Every finding on record at Greenville Gardens

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #20 and Resident #11) reviewed for infection control. 1.The facility failed to ensure staff wore PPE when entering Resident #20's room on 08/12/25 and 08/13/25 who was on contact isolation for Extended-spectrum beta-lactamase also known as ESBL (a group of bacteria that are resistant to many commonly used antibiotics. 2. The facility failed to ensure LVN F used proper hand hygiene when preforming blood sugar checks and given insulin for Resident #11 on 08/12/25. These failures could place residents and staff at risk for cross-contamination and the spread of infection.Findings included:1.Record review of Resident #20's face sheet, dated 08/13/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, ESBL, dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and diabetes (a chronic disease where the body doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels). Record review of Resident #20's quarterly MDS assessment, dated 05/08/25, indicated Resident #20 understood and was usually understood by others. Resident #20 BIMS score was 10 indicating she was moderately cognitive impaired. The MDS indicated Resident #20 required assistance with her ADLs and maximum assistance with toileting and showering. The MDS indicated Resident #20 was always incontinent of bowel and bladder. Record review of Resident #20's lab urinalysis drawn 08/07/25 and received 08/10/25 indicated a positive result of ESBL. Record review of Resident #20's comprehensive care plan, last reviewed 08/11/25 indicated she was on contact isolation and on antibiotic therapy related diagnosis of ESBL. The intervention was to give medication as ordered. Record review of Resident #20's Physician order dated 08/10/25 indicated Ciprofloxacin HCl oral tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth two times a day for UTI until 08/16/2025 for 5 Days. Record review of Resident #20's MAR dated 08/01/25 through 08/31/25 indicated she received her first dose of Ciprofloxacin HCl oral tablet 500 MG on 08/10/25 at 8:00 pm. Record review of Resident #20's Physician order dated 08/12/25 indicated Contact precautions every shift for 6 Days. During an observation on 08/11/25 at 10:40a.m., Resident #20 had a red sign by her doorway that said stop along with how to [NAME] and Doff PPE . The isolation cart was also outside her door with gowns, gloves, and mask. Resident #20 was in her bed. During an observation on 08/12/25 at 9:00 a.m., The red sign that read stop was removed from the door but the sign on how to apply and remove PPE was still on the door along with the isolation cart. During an observation on 08/12/2025 at 9:12 a.m., CNA G knocked on Resident #20's door carrying cranberry juice. CNA G entered Resident #20's room without applying any PPE. CNA G exited Resident #20's room. During an interview on 08/12/2025 at 3:28 p.m., CNA G said she did not have to put on PPE just to deliver Resident #20 cranberry juice. She said she only had to wear PPE when she provided care. She said she knew Resident #20 was on contact isolation for ESBL in her urine. She said they did not have bags in the room to put linen in, she said she brought the linen out with her and disposal of it in the regular linen barrels. She said Resident #20 was incontinent of bowel and bladder. During an interview on 08/13/25 at 10:15 a.m., Housekeeper K, said she cleaned Resident #20's room this morning and did not wear any PPE (gown). She said she was not aware of anyone on contact isolation. She said if a resident were on isolation a sign would be outside their door indication what to wear. She looked at Resident #20's door and saw the signs, but said it was not indicating what PPE (gown, gloves) she needed to wear. She said she did not wear PPE (gown) when she cleaned Resident #20's room this morning. During an interview on 08/13/25 at 12:18 p.m., Laundry Aide L was in the laundry and showed surveyor what the staff used when a resident was under contact isolation (which included an apron and gloves). He said the facility did not have any residents under contact isolation, but when the facility did have residents under contact isolation, their laundry was sent out in yellow bags and washed separately from other residents to prevent the spread of infection. During an observation and interview on 08/13/25 at 2:43 p.m., RN M was in Resident #20's room talking to her about a television show. He was standing between her bedside table and the television without any PPE (gloves or gown). He said he saw the barrier precaution sign meaning if you were providing care for someone with a wound, etc., you would wear PPE. He said if they were on isolation then you should wear gown, gloves, and mask depending on the isolation. He went back to Resident #20's room and said she was on contact isolation, but he did not need to wear any PPE (gown or gloves) unless he was providing care. 2. Record review of Resident #11's face sheet dated 08/13/25 indicated he was an [AGE] year-old female who admitted to the facility on [DATE] with the following diagnosis, diabetes (a chronic disease where the body doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels),dementia (a general term for a decline in mental ability severe enough to interfere with daily life), and high blood pressure. Record review of Resident #11's quarterly MDS dated [DATE] indicated she usually understood and was usually understood by others. The MDS also indicated she had a BIMS score of 01 which meant he was severely cognitively impaired. The MDS indicated Resident #11 required set up assistance with her ADLs. The MDS indicated Resident #11 received insulin during the last 7 day look back period. Record review of Resident #11's comprehensive care plan dated 05/06/25 indicated she had a diagnosis of diabetes. The care plan interventions were for staff to give medication as ordered and monitor/document for side effects and effectiveness. Record review of Resident #11's physician order summary report dated 05/24/25 revealed Insulin Aspart Flex Pen 100 UNIT/ML Solution pen injector Inject as per sliding scale: if 201 - 250 = 2 Units; 251 - 300 = 4Units; 301 - 350 = 6Units; 351 - 400 = 8Units; 401 -450 = 10U nits call the physician, subcutaneously three times a day for diagnosis of diabetes. During an observation and interview on 08/12/25 at 4:10 p.m., LVN F was taken Resident #11's blood sugar. He obtained a blood sugar reading of 256. He removed his gloves without hand hygiene. He opened the computer and read the medication administration record which indicated he needed to give Resident #11 4 units of insulin. He opened the cart gathered the insulin, applied gloves, and administered the insulin to Resident #11. LVN F said he did not hand hygiene after he took his gloves off or before he gave the insulin but should have to prevent cross contamination. During an interview on 08/13/25 at 4:36 p.m., the DON said she expected all staff to follow the guidelines on the sign posted on the door. She said the staff were aware of Resident #20 being on contact precautions by the sign on the door and the setup outside the door. She said staff did not have to wear PPE (gown or gloves) when they were just going into the room to talk or give medication, only if they had contact (transferring or incontinence care) with the resident. She said they did not have to have linen bags in Resident #20's room that her contact isolation linen could be washed with all other resident's clothes. The DON said she expected the nurse to hand hygiene after taken Resident #11's blood sugar and before given the insulin to prevent the spread of germs or infection. The DON said she did daily rounding to monitor for infection control issues and if she did see anything wrong, she would stop staff and re-educate them. During an interview on 08/13/25 at 4:52 p.m., the Administrator said the DON was the oversee of infection. He said for isolated residents' staff should hand hygiene before and after leaving the room. He said it was important to prevent cross-contamination. He said he expected the nurse to hand hygiene between clean and dirty procedures for infection control reasons. Record review of the facility's policy titled, Infection Prevention and Control Program, revised 6/2020, indicated, To ensure the facility established and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirement. The facility must establish an infection prevention and control program under which it #1 identifies, investigates, control, and prevent infection in the facility. Record review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, revised 10/24/22, indicated, To ensure that transmission based precautions are used when caring for residents with communicable disease or transmittal infections #3 Contact Isolation: contact isolations are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces our resident care items and the residents environment. Record review of the facility's policy titled, Hand Hygiene, revised 06/20, indicated, To ensure that all individuals use appropriate hand hygiene while at the facility. The facility considers hand hygiene the primary means to prevent the spread of infection. #7 the use of gloves does not replace hand hygiene procedures.

