor intake and weights . During an interview on 10/21/2024 at 2:40 PM, Certified Nursing Assistant (CNA) L stated she is familiar with Resident #19 and stated he received nutritional supplements. During an interview on 10/21/2024 at 2:50 PM, CNA M stated Resident #19 had previously lost weight and received nutritional supplements routinely. During a telephone interview on 10/22/2024 at 7:15 PM, Licenced Practical Nurse (LPN) N stated Resident #19 had previously lost weight and used to receive Ensure (high calorie nutritional supplement used to promote weight gain) but was changed about a month ago to the Med Pass supplement. LPN N stated the last time she worked was Sunday (10/20/2024) and had given Resident #19 Med Pass during her shift. During a telephone interview on 10/22/2024 at 7:25 PM, Registered Nurse (RN) O stated Resident #19 had previously lost weight and offered the resident supplements during his shift. During an interview on 10/23/2024 at 11:20 AM, the Director of Nursing (DON) confirmed Resident #19's medical record was not complete or accurate because the MAR did not reflect the resident's supplement order for Med Pass 120 ml BID. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Schizoaffective Disorder, Dementia, Diabetes, and Chronic Kidney Disease. Review of a Significant Change MDS assessment dated [DATE], revealed Resident #23 scored an 11 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. Further review revealed the resident had significant weight loss. Review of the medical record for Resident #23, revealed the resident weighed 274 pounds on 7/3/2024 and was sent to the hospital on 8/6/2024. Further review revealed upon readmission to the facility, Resident #23's re-admission weight was 230 pounds, which was a 5.96% weight loss in one month and 16.67% weight loss in 6 months. Review of the progress notes for Resident #23 dated 8/27/2024-9/6/2024, revealed no documentation to reflect the physician notification of the resident's significant weight loss. Review of a physician visit note for Resident #23 dated 9/6/2024, revealed . resident was sent out to [acute care hospital] on 8/6/2024 .returned 8/27/2024 with medication changes and a decrease in weight, will continue to monitor . During an interview on 10/22/2024 at 11:41 AM, the Restorative Nurse stated she participated in the management of weight fluctuations of the residents. The Restorative Nurse stated if the resident has had a significant weight loss or gain, the weight is verified and the DON, dietician, and the doctor is notified immediately. The Restorative Nurse stated Medical Director K was notified of Resident #19's significant weight loss when he returned from the hospital and failed to document the notification. During an interview on 10/23/2024 at 11:15 AM, Medical Director K stated it was his expectation to be notified of resident weight changes once a month and stated the nurses notified him every month of the residents' significant weight loss or gain. Medical Director K stated the facility contacted him regarding Resident # 23's weight loss from his recent hospitalization and this significant weight loss had been monitored since readmission. During an interview on 10/23/2024 at 11:20 AM, the DON stated it was the facility's expectation to document in the medical record doctor notification of resident's change in status, to include weight loss. The DON confirmed Resident #23's medical record was not complete or accurate when the Restorative Nurse did not document physician notification of the Resident #23's significant weight loss.

Based on facility policy review, medical record review, facility documentation review, hospital record review, and interview, the facility failed to adequately supervise 1 resident (#1) to prevent Resident #1 from obtaining and consuming an undetermined amount of acetaminophen (nonnarcotic pain reliever) 500 mg (milligram) tablets resulting in Resident #1 experiencing an acetaminophen critical level and being admitted to an Intensive Care Unit (ICU) in the hospital, which constitutes Harm for Resident #1. The findings included: Review of a facility policy Administering Medication Procedures not dated showed .15 .During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart . Resident #1 was admitted to the facility on [DATE] discharged on [DATE] and readmitted on [DATE] with diagnoses including [CONDITION(S)], Major Neurocognitive Disorder due to [CONDITION(S)], [CONDITION(S)], Pseudobulbar Affect, [NAME], Tardive Dyskinesia, [CONDITION(S)] Disorder, Migraine Headaches and [NAME] Diverticulum. Medical record review of Resident #1's comprehensive care plan dated 8/19/2019 showed .I have multiple mental health diagnosis [diagnoses] .I have episodes of crying and yelling .I ambulate without assistance, and I have an unsteady gait .I crawl out of my chair or bed and into the floor when I choose. I require redirection to my room and common areas. I kick and swing at staff when I am upset .I am physically aggressive during redirection and during care, kicking, swinging, scratching .I put nonfood items in my mouth I have a [NAME] [craving and chewing substances that have no nutritional value, such as ice, clay, soil or paper] DX [diagnosis] . The care plan was updated on 3/23/2022 and showed .I wander through out the facility, rest of the day .and require redirection .when I wander please redirect me . Medical record review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 8 indicating the resident had moderately impaired cognition. The resident had symptoms of inattention which were continuously present, exhibited verbal behavioral symptoms directed toward others and other behavioral symptoms not directed towards others 4 to 6 days during the assessment period. Resident #1 required limited assistance with one-person physical assist for bed mobility and transfers, required supervision with set-up for locomotion on and off unit, required extensive assistance of one-person physical assist with walking in room, dressing, eating, and total assistance with toilet use and personal hygiene. Medical record review of a Resident #1's Nurse Note dated 5/1/2022 at 11:30 PM showed .During rounds resident found in floor by bed yelling for help. Resident with vomitus on her and staff was assisting to whirlpool. Up in chair, resident had white, thick frothy drainage from mouth. Upon inspection of resident's mouth 2 white pills resembling Tylenol [nonnarcotic pain reliever] was found. Suction was obtained to remove all white drainage to then a chocolate pudding like substance. Resident lethargic with decreased LOC [level of consciousness]. Suctioning did arouse resident pt. [patient] to grab at things VS [vital signs] 87/66 [blood pressure, normal 120/70], R [respirations, normal 16-20] 16, Spo2 [oxygen saturation, normal 95-100] 86% on RA [room air] with 3 liters applied increase to 91%. T [temperature, normal 98.6] 91.1. D/T [due to] resident's overall condition and vital signs, resident sent to ER [emergency room ] at 11:20 PM. Conservator was notified and 911 called for transfer. At 11:30 PM .EMS [emergency medical services] arrived for transport to .[hospital] .discharged from facility . Review of Resident #1's Alleged Incident/Accident Report dated 5/1/2022 showed .Possible injestion [ingestion] of unknown substance. Resident found in floor in room, yelling for help on rounds. Resident vomited on herself. After getting resident up to take her to the whirlpool d/t vomiting, it was noted a white, frothy, and thick drainage from mouth. Resident's mouth inspected and two white pills was found causing white drainage from mouth. Resident suctioned and cleaned up. Lethargy noted. Sent to .[hospital] ER [emergency room ] for eval & Tx. [evaluation and treatment] D/T meds found in mouth, VS & Lethargy . Review of Resident #1's Medication Administration Record dated 5/1/2022-5/31/2022 showed the resident had an order for [MEDICATION(S)]-APAP (narcotic pain medication which also contains acetaminophen) 5/325 take ½ tablet by mouth every 6 hours as needed. The medication was administered 1 time during the 6:00 PM-6:00 shift on 5/1/2022. Review of a facility investigation dated 5/1/2022 showed nursing identified 2 tablets in the resident's mouth. An inspection of Resident #1's room found an empty over-the-counter bottle of acetaminophen located under her bed. The resident was transferred to the hospital for treatment and observation. The hospital records received by the facility on 5/4/2022 showed the resident had an acetaminophen level of greater than 329 and the resident was treated with NAC (N-[MEDICATION(S)]). The facility's investigation found an acetaminophen bottle was most likely obtained from the top of the 100-hall medication cart between 12:46 PM and 6:00 PM on 5/1/2022. An empty bottle labeled acetaminophen 500 mg was found in the resident's room under the resident's bed. On 5/1/2022 the resident was calling out for assistance and was witnessed on her knees at bedside by staff. The resident had a foamy substance coming from her mouth as reported by staff and 2 tablets were removed from the resident's mouth by the Registered Nurse (RN). Resident #1 was noted to have decreased vital signs and drowsiness, the physician was contacted, and the resident was transferred to the hospital for evaluation and treatment. The facility's investigation found a system failure in securing medications and found one Licensed Practical Nurse (LPN) failed to provide supervision and follow medication administration policy and procedure. Review of the facility's continued investigation dated 5/2/2022 showed .Date and Time of Alleged Incident: 5/1/2022 at approximately 10:50 PM .Investigation of Neglect: Failure to prevent physical harm .On 5/1/2022 at 11:30 PM, the abuse coordinator received a call from the Director of Nursing. The Director of Nursing reported .[Resident #1] had been observed in the floor of her room and had been noted to have 2 tablets in her mouth that were not crushed as ordered. She further stated that an empty bottle of acetaminophen was found under her bed. She reported .[Resident #1] was lethargic but awake and did not feel the situation was life threatening, she reported the resident was being sent to the hospital for assessment Staff provided care to .[Resident #1] prior to the incident report .[Resident #1] went outside several times between 2:00 PM-7:00 PM spent the day with the activity director completing art projects and spending time outside, 9:00 AM-2:00 PM with no noted distress or changes in behaviors. Staff on duty at time of incident and prior to the incident do not report witnessing .[Resident #1] with acetaminophen. She was witnessed at 9:00 PM asleep and dry in her bed by direct care .and at approximately 10:00 PM by the laundry worker asleep and in bed .All medication carts were checked for compliance immediately following incident of empty bottle by RN on duty. Medication carts were found clear on top and locked. The Director of Nursing performed a visual inspection of the 100, 200, 300, and 400 hall medication carts in the AM of 5/2/2022 and noted there was no 500mg acetaminophen bottle on the 100-hall medication cart. Review of MARS [Medication Administration Records] of residents on the 100 hall finds one resident takes a daily dose of the 500 mg acetaminophen from the bottle located on the 100-hall cart. An LPN [Licensed Practical Nurse] on 6:00 AM-6:00 PM shift 5/1/2022 had charted this medication out at 12:46 PM for Resident .One other resident located on 100 hall, has on order for 500 mg acetaminophen, which located in her role [roll] pack of medications .The LPN states she recalls placing the bottle back in the medication cart drawer following the removal of the tablets on 5/1/2022 at approximately 12:46 PM. She further states the medication cart was located in the medication room at the time the acetaminophen was removed from the bottle .Investigative findings: An empty bottle labeled acetaminophen 500 mg was found in room .under the bed of resident .At 7:36 PM on 5/2/2022 staff members reported to administration that nurse/LPN on 100 hall on the 6:00 AM-6:00 PM shift stated she believed .[Resident #1] took the medication off of her cart. Investigation finds one bottle of acetaminophen 500 mg with undetermined quantity of tablets was not secured in medication cart and finds one LPN failed to provide supervision and follow medication administration policy and procedure on 5/1/2022 . Review of Resident #1's Emergency Department (ED) Records dated 5/2/2022 showed .The patient arrives from a nursing home tonight. Per their report, the patient was found to have what appeared to be 2 white pills in her mouth. She was also noted to have an empty bottle of Tylenol in her room. EMS reports that none of the staff at the facility knew how the patient got the bottle of Tylenol .The patient is arousable, but she mostly moans and groans. She would not answer questions appropriately .Patient arrives with concern of possible overdose . The ED records showed the resident's Acetaminophen level was 329 critical with no range given .Reassessments/Updates showed .1:44 AM: Tylenol level critically high. I ordered N-[MEDICATION(S)] [NAC-drug used to treat acetaminophen overdose]. I have discussed the case with .at the Poison Control Center .Due to a high probability of clinically significant, life-threatening deterioration, the patient required my highest level of preparedness to intervene emergently . Review of Resident #1's Hospital Notes dated 5/2/2022 showed .presented to .[hospital] due to AMS [altered mental status] and found to have taken an unknown quantity of Tylenol but fount to have an acetaminophen level > [greater than] 329 and poison control was called, and recommended patient be treated with NAC and monitor in an ICU unit and a transfer was requested . Review of Resident #1's Lab Report dated 5/2/2022 at 5:21 AM, showed an Acetaminophen level of 118.4 indicated as high with a range of less than 2. Review of the facility's continued investigation dated 5/5/2022 at 3:45 PM showed .Upon Resident returning from the hospital, The Regional DON [Director of Nursing] and myself [Assistant Director of Nursing] conducted interview with the Resident. The interview was as follows .I asked Resident. Do you know why you had to go to the hospital? She replied 'no' I explained to Resident that she had gotten sick and had to go to the hospital. She replied, 'wasn't sick'. Then I explained to the Resident that she was sent to the hospital because we thought she had taken some Tylenol. I ask the Resident Did you take some Tylenol? She answered, 'yes I took four' I ask do you mean four pills. She said, 'yes four pills' I ask the Resident if she remembered where she had gotten the Tylenol? She said, 'yes on the medicine cart, on top' Resident went on to say, 'it was open' I ask was the med cart open. She said, 'no the bottle was open on top of it' I ask the resident if she remembered what time of day, she had taken the Tylenol off the cart? She said, 'Let me think, it was lunch time' To clarify I ask the Resident are you sure it was lunch time and she answered, 'yeah it was lunch time' The resident ask [asked] to go see the Activity Director because she had 'missed her' while she had been in the hospital . Observation of Resident #1 on 5/16/2022 at 9:00 AM, in the dining room, showed the resident to be up in a specialty wheelchair. She was awake, alert and no signs of distress were observed. During an interview with Resident #1 on 5/16/2022 at 9:00 AM, she stated .I don't remember what happened .I went to the hospital I was feeling bad . When Surveyor asked how the resident was feeling now, she replied .I don't know . When asked how many Tylenol did she take she replied 4. Surveyor asked is that all and she replied, yea it made me sleep. When Surveyor asked did it make you sick she stated no. When the Surveyor asked how did you get the Tylenol, she stated the drawer was unlocked I stood up and opened the drawer. When asked if she got anything else she stated, no that is all I got. When asked again how many did you take, she replied 4. When asked what time of day it was, she stated .I took it off the cart at nighttime . During an interview with Registered Nurse (RN) #1 on 5/16/2022 at 9:50 AM, she stated, .I took the medication cart from LPN #1 at 6:00 PM on 5/1/2022. I did not receive any concerns in report related to .[Resident #1]. There were no concerns with the narcotic count when I took over the cart. I do not know if there was a bottle of acetaminophen on the cart when I took it or not. I did not recall any one resident having an order for acetaminophen on my shift. I do know I did not administer any. Nothing was reported unusual with .[Resident #1] during the 6 PM-10:00 PM, shift [Resident #1] vomits frequently .She will frequently request a whirlpool because it calms her down. She is up and down throughout the night, and can get upset often. She is thickened liquids. She gets upset when she asks for a coke and we have to thicken it, or if she has been vomiting. We discourage her from immediately wanting something else to put on her stomach. She went to bed early that night. She will usually set with me at my med [medication] cart or the desk. She had put herself to bed. They went in to do rounds a little after 10:00 PM. They found her kneeling beside her bed trying to get in her chair. The CNA [Certified Nursing Assistant] had gone in to check on her and saw her in the floor. She had thrown up and went to get the other tech to help but the resident put herself back in her chair. They brought her out to put her in the whirlpool to clean her up. They brought her down the hall and she threw up again and this time she was vomiting up a white frothy substance out of her mouth. The tech came and got me and reported what was going on. I said 'let me see what is going on'. When I get to the resident another tech was with me, I told her to spit it out. She couldn't, I swept her mouth she had 2 pills that resembled Tylenol. It was the undissolved Tylenol causing the foaming, they were just coming out of her mouth. She was more drowsy than her baseline. She couldn't spit it out like she normally can. I told the other nurse [LPN #2], and the tech [CNA #1] to go search the room. That is when they found the empty bottle of acetaminophen bottle under the top of her bed. They took her to the whirlpool, and I got the suction machine and suctioned her mouth and cleared her mouth and then deep suctioned her back to the pudding. I gave her the pudding with her meds between 8:00 PM and 9:00 PM. I did not find anything else that resembled acetaminophen. I stayed until we got her out of the whirlpool, we got her dressed, and brought her to the nurses' station. I call the nurse on call, and she notified the Administrator, the conservator, and I called the physician and received an order to send her out. Then I called 911 and sent her to the ER. I asked her how much she took, and she said the whole bottle and I asked her where she got it and she would not say .We were at the desk [LPN #2 and I] when .[LPN #1] came in I gave her the keys to the med cart. I told her what happened, she said 'oh my heart hurts, I hope there are two bottles of Tylenol on this cart' I didn't know what was going on, she looked and said 'there is only one bottle'. She said she had given it to a resident, and she said 'I bet she got it off my cart I don't always lock my cart' .