Based on observation, interview, and record review, the facility failed to establish a system of receipt of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, residents' safety, and drug diversion. Findings included: During an observation and interview on 08/13/25 at 3:20 p.m., the following medications were observed in the controlled medication storage cabinet awaiting to be disposed:*Hydrocodone/APAP 5-325mg- 114 tablets RX# 88263964*Alprazolam 0.5 mg-12 tablets RX# 88285870*Diazepam 2mg- 56 tablets RX# 88264002*Diazepam 5mg- 15 tablets RX# 88263734*Lorazepam 0.5mg- 9 tablets RX# C0412656 *The DON said the controlled medications awaiting to be disposed were kept in the locked cabinet behind a locked door. The DON said she was the only one with the key to the door and the cabinet. The DON said her process when she reconciled medications that needed to be disposed of was as follows: When medications were brought to her, she checked the narcotic medication count and verified the count with the nurse, the nurse and herself signed the narcotic sheet. She stated she then placed the medication in the locked box. The DON said the pharmacy consultant and herself were responsible for reconciling the narcotic medications. The DON said she did not reconcile the medication prior to her and the pharmacist destroying the expired or discontinued medication. The DON said medications would not come up missing as she did not leave the cabinet, or the door unlocked. Record review of the facility's medication destruction binder on 08/13/25, indicated the last medication destruction was completed on 07/22/25. During an interview on 08/13/25 at 4:52 p.m., the Administrator said when narcotic medications were discontinued, they were given to the DON with the narcotic count sheet and kept locked. The Administrator said ideally, the narcotic medication should be logged as the DON received them, but the count was verified on the narcotic count sheet. The Administrator said the DON and the pharmacy consultant were responsible for ensuring the narcotic medications were accurately reconciled. The Administrator said if the narcotic medications were not reconciled then medications could come up missing. Record review of the facility's policy Narcotic Administration, revised 06/2025, indicated, To ensure the secure storage accurately administration, proper documentation, and responsible disposal of narcotics (controlled) substance in accordance with the federal (DEA) state regulations, and CMS guidelines. Controlled substance must be handled with the highest degree of accountability and security. Only authorized and licensed personnel may manage, administrator, or dispose of these medications. Procedure: Discontinued or expired medications :2 licensed nurses must document and witness the removal of discontinued or expired narcotics from active inventory. Medications must be stored, clearly labeled area pending destruction. Destructions of narcotics: Disposal must comply with DEA and State Board of nursing requirements, and a signed destruction log must be maintained.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for the memory care unit. The facility did not maintain an effective pest control program to ensure the memory care unit was free of gnats and other flying insects. This could place residents at risk for an unsanitary environment. Findings include:During an observation and attempted interview on 8/11/25 at 10:18 a.m., Resident #70 had gnats in her water cup that was at her bedside. There were also gnats flying around the room. Resident #70 resided on the locked unit. During an observation and attempted interview on 8/11/25 at 10:20 a.m. Resident #64 was standing inside his room watching the TV. He did not answer any questions. There were several gnats flying around the room. During an observation on 8/11/25 at 12:20 p.m., Resident #22 was observed swatting at gnats and yelled out, Gnats! She had her lunch [NAME] and was in the process of eating lunch. During an observation on 8/12/25 at 11:40 a.m. there were gnats in the conference room. During an interview on 8/12/25 at 3:27 p.m. CNA A said the administrator would set traps but there are always gnats flying around. She said she did not know if any other measures were taken to control the gnats. She said that the gnats were bothersome to the residents as they will swat at them. During an interview on 08/13/25 at 11:04 a.m., the Maintenance Director, said he was aware of the gnats in the locked unit. He said they had the lights that attract flying bugs on the walls, and they could be effective. He said they also had a chemicals poured in the drain that can help prevent gnats. He said it could be bothersome and a health risk to residents having gnats or other flying bugs landing on them or in their drinks. He said they are doing as much as they can to keep the insects out of the building. During an interview on 08/13/2025 at 2:45 p.m. the Administrator said the facility should be reasonably pest free for the comfort of the residents. He said that gnats or other flying insects could be bothersome to residents. He said that it could also be unsanitary if a gnat or other insects were in residents water cups or landed on their food. He said it was the responsibility of the pest control company and the maintenance director to ensure the facility was reasonably free from pests such as gnats and other flying insects. Record review of the pest control log shows that the memory care unit was treated for gnats after the survey and observations began on 8/12/2025.Record review of a facility provided policy titled, Pest Control dated 8/2020 indicated that, To ensure the Facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, Facility Staff, and visitors. The Facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. The Administrator arranges for a pest control company (Company) to visit and inspect the Facility at least once a year.Facility Staff will report to the Housekeeping Supervisor an sign of rodents or insects, including ants, in the Facility.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #50) reviewed for hospice services. The facility failed to obtain Resident #50's most current hospice certification, plan of care, nurse visit notes, interdisciplinary meetings, and medication profile. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of a face sheet dated 08/12/2025 indicated Resident #50 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cerebral atherosclerosis (arteries in the brain become narrowed or blocked due to plaque buildup which can result in serious health issues such as stroke and cognitive impairments). Record review of Resident #50's Quarterly MDS assessment dated [DATE] indicated he was rarely/never understood and rarely/never understood others. The MDS assessment indicated the Staff Assessment for Mental Status was completed due to him being rarely/never understood. The Staff Assessment for Mental Status for Resident #50 indicated he had a long-term and short-term memory problem. The MDS assessment indicated Resident #50 received hospice care while a resident at the facility. Record review of Resident #50's care plan with a date initiated of 01/20/2025, indicated he had a terminal prognosis related to cerebral atherosclerosis, and the interventions included to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of Resident #50's Order Summary Report dated 08/12/2025 indicated to admit to hospice with an order date of 02/06/2025. Record review of Resident #50's hospice binder indicated Initial Plan of Care and Interdisciplinary Care Plan dated 11/22/2024, indicated Resident #50 was admitted to hospice for routine home