[LPN #2] asked her if she didn't lock her cart up and she said 'not when I have it on the floor, I don't always lock it' . During an interview with LPN #1 on 5/16/2022 at 11:03 AM, she stated .I worked day shift on 5/1/2022, I got the cart from .[LPN #3]. There was a bottle of acetaminophen 325 mg and a bottle of 500 mg. I pulled the acetaminophen 500 mg at approximately at 12:46 PM, for another resident. I was in the medication room I pulled the med, returned the medication to the cart, left the med room, and went to the resident's room to administer the acetaminophen 1 tablet of 500 mg. I also locked the med cart before I left the med room .I got my med cart out of the med room between 1:15 PM and 1:30 PM. Stocked with fresh water, replaced my med pass supplement. I pulled the cart out into the hall, I proceeded to pass my medications as normal. The cart was locked at all times when unattended which would secure the drawer for all OTC [over-the-counter] medications. I am human and sometimes I have in error left my cart unlocked but I do not routinely leave the cart unlocked .I did not make a statement that she likely got it off my cart or could have gotten it off my cart or that I leave my cart unlocked when I am passing medications. When I reported to work the next morning, I was informed of what happened. I asked to see the keys for the 100 cart and asked me why. I said I would like to see something, when I looked there was only one bottle of acetaminophen 325, no 500 mg. I at that point I thought I had stuck my foot in my mouth, I could be looking at a nurse that let a resident get a medication from her cart and they tend to get defensive if you make a statement like the Tylenol bottle is not here. So all I said was because I was already nervous, and there was no administration staff here at that time is that it truly hurt my heart that a resident got hurt that way in this facility. When you pull a new OTC [over-the-counter] med you check the expiration date and write the date you pull it out of stock. I did not pull a bottle of acetaminophen on 4/30/2022 or on 5/1/2022 I did not realize the bottle didn't have a date .I believe the resident got the acetaminophen off or out of the cart on night shift. She had been asking for acetaminophen at the end of the shift. Why would she ask for it if she already had it at the end of the shift. I followed the resident outside after dinner and she vomited, the emesis consistent of the hot dog and chocolate cake (pureed) but no white emesis, upon bringing her back in she was taken and changed by .[CNA #2] When I spoke to .[CNA #3] the next night, she said she had changed .[Resident #1] multiple time during the night shift on the 2:00 PM 10:00 PM and she had not seen any evidence of any acetaminophen . During an interview with Certified Nursing Assistant [CNA] #6 on 5/16/2022 at 1:00 PM, she stated .I work 6:00 PM-6:00 AM. When I came in at 6:00 PM, I asked where .[Resident #1] was because she is usually at the nurses' station when I come in. The Assistant Administration said they just took her to change her. I was scheduled for the 400 hall and around 10:00 PM-10:30 PM the Nurse Assistant was going to get her vitals and he observed her with vomit all over her. He came to find me to assist him with cleaning her up. We changed her shirt and she started vomiting again so we decided it would be easier to take her to the whirlpool to clean her up. We got her in the whirlpool and vomited again and she had white frothy stuff coming out of her mouth. I told .[NA#1] I was going to go get the nurse. The nurse came in with the suction machine, she suctioned her, and 2 things looked like pills were in her mouth. The nurse told the other nurse .[LPN #2] and .[CNA #1] to go to her room and search her room. They found an empty bottle of acetaminophen, it looked like one of our bottles that we have here. It was in the floor under the bed. We thought she might have had it in her lap when we stood her up to take her pants off and when she vomited again, we just sat her back down and did not see the bottle fall out of her lap. I stayed with the nurse in the whirlpool room. I was holding her head up she was lethargic at that time. The nurse left the room to call the DON [Director of Nursing], and she came back in and said we were sending her out . During an interview with CNA #1 on 5/16/2022 at 2:50 PM, she stated .I worked from 4/30/2022 at 2:00 PM, until 2:00 AM on 5/1/2022 .[NA #1] went in to do her temperature and 02 [oxygen]. He said she was down on all fours and asking for help and she had a little vomit on her. [Another CNA] went to the room with him, and they brought her out to take her to the whirlpool because she likes it. They were in the hallway. The nurse was on her way to check on her .[NA #1] said she had foam coming out of her mouth. I walked down to help with the nurse she was wiping .[Resident #1's] mouth. She was trying to spit it out and the nurse was able to get the 2 pills out of her mouth. I left them at that time and went to clean up her room. The nurse went into the shower with them .[LPN #2] and I went to the room and searched it that is when we found the empty bottle of acetaminophen right under the edge of the bed .[Resident #1] will pick up anything she can like cigarette butts, grass, mulch or anything else she can pick up she will put it in her chair . During an interview with Resident #1's Primary Care Physician on 5/16/2022 at 4:10 PM, he stated .a level of greater than 329 of acetaminophen is a toxic level .I don't think she will have any long term negative effects because the facility acted promptly .she will eat anything she can get her hands on .She was discharged to the hospital and admitted to ICU [intensive care unit] .She was treated with N-[MEDICATION(S)] in the hospital. Any level greater than 100 is a treatable level. It is hard to know what could have happened had it not been discovered when it was .She could have been sick for a day or two with vomiting or it could have led to long term sequela, and could have been fatal if untreated depending on the amount she had taken . During an interview with the facility's Pharmacist on 5/16/2022 at 4:20 PM he stated .there is no way to determine how many acetaminophen 500 mg the resident ingested based on the lab value of greater than 329 .anything greater than 200 is a risk for damaging the liver if gone untreated for greater than 4 hours . During an interview with LPN #2 on 5/17/2022 at 5:00 AM, she stated .somewhere around 7:15 PM .[Resident #1] rolled up to me and asked me to give her medications. I pointed to .[RN #1] and told her that was her nurse. She rolled up to another resident and started talking. I didn't see her again until 10:30 when .[NA #1] came out in the hall and said .[Resident #1] was in the floor she was throwing up and saying help me. We got her up in her chair and they were going to take her to the whirlpool to clean her up. Somebody said she has something in her mouth .it was 2 white tablets she was trying to spit them out. I reached in and swooped them out of her mouth. It was 2 whole dissolving tablets, it appeared to be Tylenol. They put her in the whirlpool and the other CNA .went to search her room and found an empty bottle of acetaminophen under her bed. It looked just like what we have. It was the same brand. It was empty and did not have a date on it. I brought the bottle to .[RN #1] who was in with the resident in the whirlpool room and discussed it could be an acetaminophen overdose. By that time the resident was getting lethargic, and we had to suction her. There was white [MEDICATION(S)] stuff then chocolate pudding. There wasn't anything else. We got her out of the whirlpool and took her vitals. Her blood pressure and oxygen level were down. We called the chain of command and sent her out .[LPN #1] came in the next morning and we told her what happened. She went and looked in the med [medicine] cart and said 'there was a bottle of 500 mg acetaminophen in here yesterday, but it is gone' .She said 'I know she got it from this cart it isn't in here. Oh, my heart hurts for her'. And she did say 'I don't always lock my cart.' That was all she said . During an interview with NA #1 on 5/17/2022 at 5:20 AM, he stated .I've only been here about a month [Resident #1] was in her room. I'm not sure if that was her normal or not it was only the 3rd night I had worked with her. I went in to take vital signs and I heard her say 'help me'. I saw her in the floor, and she had thrown up. I went in the hall and got [CNA] to help me. She was trying to get herself up in the wheelchair. We decided to take her to the whirlpool to clean her up. When we got in the hall she was still vomiting and the nurse swept her mouth and found 2 tablets. The nurse came and suctioned her .[CNA #1] found an empty bottle of acetaminophen under her bed. The nurse asked her how many she took, and she said, 'all of them.' We got her dressed and sent her to the hospital .She was not really vomiting it was more like a dry heave .we couldn't get her to talk . During an interview with the Assistant Administrator on 5/17/2022 at 4:15 PM, she stated .the Central Supply coordinator came in at approximately 8:00 AM on 5/2/2022 .by 9:00 AM, I was able to reach out to our over-the-counter medication suppliers for verification of the lot numbers on the acetaminophen bottle. We received verification at approximately 10:30 AM the bottle was the facility's . During an interview the Assistant Administrator confirmed the facility failed to properly secure medications and failed to provide adequate supervision of Resident #1 to prevent the resident from taking a bottle of acetaminophen and consuming an undetermined number of tablets causing harm to Resident #1.

Based on review of facility policy, medical record review, review of a facility investigation, review of an incident report, observations, and interviews, the facility failed to prevent abuse of 1 resident (Resident #1) of 9 residents reviewed for abuse, resulting in Resident #1 being abused by staff. The findings included: Review of the facility's policy titled Abuse Prevention Policy & Procedure, last reviewed on 1/22/2020 showed .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse .Physical Abuse: The infliction of physical pain or injury, includes but not limited to: slapping, pinching, hitting, kicking, or shoving . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1 scored a 5 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and the resident required assistance of one or more persons with activities of daily living (ADL's). Review of a facility investigation dated 1/25/2020 showed Certified Nursing Assistant (CNA) #3 told Licensed Practical Nurse (LPN) #1, LPN #2, and Hospitality Aide #1, that she had .'whooped on the bottom' of (Resident #1) to get her to go to bed .'tapped her on the bottom like tapping your leg to the beat of the music' so she would go to bed . Review of a facility Incident/Accident report dated 1/25/2020 showed .Name .(Resident #1) .Employee had made the statement in front of other staff that she had 'whipped' residents bottom when she put her to bed .conversation with me (Director of Nursing) on the phone employee stated 'I tapped, patted her bottom' . Observation in Resident #1's room on 2/3/2020 at 1:55 PM showed the resident lying in bed. No fearful or anxious behaviors were observed. The resident made no attempt to communicate with the surveyor. During an interview on 2/3/2020 at 6:40 AM, CNA #3 stated .I had (Resident #3) with me .she had been yelling and trying to push herself out of her wheelchair. I asked her if she wanted her bottom whooped .(LPN#1) heard me and said 'what you whoop residents' .I told her 'I had whooped (Resident #1) when I was trying to get her in to bed' .I would never hurt any of my residents .I had no intent of abuse, I just was trying to get her in the bed . During an interview on 2/3/2020 at 7:20 AM, Hospitality Aide #1 stated .I was coming down the hall to the nurses station .I overheard .(CNA#3) talking to .(LPN #1) .(CNA #3) just blurted out she had smacked one of the residents .she said (Resident #1) .(LPN #1) asked her what did you say and she said 'oh I lightly smacked one of the residents' .(LPN #1) said 'you can't do that, that is abuse and I have to report it' . During an interview on 2/3/2020 at 7:30 AM, the Administrator stated .(CNA #3) had admitted to smacking (Resident #3) on the bottom .I received a phone call from (LPN #1) she said .(CNA #3) is here and she has something to tell you .(CNA #3) reported she had said .she had whooped (Resident #1) .(CNA #3) did admit she patted (Resident #1) on the bottom like you tap your leg to the music, but when she described it at the team area she stated she whooped (Resident #1) .when asked why she did that she said it was to get her to go to bed .on the follow up interview (CNA #3) said it was to try to get (Resident #1) to participate in the act of getting her to go to bed . During an interview on 2/3/2020 at 10:00 AM, LPN #1 stated .I was sitting at the team area .(CNA #3) was talking about how she 'has to whoop (Resident #1) to get her to go to bed' .I said do you know what you are saying, do you know what you are talking about, she said yes she knew what she was saying she said 'I have to whoop (Resident #1) to get her to go to bed' . During an interview on 2/3/2020 at 2:15 PM, the Director of Nursing (DON) stated .When I talked to (CNA #3) I asked her why .was she trying to punish her (Resident #1) hurt her or what .she said no and she thought if she (Resident #1) was going to act like a child .she treated her like one she would go to bed. I asked her if she thought it was appropriate to treat anyone this way and she said I guess not, but she said she wasn't being mean or trying to hurt her . During an interview on 2/4/2020 at 11:30 AM, the Administrator stated .(CNA #3) was overheard saying she had 'whooped (Resident #1) on the bottom' . The Administrator confirmed the facility failed to prevent abuse to Resident #1.

Based on review of facility policies, review of a facility document, medical record review, and interviews, the facility failed to report an allegation of abuse to the State Survey Agency timely for 1 resident (#1) of 3 residents reviewed for abuse. The findings included: Review of facility policy Reporting Abuse to State Agencies and Other Entities/Individual Policy dated 1/1/19 revealed .The facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident are reported immediately, but not later than 2 hours after the allegation is made . Review of facility document Alleged Incident/Accident Report dated 7/24/19 at 7:15 PM revealed .(Resident #1) informed this nurse that (Resident #2) inappropriately touched her breast .Assessment reveals no scratches, redness, discolorations or injuries/impairment noted. Resident is without emotional distress, tremors or anxiety at this time . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) for Resident #1 dated 7/1/19 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #2 dated 5/20/19 revealed a BIMS score of 6, indicating severe cognitive impairment. Interview with Resident #1 on 7/29/19 at 10:45 AM, in her room, revealed .I had been talking about watching a movie all that day .(Resident #2) rolled me back to my room, he had helped me once before .I thought we were going to watch a movie .he grabbed my breast inside my shirt and put them in his mouth. He pulled his penis out and placed my hand on his penis .I got away from him .rolled out of the room to the nurses' station .I pushed my call light before I left the room, I saw .(Licensed Practical Nurse #1) at the end of the hall and I asked the nurse to remove (Resident #2) and he made him leave . Interview with Registered Nurse (RN) #1 on 7/29/19 at 12:05 PM, in the conference room, revealed .(Resident #1) was going down the hall heading to .(LPN #1) and saw the janitor first .(Resident #1) reported the incident to (the Janitor) then she went on down the hall and reported it to (LPN #1). (LPN #1) called the Administrator and (Administrator) called me and I came in and started the investigation and .(Administrator) reported the incident (to the State Survey Agency) the next day . Interview with Resident #2 on 7/29/19 at 1:10 PM, in his room, revealed the resident recalled the incident and stated .well it was after supper and I pushed her (Resident #1) back to her room .I sat there for about 15 minutes .I touched her breasts .underneath her shirt .(Resident #1) touched me in the penis area, but then she got to thinking about her ole man and stopped and she just talked about him .we hadn't ever done anything before . Interview with the Administrator on 7/29/19 at 5:20 PM, in the conference room, revealed .it appeared to be consensual, and it was a he said she said .(Resident #1) reported the incident on (7/24/19) and I did not report the allegation until the next morning . Continued interview confirmed the facility failed report an allegation of abuse timely to the State Survey Agency and failed to follow facility policy.