care. There was no current plan of care to indicate Resident #50 was receiving routine nursing home care or an updated Interdisciplinary Care Plan. Plan of care review dated 12/18/2024. There was no current plan of care review. For Certification/Recertification for Benefit Period Number begin date 11/22/2024 through Recert due date 2/2/2025. There was no updated recertification. Resident #50's hospice medications were dated 1/21/2025. Resident #50's binder had no hospice nurses' notes. During an interview on 08/12/2025 at 12:41 PM, the Medical Records designee said she scanned the hospice documents weekly into the resident's electronic health record, and some of the documents were kept in the residents' hospice binders. The Medical Records designee said she was not responsible for ensuring the hospice documents were in the facility and updated. The Medical Records designee said she was only responsible for scanning the documents into the electronic health record. During an interview on 08/12/2025 at 2:12 PM, the hospice nurse said her nurse visits were two times a week. The hospice nurse said the resident's hospice binder should have an updated medication profile, hospice care plan, and interdisciplinary group meetings. The hospice nurse said she did not take the nurses notes to the facility. The hospice nurse said the updated care plans should be provided to the facility weekly, the interdisciplinary group meetings were completed every other week and should be provided to the facility probably monthly. The hospice nurse said she was responsible for bringing Resident #50's medication profile, hospice care plan, and interdisciplinary group meetings to the facility. The hospice nurse said she had not been bringing the hospice documents weekly, but she thought she was taking them monthly. The hospice nurse said she placed them in Resident #50's hospice binder. The hospice nurse said it was important for the medication profile, hospice care plan, and interdisciplinary group meetings to be provided to the facility for continuity of care. During an interview on 08/13/2025 at 2:56 PM, the DON said Resident #50 should have a hospice binder with all of the required hospice documents, and they should be up to date. The DON said they were trying to go electronic and there should also be documents uploaded in Resident #50's electronic health record. The DON said Medical Records was responsible for ensuring the hospice documents were in the electronic health record. The DON said it was important for the hospice documents to be in the facility and updated to ensure the proper care was given to the residents and for the patient information to be correct. During an interview on 08/13/2025 at 3:22 PM, the Administrator said he expected for the required hospice documents to be in the facility. The Administrator said Medical Records was responsible for ensuring the hospice documents were in the facility. The Administrator said it was important for the hospice documents to be in the facility to ensure both entities were providing the necessary care to the residents and to ensure continuity of care. Record review of the Single Patient Agreement For Residential Hospice Services Provided in a Nursing Facility for Resident #50 dated 04/03/2025, indicated, Clinical Records and Discharge Summary. [hospice company] and Facility shall each prepare and maintain complete and detailed clinical records concerning the Hospice Patient receiving Facility Room and Board Services under this Agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state law and regulations and applicable Medicare and Medicaid program guidelines. Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, the Hospice Patient (including evaluations, treatments, progress notes, authorizations for admission to hospice and/or Facility and physician orders entered pursuant to this Agreement) as required by this Agreement.

Based on observations, interviews, and record review the facility failed ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 of 22 residents (Resident #40) reviewed for food preferences and the accommodation of resident's meal choices. The facility did not honor Resident #40's preference for dislike of tomatoes products and green peas on 07/21/25, 08/07/25, and 08/10/25. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #40's face sheet, dated 08/13/25, reflected Resident #40 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included chronic systolic (congestive) heart failure (condition where the heart's left ventricle was weakened and cannot contract forcefully enough to pump an adequate amount of blood throughout the body). Record review of Resident #40's quarterly MDS assessment, dated 06/15/25, reflected Resident #40 made herself understood, and understood others. Resident #40's BIMS score was 14, which indicated her cognition was intact. Resident #40 was independent with eating. Resident #40 had not had a 5% weight loss or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #40's comprehensive care plan revised on 06/11/24, reflected Resident #40 had the potential for nutritional problem related diet restrictions and morbid obesity. The care plan interventions included provide, serve diet as ordered. Record review of Resident #40's order summary report dated 08/13/25 reflected there was not an order for her dislikes. Record review of the residents' dietary cards reflected Resident #40 disliked green peas and tomato products. Record review of a photographic record submitted by Resident #40 on 08/11/25 revealed Resident #40 received buttered peas on 07/21/25, five way mixed vegetables that included green peas on 08/07/25 and spaghetti with meat sauce on 08/10/25. During an interview on 08/11/25 at 3:38 p.m., Resident #40 stated she did not like tomato products or green peas, and she continued to receive tomatoes products and green peas after she had told the kitchen staff, she did not like it. Resident #40 stated she received spaghetti with tomato sauce on yesterday (08/10/25). Resident #40 stated she felt they don't take my feelings into consideration and they don't care. During an interview on 08/12/25 at 4:30 p.m., the Dietary Manager stated he was aware that Resident #40 dislike tomato products and green peas and expected she did not receive those food items. The Dietary Manager stated he had spoken with her a few times about when she received something she did not like to ask for an alternative. The Dietary Manager stated he was not aware that she received spaghetti with tomato meat sauce on yesterday (08/10/25). The Dietary Manager stated the cook was responsible for ensuring she received an alternative if those items were on the menu. The Dietary Manager stated he had in serviced the staff but it's time to take disciplinary actions. The Dietary Manager stated he was responsible for overseeing by monitoring meals and in servicing staff. The Dietary Manager stated it was important for Resident #40's food dislikes to be followed to prevent the potential of weight loss. During an interview on 08/13/25 at 4:26 p.m., the Administrator stated he expected food preferences/dislikes to be followed. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing by spot checks during meal service. The Administrator stated it was important for their food preferences/dislikes to be followed because it was their right and prevent potential weight loss. Record review of the facility's policy titled Resident Rights-Accommodation of Needs revised 08/2020 indicated. To ensure that the Facility provides an environment and services that meet residents' individual needs. I. Residents' individual needs and preferences are accommodated.

Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 2 of 22 residents (Residents #25 and #62) reviewed for medications at their bedside. 1. The facility did not ensure Resident #25's hydrocortisone cream (topical ointment used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) was not left on her dresser. 2. The facility did not ensure Resident #62's omeprazole (used to treat excess stomach acid) was not left on her bedside table. These failures could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.Findings included: 1. Record review of Resident #25's face sheet, dated 08/13/25, reflected Resident #25 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (brain chemical imbalance in the blood). Record review of Resident #25's quarterly MDS assessment, dated 07/12/25, reflected Resident #25 made herself understood and understood others. Resident #25's BIMS score was 12, which indicated her cognition was moderately impaired. Record review of Resident #25's comprehensive care plan revised on 02/13/25 reflected Resident #20 had impaired cognitive function/dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) or impaired thought processes related Alzheimer's (progressive disease that destroys memory and other important mental functions), dementia, AMS, and acute or chronic metabolic encephalopathy. The care plan interventions included administer medications as ordered. Record review of Resident #25's order summary report dated 08/11/25 reflected there was no order for hydrocortisone cream in the summary. During an interview and observation on 08/11/25 at 2:45 p.m., a tube labeled hydrocortisone cream 1% was observed on Resident #25's dresser. Resident #25 stated a staff gave her the tube of medication when she was on Hall 200. Resident #25 stated she could not remember the staff name. Resident #25 stated she used the medication for her hemorrhoids (swollen inflamed veins in the rectum). 2. Record review of Resident #62's face sheet, dated 08/13/25, reflected Resident #62 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included bipolar (a disorder associated with episodes of mood swings ranging from depression lows to manic highs). Record review of Resident #62's quarterly MDS, dated [DATE], reflected Resident #62 made herself understood and understood others. Resident #62's BIMS score was 13, which indicated her cognition was intact. Record review of Resident #62's comprehensive care plan revised on 05/28/24 reflected Resident #62 had an ADL Self-Care Performance Deficit related to PAD (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The care plan interventions included x1 staff participation with personal hygiene. Record review of Resident #62's order summary report dated 08/11/25 reflected there was no order for omeprazole in the summary. During an interview and observation on 08/11/25 at 3:57 p.m., a bottled labeled omeprazole was observed on Resident #62's bedside table. Resident #62 stated she bought the medication herself from the store for her gut. Resident #62 stated staff were aware of her having the medication at her bedside. During an interview on 08/13/25 at 3:11 p.m., ADON C stated she was the 6a-2p charge nurse for Resident #25 and #62. ADON C stated neither resident had been evaluated for self-administration of medications. ADON C stated if a resident was able to self- administer, he/she must be assessed for competence, complete a medication self-administration evaluation and an order from the physician must be obtained. ADON C stated during rounds, the Housekeeping Manager alerted her to come in Resident #25 room, and once she went in the room, the Housekeeping Manager showed her the hydrocortisone cream on her dresser. The Housekeeping Manager stated she removed the medication and educated Resident #25 that she was not allowed to keep the cream in her room. ADON C stated she was unaware Resident #62 had omeprazole on her bedside table. ADON C stated medications should be stored on the medication cart. ADON C stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 08/13/25 beginning at 4:00 p.m., the DON stated she expected medications to be stored on the medication cart. The DON stated if a resident was able to self-administer, he/she must be assessed, and obtain an order. The DON stated all staff should be ensuring medications were not left at bedside. The DON stated she was responsible for monitoring medications at bedside by daily rounds and ambassador rounds completed by the Housekeeping Manager. The DON stated during her rounds on 08/11/25, there were no medications at bedside. The DON stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 08/13/25 at 4:11 p.m., the Housekeeping Manager stated she was responsible for ambassador rounds for Resident #25 and Resident #62. The Housekeeping Manager stated during her rounds on 08/11/25, she did notice the cream on Resident #25's dresser. The Housekeeping Manager stated she reported to ADON C, and she came in and removed the medication. The Housekeeping Manager stated she would not know what omeprazole looked like, so she did not see any medication on her bedside table. During an interview on 08/13/25 beginning at 4:26 p.m., the Administrator stated medications should be locked/secured in the nurse's cart and administered by the nurse or MA. The Administrator stated he monitored medications at bedside by ensuring the ambassador rounds were completed daily. The Administrator stated it was important to ensure medications were not left at bedside for resident safety. Record review of the facility's policy titled, Storage of Medications, revised 08/2020 reflected. Medications and biologicals are stored safely, securely, and properly. 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications.

Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 22 residents (Residents #75 and #39) reviewed for nutrition. 1. The facility did not ensure Resident #75 was given chopped meats for lunch on 08/11/25 as ordered by the physician. 2. The facility did not ensure Resident #39 was given chopped meats for lunch on 08/11/25. This failure could place residents at risk for choking, poor intake, weight loss, and unmet nutritional needs. Findings Included: 1. Record review of Resident #75's face sheet dated 08/13/25 indicated he was an [AGE] year-old female who admitted to the facility on [DATE] dysphagia (medical term for difficulty swallowing), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), and malnutrition (a serious condition resulting from an imbalance in nutrient intake, leading to deficiencies or excesses that negatively impact health). Record review of Resident #75's quarterly MDS dated [DATE] indicated she usually understood and was usually understood by others. The MDS also indicated she had a BIMS score of 03s which meant he was severely cognitively impaired. The MDS indicated Resident #75 required assistance with her ADLs including eating. Resident #75 did not have a 5% weight loss or more in the last month or loss of 10% or more in last 6 months. Record review of Resident #75's comprehensive care plan dated 04/23/25 indicated she had a regular diet, regular consistency, with thin liquids. The care plan interventions included: serve diet as ordered by the physician. Record review of Resident #75's physician order summary report dated 05/20/25 indicated she had an order for a regular with chopped meat texture, thin consistency. Record review of Resident #75's lunch meal ticket dated 08/11/25, reflected chopped meats. During a dining observation and interview on 08/11/2025 at 12:04 p.m., Resident #75 was eating her lunch and had taken 1-2 bites of her whole fish sandwich when the state surveyor saw her tray card which read chopped meat. CNA N said she served Resident #75 her lunch tray but did not see that her tray card said chopped meats. CNA N took the lunch tray back to the kitchen staff and they prepared the correct diet with chopped meats. 2.Record review of Resident #39's face sheet, dated 08/13/25, reflected Resident #39 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included malnutrition (a serious condition resulting from an imbalance in nutrient intake, leading to deficiencies or excesses that negatively impact health). dementia (a general term for a decline in mental ability severe enough to interfere with daily life), and bipolar (a mental illness characterized by extreme shifts in mood, energy, and activity levels). Record review of Resident #39's quarterly MDS assessment, dated 07/08/25, reflected Resident #39 rarely made herself understood, and was rarely understood by others. Resident #39's was severely modified with daily decision making. Resident #39 required assistance with all ADLs including eating. Resident #39 did not have a 5% weight loss or more in the last month or loss of 10% or more in last 6 months. Record review of Resident #39's comprehensive care plan revised on 06/17/25, reflected Resident #39 had a potential for nutritional problems and a diet order other than regular with chopped meats. The care plan interventions were to serve diet as ordered by the physician and RD assess per facility protocol. Record review of Resident #39's physician order summary report, dated 01/25/22, reflected regular texture, regular with thin liquid consistency. Record review of Resident #39's lunch meal ticket dated 08/11/25, reflected regular with chopped meats. During a dining observation and interview on 08/11/2025 at 12:04 p.m., Resident #39 was served a whole fish sandwich and her tray card said chopped meats. CNA N said she served Resident #39 her lunch tray but did not see her card said chopped meats. CNA N took the lunch tray back to the kitchen staff and they prepared the correct diet of chopped meats. During an interview on 08/11/2025 at 1:15 p.m., Resident #39 was unable to say what her correct diet was supposed to be. During an interview on 08/13/25 at 12:14 p.m., the Dietary Manager said a resident with chopped meat diet, means the meat should be cut into smaller pieces. He said the cook was responsible for ensuring the meat was cut before serving. He said it would be hard for Resident #39 and Resident # 75 to cut their meat. He said he did random spot checks of trays being served out of the kitchen. The Dietary Manager said it was important to ensure residents received the correct diet order for proper nutrients. During an observation and interview on 08/13/25 at 12:57 p.m., [NAME] H said she prepared Resident #75 and Resident #39's tray. She said she thought chopped meats meant she should have cut the fish sandwich into four pieces. She reviewed her diet recipe for chopped meats and verified she should have cut the fish into 4 pieces, she said she missed that on the recipe and did not cut Resident #75's or Resident #39's sandwich. She said by not following the recipe, or diet order she placed the residents at a risk of choking. During an interview on 08/13/2025 at 4:20 p.m., ADON D said she was the nurse checking the trays on Monday (08/11/25) and did not read the tray cards thoroughly therefore she did not see where the ticket said chopped meats. She said it was an overcite and could have cause choking for the residents. During an interview on 08/13/25 at 4:36 p.m., the DON said she expected the diet order to be followed. The DON said the Dietary Manager was responsible for monitoring diet orders. She said the nurses should be checking the trays before they were served to ensure the diet was correct. The DON said the risk of not receiving chopped meat for Resident #75 and Resident #39 could have been difficulty swallowing and/or choking. During an interview on 08/13/25 at 4:52 p.m., the Administrator said he expected the diet order to be followed. The Administrator said the Dietary Manager, the cook and the nurses were responsible for monitoring diet orders. The Administrator stated she oversees the kitchen by random spot checks several times a week and has not had any issues with staff not following the diet orders. The Administrator said it was important to ensure Resident #75 and Resident #39received chopped meats to prevent choking. Record review of the facility policy Therapeutic Diets, revised 12/2020, indicated, Policy: To ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders. Therapeutic diets or diets that deviate from the regular diet and require a physician's order. Procedure: 1B. The therapeutic diet will be reflected on the resident's tray card.2. Therapeutic diets are reflected on the menu extension. 3. The nutritional manager is responsible for ensuring the correct type and amount of food is purchased to meet the needs of the resident receiving therapeutic diet. 5. The nutrition service manager will periodically review the residents tray card and the physician's nutrition orders to ensure that the information is consistent.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #74) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #74's foley catheter was secured on 08/11/25. This failure could place residents at risk for urinary tract infections and a decreased quality of life. Findings included: Record review of Resident #74's face sheet, dated 08/13/25, reflected Resident #74 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included benign prostatic hyperplasia without lower urinary tract (enlargement of the prostate which did not result in difficulty urinating). Record review of Resident #74's quarterly MDS dated [DATE] reflected Resident #74 sometimes understood others and sometimes was understood by others. The assessment reflected Resident #74 had short- and long-term problems. Resident #74 was dependent with toileting. The assessment indicated Resident #74 had an indwelling catheter (tube inserted into the bladder). Record review of Resident #74's comprehensive care plan revised 11/09/23 reflected he had BPH with obstructive uropathy (urine flow is obstructed) and required a suprapubic catheter. The care plan interventions included: ensure leg strap was in place to secure foley. The intervention was revised on 08/12/25 after surveyor intervention that Resident #74 was non-compliant-pulls off strap. Record