Based on review of a facility policy, medical record review, observation and interview, the facility failed to ensure 1 resident (#26) was free from physical restraints of 3 residents reviewed for restraints of 24 sampled residents . The findings include: Review of the facility policy Use of Restraints Procedures, (undated), revealed .Examples of devices that may be considered physical restraints include .seat belts .Prior to a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints .Restraints shall only be used upon the order of a physician and after obtaining consent from the resident and/or representative .Orders for restraints will be reviewed monthly through the restraint reduction committee .Care plans for restraints shall include the measures taken to systematically reduce or eliminate the need for restraint use . Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #26's admission Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 00, indicating severe cognitive impairment. Continued review revealed Resident #26 was coded for walking in the room and in the corridor on the unit as requiring supervision only. Further review revealed Resident #26 was coded for physical restraints as .not used . Observation of Resident #26 on 4/14/19 at 10:25 AM, on the 400 hall, revealed the resident asleep in the wheelchair with a seat belt buckled across his lap. Continued observation and interview with the Infection Preventionist on 4/14/19 at 10:30 AM, on the 400 hall, revealed Resident #26 had a seat belt buckled across his lap and .He can't unclick it on command . Further observation revealed the resident was unable to comply with multiple staff requests to demonstrate ability to self-release the seat belt. Observations of Resident #26 on 4/14/19 at 2:46 PM, 4/15/19 at 9:04 AM, and 4/16/19 at 9:03 AM revealed Resident #26 in his room seated in the wheelchair with the seat belt buckled across his lap. Observation of Resident #26 on 4/16/19 at 10:00 AM, on the 400 hall, revealed the resident in the wheelchair with the seat belt buckled across his lap. Continued observation revealed the resident was unable to comply with multiple staff requests to demonstrate ability to self-release the seat belt. Interview with Certified Nursing Assistant (CNA) #1 on 4/16/19 at 10:00 AM, on the 400 hall revealed .he's had that chair (with the seat belt) a good month or so . Continued interview revealed facility staff regularly applied Resident #26's seatbelt. Further interview confirmed the resident ambulated in the facility daily. Interview with the Director of Nursing on 4/16/19 at 11:10 AM, on the 400 hall, confirmed .The seat belt is not supposed to be there; they didn't remove it (from the wheelchair) .he (Resident #26) wouldn't be able to do undo it . Further interview confirmed the seat belt is a restraint and the facility failed to complete a pre-restraining assessment, obtain a physician's order for the restraint, obtain a signed restraint consent form and care plan for the restraint.

Based on facility policy review, medical record review, review of facility documentation, observation and interview, the facility failed to implement an intervention to prevent future falls for 1 resident (#53) of 3 residents reviewed for falls of 20 sampled residents. The findings include: Review of the facility policy, Falls Prevention Program Procedures, undated, revealed .The director of nursing will provide oversight and follow up for interventions and notify individual departments of intervention implementation .The safety committee will review falls monthly to ensure safety measures and policies are implemented . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #53's Morse Fall Scale documentation, dated 12/26/18, revealed the admission fall risk assessment with the score of 45, indicating high risk for falls. Medical record review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the brief interview for mental status indicating the resident was cognitively aware. Continued interview revealed Resident #53 required extensive assistance of 1staff for bedmobility and 2 staff for transfers. Medical record review of the Resident's current comprehensive care plan, originally dated 1/5/19 and updated 4/2/19, revealed .I have a history of falls .when I am upset I will slide myself into the floor .this puts me at risk for falls/injury .I am on fall awareness program . Further review revealed .New Interventions .Keep bed in low position . Medical record review of Resident #53's Morse Fall Scale documentation, dated 1/19/19, revealed a score of 75, indicating high risk for falls. Review of the facility documentation, dated 1/19/19, revealed Resident #53 .slid out of bed . and there was .no apparent injury . Further review revealed .Summary of Events .Educated resident on importance of bed remaining in low position .Interventions placed: .Adjust height of bed . Medical record review of the Nurse's Notes dated 1/21/19 at 2:00 PM, revealed .L (left) mid thigh swollen, heat, knot has formed, called MD (medical doctor) . Further review of the Nurse's Note dated 1/21/19 at 2:05 (PM), revealed .Called EMS (Emergency Medical Services)/911 to transport Resident for eval (evaluation) and treatment . Medical record review of the (named) Regional Medical Center Consultation documentation, dated 1/21/19, revealed .ASSESSMENT: left femur fracture from a fall out of bed at the nursing home . Review of the facility documentation of Resident #53's Falls Awareness Checklist, dated for (MONTH) 2019, revealed the low bed intervention was not on the checklist provided (the checklist was identified as part of the bedside care plan). Multiple observations over the course of each survey day from 4/14/19 to 4/16/19 revealed the bed in the mid-height position. Observation and interview with CNA (Certified Nurse Aide) #1 and CNA #2 on 4/16/19 at 10:05 AM, in the resident's room, revealed .I'd say her bed is in the mid position .This is where her bed normally is . Interview with the Falls Preventionist on 4/16/19 at 10:07 AM, on the 400 hall, revealed Resident #53 slid out of bed on 1/19/19 resulting in a fractured femur. Continued interview confirmed .After the fall on the 19th we did education and adjusted the height of the bed .bed in the low position was new intervention . Further interview confirmed the low bed position was not included on her Falls Awareness Checklist. Observation and interview with Licensed Practical Nurse #1 on 4/16/19 at 10:38 AM, in the resident's room, confirmed .I would say it's (the bed) not (in the low position) .this is normal for her bed . Observation and interview with the Director of Nursing on 4/16/19 at 11:16 AM, on the 400 hall, confirmed Resident #53's bed was not in the low position and the fall intervention was not in place.

Based on facility policy review, medical record review, observation and interview, the facility failed to maintain dignity for 1 resident (#47) of 24 residents reviewed for dignity. The findings include: Review of the facility policy, Quality of Life Dignity Procedures, undated, revealed .Procedures .Residents shall be treated with dignity and respect at all times .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #47's current care plan dated 12/7/18, revealed (written in the resident's voice) .I have a [DIAGNOSES REDACTED].I sometimes refuse care .changing clothes .I prefer to sleep naked and when I am up in geri chair (medical recliner) I do not like to wear pants, please ensure I am covered with a blanket at these times . Medical record review of the annual Minimum Data Set ((MDS) dated [DATE], revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 5, indicating the resident was severely cognitively impaired. Continued review revealed he was totally dependent on staff for dressing, toileting and personal hygiene and required the assistance of 2 people. Observation of Resident #47 on 4/15/19 at 9:32 AM, in the resident's room with the privacy curtain closed, revealed he was unclothed and lying in the bed on an incontinent pad. Continued observation revealed he was not covered and the resident's male genitalia was exposed. Further observation revealed the resident's roommate was present, lying in the other bed in the room. Observation of Resident #47 with the Certified Nursing Assistant (CNA) Supervisor on 4/15/19 at 9:39 AM, in the resident's room, revealed the CNA Supervisor entered the resident's room and asked Resident #47 if he wanted a gown and blanket, the resident stated yes and a hospital gown was put on the resident and he was covered with a blanket. Interview with the MDS Coordinator on 04/15/19 at 9:35 AM, in the MDS office, confirmed the resident should have been covered by a blanket. Further interview confirmed the facility failed to maintain Resident #47's dignity. Interview with CNA #3 (the CNA assigned to Resident #47) on 4/15/19 at 9:50 AM, outside of the resident's room, revealed the CNA stated I was going to go back in and cover him up later and confirmed the resident had been left unclothed and uncovered.

Based on review of the facility policy, medical record review, and interview the facility failed to prevent abuse for 1 resident (#60) of 10 residents reviewed for abuse. The findings included: Review of the facility Abuse Policy revised 12/2016 revealed .As part of the resident abuse prevention, the administration will .Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff . Medical record review revealed Resident # 60 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating the resident had severe cognitive impairment and required extensive assistance of 2 for transfers. Review of the Resident Abuse Investigation Form dated 6/19/17 revealed Certified Nursing Assistant (CNA) #2 and CNA #3 assisted Resident #60 in the 400 shower room with a transfer from the lift. Further review revealed the resident struck CNA #2 in the face, CNA #2 placed her hands on the residents face and stated to the resident .I will slap the[***]out of you . This was witnessed by CNA #3 and Licensed Practical Nurse (LPN) #1. Review of a signed statement of LPN #1 dated 6/19/17 revealed .CNA (#1) tapping the right side of the face with her open hand of resident .(#60) .and then heard her say I will slap the[***]out of you while pointing her finger at resident .face .Resident .was moving her arms, like she was being combative and she looked angry before (CNA #2) made the statement. Resident .did not appear upset, she was not tearful, she was just looking at (CNA #2) after the incident .(CNA #2) was asked to clock out and leave by (LPN #2) . Review of a signed statement by CNA #3 dated 6/19/17 revealed .(CNA #2) and myself were transferring resident .from the shower chair to her chair .resident .smacked CNA (#2)with her right hand. I witnessed (CNA#2) grabbing her face lightly, she was not rough and then I heard (CNA #2) state (Resident #60) if we was on the streets I would have slapped the[***]out of you .I .immediately transferred resident .to the hallway. Resident .was quiet after the incident but did not appear upset .there was no visible redness on cheeks . Review of a signed statement by CNA #2 dated 6/19/17 revealed .I was giving a shower with CNA (#) for resident .(#60). Following the shower .CNA (#3) requested I assist .the lift back to her chair from the shower chair Resident (#60) smacked me in the face when I place her into her chair. My glasses went sideways. I grabbed her face with my hand, not hard, but so she was looking @ (at) me and said, if we were on the streets I would have slapped the[***]out of you I was joking. I wasn't mad at her. She and I joke around a lot. She is all the time saying F .You .(LPN #2) came into the shower room and requested I clocked out and leave @ approximately 9:13 am . Review of CNA #2's personnel file revealed the CNA was terminated for verbal abuse and unprofessional conduct on 6/19/17. Interview with LPN #1 on 4/16/18 at 6:30 PM by telephone, confirmed CNA #3 she witnessed CNA #2 placed her hand on the resident's cheek, pat her face lightly, and stated she would .slap the[***]out of her . Further interview confirmed she reported the incident to LPN #2 and CNA #2 was told to leave the facility immediately. Interview with LPN #2 on 4/17/18 at 8:15 AM, by telephone, confirmed LPN #1 came to her to report that she heard CNA #2 state to Resident #60 if she was on the street she would whoop her ass. Continued interview confirmed LPN #2 told the CNA she was to clock out and escorted the CNA to the time clock and observed her leave the building.

Based on facility policy review, observation, and interview the facility failed to follow the facility's policy for Infection Control during a dressing change for 1 (#36) resident of 40 residents reviewed. The findings included: Review of the facility policy .Wound Care . revealed .1. Use disposable cloth .to establish clean field on resident's over bed table. Place all items to be used during the procedure on the clean field .6. Put on gloves .if soiling of your skin .with body fluids is likely . Observation on 4/16/18 at 8:45 AM, in the resident (#36)'s room, revealed the Wound Care Nurse, and Licensed Practical Nurse (LPN) #1 beginning a dressing change. Observation revealed the Wound Care Nurse removed dressings from the resident's lower extremities and measured six wounds with six individual plastic wound measurement tools touching the wounds to the measurement tools. Continued observation revealed the Wound Care Nurse placed the measurement tools on an uncovered over bed table. Further observation revealed LPN #1 placed the contaminated measurement tools on the resident's uncovered night stand, the Wound Care Nurse failed to clean the over bed table, placed the clean dressings items on the side of the over bed table were soiled measurement tools had been and rolled out a disposable cloth on the opposite side of the over bed table. Observation revealed the Wound Nurse obtained the clean dressing items from the soiled side of over bed table placed them on a disposable cloth. Continued observation revealed the Wound Care Nurse asked LPN #1 to obtain an unused measurement tool which had been placed with the soiled measurement tools off the residents night stand. Observation revealed the LPN obtained the unused measurement tool from the residents night stand with ungloved hands and handed to the Wound Care Nurse to obtain measurement of area to resident's buttocks. Interview with the Wound Care Nurse on 4/16/18 at 1:02 PM, at the Nurse's Station, confirmed the facility's policy for Wound Care was not followed and infection control was not maintained during the dressing change.

Based on facility policy review, observation, and interview the facility failed to complete the required direct care daily staffing roster posted for the day shift for two days. The findings included: Review of the facility policy .Posting Direct Care Daily Staffing Numbers . revealed .Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents . Observation at the Nurses Sation on 4/15/18 at 10:43 AM, revealed the facility direct care staffing sheets were incomplete for day shift on 4/14/18 and 4/15/18. Interview with the Director of Nursing (DON) on 4/15/18 at 11:30 AM, in the conference room, confirmed the facility policy for posting daily staffing was not followed.

Based on facility policy review, medical record review, and interview, the facility failed to ensure 2 residents (#29 and #51) of 5 residentsreviewed were assessed every shift for behavior symptoms reviewed for unnecessary medication. The findings included: Review of the facility policy, Antipsychotic Medication Use, dated 1/8/17, revealed .antipsychotic medication therapy .the interdisciplinary team .ensure appropriate use, evaluation, and monitoring .nursing will document any behaviors and interventions .nursing will monitor daily adverse effects . Review of the facility policy, Behavior Assessment and Monitoring, dated 2/2014, revealed .nursing staff will identify, document, and inform the physician .new .or worsening behavioral symptoms .using facility .behavioral screening tool .will be documented .medications .prescribed for behavioral symptoms .monitoring for efficacy and adverse consequences .for gradual dose reduction .being treated for [REDACTED].staff .document ongoing .changes (positive or negative) .document .behavior assessment forms . Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Assessment Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. Medical record review of a Care Plan dated 5/12/15, revealed .mental health diagnosis .at risk for daily challenges .history of biting .refused meds .yelling .pinching .throwing .urinate on staff .administer medications as ordered and monitor for effectiveness .monitor for changes in mood/behavior report .due to the use of multiple medications including psychoactives .at risk for adverse reactions .report to MD (medical doctor) .monitor for changes in behavior/mood . Medical record review of a Physician's Recapitulation Orders dated 3/1/17 through 3/31/17 revealed .[MEDICATION NAME] (medication for depression) 25 mg (milligrams) tab (tablet) .take 1 tablet by mouth once daily for anxiety .[MEDICATION NAME] (medication for anxiety) 0.5 mg tablet .take 1 tablet by mouth three times daily . Medical record review of the Monthly Behavior Nursing Log dated 3/2017, revealed the following dates with no assessment for Behavioral Symptoms, Interventions, and Outcomes: * 3/7/17 second shift * 3/8/17 third shift * 3/15/17 second shift * 3/16/17 third shift * 3/17/17 first shift Medical record review revealed Resident #51 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Annual Assessment MDS dated [DATE], revealed a BIMS score of 7 out of 15 indicating severe cognitive impairment. Medical record review of a Care Plan dated 2/19/16, revealed .multiple mental health diagnosis .risk for daily challenges with .behavior, mood .can be combative .verbally aggressive .can be difficult .use vulgar language .threaten to kick .can be sexually inappropriate .administer medications as ordered and monitor .monitor for changes in mood/behavior report .due to the use of multiple medications including psychoactives .at risk .report abnormals to MD . Medical record review of a Physician's Recapitulation Orders dated 3/1/17 through 3/31/17 revealed .[MEDICATION NAME] 100 mg tab .take 1 tablet by mouth daily .take w (with) /50 mg = (equal) 150 mg .[MEDICATION NAME] 50 mg tab .take 1 tablet by mouth daily .take w/100 mg = 150 mg .[MEDICATION NAME] (psychotic medication) 2.5 mg tab .take 1 tablet by mouth twice daily .[MEDICATION NAME] 1 mg tablet .take 1 tablet by mouth three times daily (hold for sedation) . Medical record review of the Monthly Behavior Nursing Log dated 3/2017, revealed the following dates with no assessment for Behavioral Symptoms, Interventions, and Outcomes: * 3/15/17 second shift * 3/16/17 third shift * 3/17/17 first shift Interview with Licensed Practical Nurse (LPN) #1 on 3/22/17 at 10:55 AM, in the Nursing Station revealed .the nurses are to assess the residents' behaviors every shift . Interview with the Director of Nursing (DON) on 3/22/17 at 11:00 AM, in the Nursing Station, confirmed the facility failed to ensure behavior symptoms were monitored and documented every shift for Resident #29 and #51 per facility policy.