review of Resident #74's order summary report dated 08/12/25 reflected to check placement of s/p catheter securement device every shift with a start date of 05/14/25. During an observation and interview on 08/11/25 at 3:23 p.m., Resident #74 was in his wheelchair in his room. ADON C and ADON D showed the state surveyor Resident #74's foley catheter which was not secured to his leg. ADON C stated she did not know why the catheter was not secured to his leg. ADON C stated the catheters were checked daily by the nurses to ensure they were secured. ADON C stated she was the 6a-2p charge nurse for Resident #74, and the catheter was secured when she completed his head-to-toe assessment during her shift. The foley catheter strap was nowhere to be found in Resident #74's pants. ADON C stated if the catheter was not secured it could cause trauma which could lead to an infection. During an interview on 08/11/25 at 4:00 p.m., RN E stated she was Resident #74's 2p-10p charge nurse. RN E stated she did not know why Resident #74's catheter was not secured. RN E stated the catheters were checked every shift by the nurses to ensure they were secured. RN E stated she had not completed an assessment to ensure his catheter was secured because Resident #74 was in the day area. RN E stated it was important his catheter was secured to prevent trauma to his urethra (tube that carried urine from the bladder to the outside of the body). During an interview on 08/13/25 at 4:00 p.m., the DON stated charge nurses, and CNAs should be checking to ensure the foley catheters were secured. The DON stated she was responsible for monitoring and overseeing catheter securement by daily rounds. The DON stated she had not noticed any issues with the foley catheters not being secured. The DON stated it was important for Resident #74's foley catheter to be secured to prevent an injury. During an interview on 08/13/25 at 4:26 p.m., the Administrator stated catheters should be always secured. The Administrator stated the DON was responsible for monitoring and overseeing by frequent rounding. The Administrator stated it was important for the foley catheter to be secured to prevent an injury occurring. Record review of the facility's policy titled, Care of Catheter, revised 06/2020 reflected. To prevent catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary. III. Proper Techniques for Urinary Catheter Maintenance. c. anchor the catheter with a leg strap to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 6 residents (Resident #30) reviewed for care plans. The facility failed to ensure a care plan was developed for Resident #30's medication of Clonazepam used to produce a calming effect on the brain and nerves, which helps to reduce anxiety, prevent seizures, and promote relaxation. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: Record review of Resident #30's face sheet, dated 08/13/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, anxiety (a feeling of fear, dread, and uneasiness), depression (a serious mental disorder characterized by persistent sadness, loss of interest in activities, and difficulty functioning in daily life), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Record review of Resident #30's quarterly MDS assessment, dated 06/09/25, indicated Resident #30 was understood and was usually understood by others. Resident #30's BIMS score was 03 indicating her cognition was severely impaired. The MDS indicated Resident #30 required maximum assistance with her ADLs. The MDS indicated Resident #30 received an antianxiety medication during the 7-day look back period. Record review of Resident #30's comprehensive care plan, last reviewed 06/30/25 did not indicate a care plan for Clonazepam. Record review of Resident #30's Physician order dated 07/14/25 revealed Resident #30 had Clonazepam Oral Tablet 0.5 MG (Clonazepam). Give 1 tablet by mouth in the morning for anxiety. Record review of Resident #30's Physician order dated 07/14/25 revealed Resident #30 had Clonazepam Oral Tablet 1 MG (Clonazepam). Give 1 tablet by mouth at bedtime for anxiety. During an observation and interview on 08/13/25 at 4:30 p.m., the MDS Coordinator said she was responsible to update the care plans when she did the admission, quarterly, annual, or significant change MDS. She said she could not say who was responsible for acute care plans. She said she was made aware of any residents' change(s) in the morning meeting. The MDS Coordinator looked at Resident #30's care plan and said she did not see her Clonazepam added to her care plan. She said care plans were done to establish a plan of care for all residents. During an interview on 08/13/25 at 4:36 p.m., the DON said the MDS Coordinator was responsible for the care plans, but she was the overseer. The DON said she and the other nurse managers were supposed to do the acute care plans. She said they talked about all resident's changes (orders, behaviors, etc.,) during the morning stand-up meeting. She said she could not say why Resident #30's care plan was not updated to include her Clonazepam. The DON said the purpose of the care plans was to keep everyone informed of the resident's care. During an interview on 08/13/25 at 4:52 p.m., the Administrator said the MDS Coordinator, and the DON were responsible for the care plans, and he was the overseer. The Administrator said they had morning meetings daily and discussed any changes with a resident. He stated he expected the administration nurses to update the care plan during that meeting. He said care plans were done for the care the resident needed. Record review of the facility's policy titled, Care Planning, revised 10/24/22, indicated, Policy: To ensure that a comprehensive person-centered care plan developed for each resident based on their individual assessed needs. The IDT will revise the comprehensive care plan as needed at the following intervals: A per RAI schedule, B. as dictated by changes in the resident condition, E. other times as appropriate or necessary.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 22 residents reviewed for resident rights. (Resident #44) The facility failed to ensure Resident #44's bathroom light was functioning properly and not flashing on and off rapidly. This failure could place residents at risk for diminished quality of life in an environment that is not homelike. Findings included:During an observation and interview on 8/11/25 at 10:43 a.m. Resident #44's bathroom door was open, and his bathroom light was flashing rapidly. Resident #44 said it bothered him that the light was flashing rapidly. He said he did not know how long it had been flashing. Surveyor asked what about the light flashing bothered him and he was unable to give a reply. Resident #44 was on the locked unit . During an observation on 8/12/25 at 9:30 a.m. it was observed the light in Resident #44's bathroom was still flashing on and off rapidly.During an interview on 8/13/25 at 11:04 a.m., the Maintenance Director said he ordered more lights on 8/12/25 and they should be delivered on 8/13/25 so he could fix the lights. He said he ordered 4-bathroom lights in total. He said that the bathroom light in room [ROOM NUMBER] was not reported to him nor was it in his maintenance logbook. He said that staff are required to report issues such as a malfunctioning light in the logbook. He said that he did know that the lights were flashing and that is why he ordered the new lights. Record review of the facility's maintenance log revealed that there was no report of Resident #44's bathroom light malfunctioning. During an interview on 08/13/2025 at 2:45 p.m., the Administrator said that a flashing light could make an uncomfortable environment for residents. He said that he expects that his maintenance staff ensure that lighting is kept comfortable for all residents. He said it is the responsibility of the Maintenance Director to ensure that such issues were fixed. Record review of the facility's policy revised on August 2020 titled Resident Rooms and Environment indicated that the purpose of the policy was to, To provide residents with a safe, clean, comfortable and homelike environment. The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk. To this end, the Facility encourages residents to use their personal belongings to the extent possible. Lighting that is comfortable (minimum glare) yet adequate (suitable to the task).