Based on interview and a review of facility written agreements, the facility failed to obtain written agreements to provide physical, occupational, and speech therapy for residents as needed. The findings included: Interview with the Administrator on July 17, 2012, at 3:00 p.m., in the Administrator's office, revealed when a resident was in need of specialized rehabilitative services, the resident was transported to an outpatient therapy center affiliated with a community hospital approximately twenty miles from the facility. Continued interview with the Administrator revealed the facility had a transfer agreement with the community hospital, and this agreement included the provision of specialized rehabilitative services to facility residents. Review of the transfer agreement between the facility and the community hospital revealed the transfer agreement did not include provision for physical, occupational, and speech therapies to facility residents. Interview with the Administrator on July 18, 2012, at 1:00 p.m., in the Administrator's office, confirmed the facility failed to obtain written agreements for the provision of specialized rehabilitative services.

Based on medical record review, policy review, review of Environmental Check sheets, review of Safety Committee minutes, observation and interview, the facility failed to prevent the elopement off the facility's property for one resident (#11) of sixteen residents reviewed. The facility's failure to prevent the elopement (off the facility property) placed resident #11 at risk for harm and in Immediate Jeopardy. The Administrator, Assistant Administrator, and the Director of Nursing were notified of the Immediate Jeopardy and Substandard Quality of care on October 6, 2010 at 3:30 p.m., in the Administrator's office. The Immediate Jeopardy was effective from September 12, 2010, through October 6, 2010, and was removed on October 6, 2010, based corrective actions implemented and verified through observations, interviews, policy review, and verification of staff in-service on site by the surveyor on October 7, 2010. Non-compliance continues at a "D" (no harm with potential for more than minimal harm that is not an Immediate Jeopardy) level for monitoring of corrective actions. The findings included: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had long and short term memory impairment, had modified independence with daily decision making skills; was independent with ambulation in the room and required supervision with ambulation in the hallway. Continued review revealed the resident exhibited wandering behavior 4-6 times but not daily in the last seven days and the behavior was not easily altered. Medical record review of the Elopement Risk Assessments dated September 2, September 10, and September 27, 2010, revealed the resident was at high risk for elopement. Medical record review of the interim care plan revealed the resident was at risk for elopement and the facility had care planned to provide for safe wandering, involve in activities, redirect resident and evaluate exit seeking behavior to determine cause/pattern. Medical record review of the Nurse's note dated September 3, 2010, at 1315 (1:15 p.m.) revealed "resident agitated trying to exit building out all of exits. Nurse Practitioner notified...has been redirected (with) some success..." Medical record review of the documentation of every 15 minutes checks dated September 3, 2010, revealed the resident was placed on every fifteen minute checks and the checks have continue through October 7, 2010. Medical record review of the Nurse's note dated September 4, 2010, at 0900 (9:00 a.m.) revealed "...res (resident) appears very anxious. Standing (with) both arms crossed speech clear. Refused to allow this Nurse to touch and assess (resident) at this time. Res attempted to go out 100 hall door x (times) 2 and lobby door x1 this a.m. Redirected (with) success (after) several attempts..." Medical record review of the Nurse's note dated September 4, 2010, revealed "...at beginning of shift was going to doors and sounding alarm. Resident out 300 hall (at) one point sitting on bench. Nurse had to encourage res to come back in building. Rsd (resident) came back in and then to dining room...rsd did not exhibit any (increase) agitation..." Medical record review of the Nurse's note dated September 6, 2010, 1600 (4:00 p.m.) revealed "Rsd went out 100 hall door and followed by CNA (Certified Nursing Assistant) rsd went around to front of building and sat on picnic table. CNA's and Nurses out to assist (with) getting rsd back in building. After sitting at table for 10 minutes rsd returned to inside of building...Upon returning inside of building resd (resident) cont (continued) to go from door to door pushing on doors. Explained to rsd that (resident) could not be outside alone..." Medical record review of the Nurse's note dated September 8, 2010, at 0800 (8:00 a.m.) revealed "medicated with PRN (as needed) Ativan (medication used for anxiety) d/t (due to) (increased) agitation pacing, going to exit doors and difficult to redirect..." Medical record review of the Nurse's note dated September 9, 2010, at 0700 (7:00 a.m.) revealed " ...attempting to go out 300 hall door sounding alarm. When this Nurse attempted to redirect back to room rsd became agitated. Yelling out and cursing. Assisted rsd into DR (dining room) for breakfast. Gave po (by mouth) prn Ativan..." Medical record review of the Nurse's note dated September 11, 2010, revealed "...Resident ambulating up and down halls quite frequently this shift. Attempting to open front door 200 hall door and 400 hall door. Staff was able to redirect resident successfully. Resident displayed (no) signs of increased agitation (with) staff this shift." Medical record review of the Nurse's note dated September 12, 2010, at 1805 (6:05 p.m.) revealed "A resident (good samaritan) of Van Buren County (witness #1) notified staff member of a strange...man whom...believed to be a resident of this facility walking along side the court house. Code Forrest (code to alert staff to potential elopement) initiated immediately. Resident (#11) not to be found in the facility. Law enforcement and rescue squad notified. Licensed Practical Nurse #1, Environmental Services employee #1, and Certified Nursing Assisted #1 left facility via personal vehicle to search for resident. The remaining staff searched grounds. (witness #1) returned resident to facility per personal vehicle. Head to toe assessment complete. Resident's status unaltered d/t (due to) elopement...Resident stated 'I was going home to my mother'. Resident placed on (one on one ) care per staff." Continued review revealed the Assistant Administrator, Director of Nursing, Social Services, Physician and responsible party were notified. Review of the Elopement Policy revealed "...Code Forrest will be the code to alert staff of potential elopement..." Medical record review of the documentation of every fifteen minute checks dated September 12, 2010, revealed the resident was documented as "walking" (within facility) at 6:00 p.m. and 6:15 p.m.,at 6:30.p.m., "left the building". Continued review revealed at 6:45 p.m. "found and back in building..." Review of the facility investigation dated September 12, 2010, revealed " ...(no) injuries noted. Alarms checked and verified ensure working. Resident on elopement program. NP (Nurse Practitioner) seen on Monday for eval (evaluation) and med (medication) review..." Review of the environmental checks documentation to include door alarm checks dated September 12, 2010, through September 18, 2010, revealed on September 12, 2010, the door alarms were checked every two hours and documented as functioning. Medical record review of the documentation of one on one observation revealed the resident was placed on one on one observation on September 12, 2010, (after elopement) at 10:00 p.m. through September 15, 2010. Medical record review of the Social Services notes dated September 13, 2010 through October 1, 2010, revealed multiple attempts were made to find alternate placement for the resident. Medical record review of the Nurse's note dated September 13, 2010, at 1800 (6:00 p.m.) revealed "...attempting to exit facility through doors x 3. Resid (resident) redirected x2 staff effective (at) this time..." Medical record review of the Mental Health Nurse Practitioner note dated September 13, 2010, revealed "...Will add Haldol (antipsychotic medication) IM (intramuscular) every two weeks, increase Neurontin to 600 mg (milligrams) bid (twice a day) for mood, and Klonipin 1 mg at 8am and 4pm..." Medical record review of the physician's orders [REDACTED]. Klonipin 1mg (at) 8am (and)1pm." Medical record review of the care plan dated September 15, 2010, revealed the resident was at risk for elopement and the facility had implemented "...Assist in orientation to facility and room with verbal cues. Encourage group activities and attempt to keep occupied. Monitor resident's location with frequent visual checks. Put familiar items