Based on interview, and record review, the facility failed to ensure residents were permitted to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and failed to ensure a resident was not transferred or discharged for 1 of 3 residents (Resident #1) reviewed for discharge requirements. The facility failed to allow Resident #1 to return to the facility after being sent to the behavioral hospital for treatment. This failure could place residents at risk for inappropriate discharge from the facility and cause psychological harm. Findings included: Record review of a face sheet dated 06/19/2024 indicated Resident #1 was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood) and dementia in other diseases classified elsewhere with other behavioral disturbance (deterioration of memory, language, and other thinking abilities with behaviors). Record review of the Discharge MDS assessment indicated Resident #1 was discharged with return anticipated on 05/16/2024 to an inpatient psychiatric facility. The MDS assessment indicated Resident #1 had a short-term memory problem. The MDS assessment indicated Resident #1 had delusions. The MDS assessment indicated Resident #1 exhibited verbal and physical behavioral symptoms directed towards others 1 to 3 days in the 7 day look back period. The MDS assessment indicated Resident #1 required substantial/maximal assistance with toileting hygiene, bathing, lower body , and partial to moderate assistance with upper body dressing and personal hygiene. Record review of Resident #1's care plan revised 05/10/2024 indicated Resident #1 wished to be discharged to another facility to be closer to his family, and he had discharged to another facility but was readmitted to the facility. Interventions included to establish a pre-discharge plan with Resident #1/family/caregivers and evaluate progress and revise plan and to evaluate and discuss with Resident #1/ family/caregivers the prognosis for independent or assisted living. Identify, discuss, and address limitations, risks, benefits and needs for maximum independence. Record review of Resident #1's Order Summary Report dated active orders as of 05/01/2024 did not indicate any orders discharge orders. Record review of Resident #1's progress notes indicated: 05/03/2024: Social Worker spoke Resident #1's family member regarding referral to another nursing facility. Resident #1 family member did not want to move resident at this time due to recent changes in behavior . Author: Social Worker 05/10/2024: This nurse observe the resident running down the hallway, aggressive with fist up, combative and screaming, attacking staff and resident, was separated from the staff and other residents, resident immediately removed away from residents, assisted by staff to the room to be place in bed, support provided assessment performed V/S: 124/72,83,18,97.3,96%, denies pain or discomfort, ROM completed able to move all extremities, no neuro changes, MD, Family and DON notified Author RN A. 05/13/2024: Social worker sent clinicals to behavioral health hospitals family member aware Author: Social Worker 05/16/2024: Social Worker filed for emergency commitment with justice court judge signed off on mental health warrant. Family member aware of update. resident then discharged at this time, transported by Police Department to the behavioral hospital. Author: Social Worker. 05/16/2024: Resident left the unit transported by the Police Department to behavioral hospital call was made to report, family member was notified. Author: RN A. During an interview on 06/18/2024 at 4:34 PM, Discharge Planner B, the discharge planner at the behavioral hospital, said Resident #1 had discharged home to return with is family today (06/18/2024). Discharge Planner B said the nursing facility did not want to take Resident #1 back after he was stabilized and completed his treatment. Discharge Planner B said Marketing Coordinator C had gone to evaluate Resident #1 on 06/10/2024. The discharge planner said Marketing Coordinator C had notified her the nursing facility was not taking Resident #1 back that it was a corporate decision. During an interview on 06/19/2024 at 12:29 PM, the Social Worker said Resident #1 discharged to the behavioral hospital on 05/16/2024 due to aggressive behaviors and harming staff and residents. The Social Worker said he was potentially supposed to return to the facility. The Social Worker said she was not a part of the decision for Resident #1 to not return to the facility. The Social Worker said the Administrator and corporate had a meeting about allowing Resident #1 to return to the facility, and they had made the decision not to allow him to return due to his aggressive behavior. The Social Worker said prior to Resident #1 being sent to the behavioral hospital on 05/16/2024, his family member had wanted him placed at a facility closer to them, but at when he was sent to the behavioral hospital this was no longer the case. The Social Worker said typically when someone was discharged from the facility they planned for the discharge and set up necessary services. The Social Worker said she was not aware what the discharge process was when a resident was not allowed to return from the hospital because this was the first resident, she had encountered that was not allowed to return. During an interview on 06/19/2024 at 1:19 PM, the DON said when a resident discharged from the hospital corporate reviewed the residents' records prior to them returning to the facility to ensure the facility could meet their needs. The DON said Resident #1 was discharged to the behavioral hospital due to his behaviors that he was a hazard to himself, others, and staff. The DON said to her knowledge the behavioral hospital had not attempted to send Resident #1 back to the nursing facility. The DON said the only notification she received was that Resident #1 had discharged back home to his family. During an interview on 06/19/2024 at 2:02 PM, Regional Admission Coordinator D said Resident #1's family member wanted him at a facility closer to them. Regional Admission Coordinator D said Marketing Coordinator C had provided the behavioral hospital with a list of facilities closer to Resident #1's family. Regional Admission Coordinator D said they had assumed Resident #1 had been placed at a different facility. Regional Admission Coordinator D said to her knowledge Marketing Coordinator C had not gone to the behavioral hospital to evaluate Resident #1 for admission to the nursing facility. During an attempted interview on 06/19/2024 at 2:21 PM, Marketing Coordinator C did not answer the phone. During an interview on 06/19/2024 at 2:23 PM, Resident #1's family member said they were notified Resident #1 was sent to the behavioral hospital due to altercations with other residents by the Social Worker. The family member