in resident's room to assist (resident) in identifying (resident's) room..." Review of the facility safety committee meeting minutes dated September 16, 2010, revealed "...addition of tint to windows on the doors to draw less attraction to exit doors..." Medical record review of the Nurse's note dated September 18, 2010, revealed "...rsd (resident) was at exit doors pushing on them. Did go out door x1. Rsd passed in hallway several times and required redirecting to room..." Observation on October 5, 2010, at 11:00 a.m ., revealed the resident asleep in bed with a yellow bracelet on the wrist and a balloon attached to the resident's door. Interview with the Director of Nursing and the Assistant Administrator on October 5, 2010, at 11:00 a.m., in the Director of Nursing office, confirmed on September 12, 2010, a little after 6:00 p.m., received a call from staff that the resident had eloped. Continue interview confirmed Code Forrest was initated by staff after witness #1 reported to the staff a resident was seen off the property. Further interview confirmed the staff on duty were interviewed and denied hearing a door alarm, and confirmed no written staff statements were obtained prior to October 5, 2010. Continued interview confirmed the resident was returned to the facility by witness #1 and was found without injuries. Interview with Social Services on October 5, 2010, at 12:30 p.m., in the Director of Nursing Office confirmed multiple attempts have been made for alternate placement but have been unsuccessful. Interview with LPN (Licensed Practical Nurse) #1 (on duty at the time of the incident on September 12, 2010) on October 5, at 2:00 p.m., in the Director of Nursing office, confirmed on September 12, 2010, Environmental Services employee #1 reported the resident got out of the building. Continued interview confirmed Code Forrest was initiated, the Director of Nursing and police were notified, and denied hearing any door alarm sound. Interview with Environmental Services employee #1 on October 5, 2010, at 2:15, p.m., in the Director of Nursing office confirmed on September 12, 2010, Environmental Services employee #1 heard witness #1 report resident maybe off the property. Continued interview confirmed all door alarms were checked at 6:00 p.m., as documented on the environmental checks documentation, and upon notification of the elopement Environmental Services employee notified CNA #2, and all door alarms were checked again and a gate on the grounds outside of the 300 hall was unlatched. Interview with Certified Nursing Assistant #1 (assigned to the resident at the time of the incident on September 12, 2010) on October 5, 2010, at 2:25 p.m., with the Director of Nursing present, in the Director of Nursing's office confirmed, CNA #1 was assigned to the resident, and was aware the resident required every fifteen minute checks due to exit seeking behavior. Continued interview confirmed CNA #1 made a visual check documented at 6:00 p.m; however, CNA #1 was assigned to the dining room and the and did not make a visual check as documented at 6:15 p.m. Further interview confirmed a Code Forrest was initiated and CNA #1 assisted in the search for the resident. Telephone interview with LPN #2 (on duty at the time of the incident on September 12, 2010) October 5,2010, at 7:15 p.m., confirmed September 12, 2010, the resident did elope from the facility property. Continued interview confirmed a Code Forrest was initiated and LPN #2 and two other employees got in private vehicle to search for the resident. Further interview confirmed no door alarm was heard. Telephone interview with witness #1 on October 6, 2010 at 8:20 a.m. confirmed on September 12, 2010, while driving witness #1 noticed a male walking down the sidewalk. Continued interview revealed witness #1 thought it might be a resident from the facility and witness #1 went to the facility and notified staff (unsure name of staff). Continued interview confirmed witness #1 returned to their private vehicle and drove down the road and found the resident walking on the side of the road, (about ? mile from the facility) called the resident by name, and the resident got into the vehicle and was returned to the facility. Further interview confirmed from that approximately 15 to 20 minutes had elapsed from the time witness #1 saw the resident walking until the resident was returned to the facility. Interview with the Safety Officer on October 6, 2010, at 9:25 a.m. in the office, revealed the Interdisciplinary Safety Committee met on September 18, 2010, the elopement was discussed and the committee recommended tinting of the windows on the doors. Telephone interview with CNA #3 (on duty September 12, 2010) on October 6, 2010, at 10:00 a.m., confirmed on September 12, 2010, a Code Forrest was initiated after witness #1 notified the facility of the elopement, and Certified Nursing Assistant #3 got in vehicle to assist in searching for the resident. Continued interview confirmed Certified Nursing Assistant #3 did not hear a door alarm. Telephone interview on October 6, 2010, at 10:15 a.m. with CNA #4 (on duty at the time of the incident on September 12, 2010) confirmed Environmental Services employee #1 came to the dining room and reported to Certified Nursing Assistant #4 that a resident had been seen up at the court house. Continued interview confirmed the elopement was reported to LPN #2. Further interview confirmed CNA #4 did not recall hearing a door alarm sound. Observation of the elopement site and interview on October 6, 2010, at 11:00 a.m., with the Director of Nursing and the Assistant Administrator confirmed the resident went approximately ? to ? of a mile from the facility property. Further observation revealed two intersections between the facility and the location the resident was located. Continued observation revealed 5 cars passed through the intersection in a 7 minute period. Interview with the Administrator, Assistant Administrator and the Director of Nursing on October 6, 2010, at 1:00 p.m., in the Administrator's office, confirmed the resident was placed on every fifteen minute checks beginning September 3, 2010, related to exit seeking behaviors. Continued interview confirmed on September 12, 2010, the resident eloped off the facility property without staff knowledge and staff were made aware of the elopement by witness #1; the resident was gone approximately 20 minutes before being returned to the facility by witness #1, and upon return resident #11 was placed on one on one supervision for 48 hours. Further interview confirmed the facility had implemented the following interventions after resident #11 eloped: the alarm company changed the key pad codes for all exit doors on September 13, 2010; Mental Health Nurse Practitioner evaluated the resident on September 13, 2010, and ordered medication changes; Social Services began looking for alternate placement on September 13, 2010; all staff in-service on elopement was conducted on September 23, 2010; the facility began tinting of the exit door windows on the week of September 24, 2010, and completed the tinting on October 5, 2010; the residents identified at risk for elopement were reassessed by October 6, 2010; beginning October 5, 2010, all nursing staff were in-serviced on documentation and every fifteen minute checks until 100% all nursing staff have been inserviced prior to returning to work the next scheduled shift. The facility's corrective actions were confirmed through observation, documentation review, and interview of multiple staff to remove the Immediate Jeopardy. Observation on October 6, 2010, with the Director of Nursing at 11:15 a.m., revealed all residents indentified at risk for elopement had a yellow bracelet on the wrist and a balloon on the residents' room doors as per the facility elopement policy; exit doors were tinted and alarms were functioning. Review of the Elopement Risk Assessments for the residents indentified at risk for elopement were updated by October 6, 2010. Review of in-service records revealed all staff were in-serviced on elopement on September 23, 2010, and in-service for all nursing staff on documentation and every fifteen minute checks began on October 5, 2010. Multiple staff including environmental services and Nursing staff including LPN's, RN's (Registered Nurses), CNA's on multiple shifts were interviewed from October 5, 2010, through October 7, 2010, and confirmed they have been in-serviced on interventions and monitoring to prevent elopement, accurate documentation and visual observation for monitoring wandering residents when completing every 15 minute checks. Verification of the facility's interventions was completed by record review, observation and interview October 5, 2010, through October 7, 2010, to confirm the facility had removed the Immediate Jeopardy (A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) from a "J" level to "D" level (no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy) effective October 6, 2010, and noncompliance continues at a "D" level. C/OTN 809