said they thought Resident #1 was going to return to the nursing facility after being discharged from the behavioral hospital. Resident #1's family member said prior to him going to the behavioral hospital she had wanted him to go to a facility closer to them, but it was attempted and not successful in the past. Resident #1's family member said her expectations were for him to return to the nursing facility after his stay at the behavioral hospital. Resident #1's family member said that is why she called the nursing facility to see if he had returned from the behavioral hospital stay. Resident #1's family member said on Friday (06/14/2024) she called the nursing facility and was told they had a bed for Resident #1, and on Monday (06/17/24) she had called the nursing facility to see if Resident #1 had returned, and she was told by the Administrator he would not return to the facility because they did not have a bed for him and the facility could not meet his needs. Resident #1's family member said when he discharged from the facility, they had not notified her of how long they would hold his bed. Resident #1's family member said prior to her calling on Monday 06/17/2024 nobody from the facility had contacted her to notify her Resident #1 would not be allowed to return to the facility. Resident #1's family member said Resident #1 had been discharged home to them yesterday, 06/18/2024, morning. Resident #1's family member said due to their older age and health issues they were able to care for Resident #1 for a few days, but not long-term. Resident #1's family member assisted with a phone interview with Resident #1. Resident #1 said he was feeling fine, and he wanted to return to the nursing facility. During an interview on 06/19/2024 at 3:01 PM, the Administrator said he was new to the facility and had only been at the facility for 5 days. The Administrator said they currently did not have a bed available on the secured unit for Resident #1. The Administrator said he had not talked to Resident #1's family member. The Administrator said he was not sure how long they were required to hold a bed. The Administrator said he did not know if Resident #1 had been discharged properly because he was not aware of the full extent of what happened with Resident #1. The Administrator said he believed the NP had deemed Resident #1 not appropriate to return to the facility because it was not safe for anybody. During an attempted phone interview on 06/19/2024 at 3:31 PM, the NP did not answer the phone. During an attempted phone interview on 06/19/2024 at 3:33 PM, the previous Administrator did not answer the phone. During an interview on 06/19/2024 at 5:53 PM, the Administrator said he messaged Marketing Coordinator C to inform her to answer the phone for a phone interview regarding Resident #1. Requested Resident #1's discharge summary from the Administrator at this time. During an attempted interview on 06/19/2024 at 6:22 PM, Marketing Coordinator C did not answer the phone. During an interview on 06/19/2024 at 6:30 PM, informed the Administrator Resident #1's discharge summary had not been provided. The Administrator said he would provide Resident #1's discharge summary. Resident #1's discharge summary was not received upon exit of the facility. Record review of an undated e-mail from the NP regarding Resident #1 addressed to the DON and the Administrator indicated, Good afternoon, due to previous physical altercations and aggression with staff and residents, I feel that it will be best for a patient to go to a more secure unit. Record review of the facility's policy titled, Transfer and Discharge, revised 10/24/2022, indicated, To ensure that residents are transferred and discharged from the Facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider . C. In a situation where the Facility initiates discharge while the resident is in the hospital following emergency transfer, the Facility must have evidence that the resident's status at the time the resident seeks to return to the facility (not at the time the resident was transferred for acute care) meets one of the criteria for discharge outlined in the Policy Section I. A-F above. i. The resident has the right to return to the Facility pending an appeal of any facility-initiated discharge unless the return would endanger the health or safety of the resident or other individuals in the Facility. In this circumstance, the Facility must document the danger that the failure to transfer or discharge the resident would pose . H. The medical record will contain written documentation from a physician if the resident is transferred/ discharged because: i. The safety of individuals in the Facility is endangered by the resident's presence; or ii. The health of individuals in the Facility would otherwise be endangered by the resident's presence. I. The resident or his/her personal representative will be provided with a copy of the Discharge Care Plan and Discharge Summary .

Based on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 5 residents (Resident #2, and Resident #3) reviewed for abuse and neglect reporting. The facility failed to report to HHSC when Resident #1 pulled Resident #2's hair which caused Resident #2 to fall and be sent to the ER for evaluation on 04/30/2024. The facility failed to report to HHSC when Resident #1 hit Resident #3 on the chest on 05/10/2024. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 06/19/2024 indicated Resident #1 was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood) and dementia in other diseases classified elsewhere with other behavioral disturbance (deterioration of memory, language, and other thinking abilities with behaviors). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was rarely/never able to make himself understood and sometimes understood others. The MDS assessment indicated Resident #1 had a short-term and long-term memory problem. The MDS assessment indicated Resident #1 did not experience hallucinations or delusions. The MDS assessment indicated Resident #1 exhibited verbal behavioral symptoms directed towards others 1 to 3 days in the 7 day look back period. The MDS assessment did not indicate Resident #1 exhibited physical or other behavioral symptoms directed towards others. The MDS assessment indicated Resident #1's behaviors did not put others at significant risk for physical injury. The MDS assessment indicated Resident #1's behaviors significantly disrupted care or living environment. The MDS assessment indicated Resident #1 required substantial/maximal assistance with toileting hygiene, bathing, lower body , and partial to moderate assistance with upper body dressing and personal hygiene. Record review of Resident #1's care plan last reviewed 06/03/2024 indicated he had a behavior problem related to dementia with psychosis, schizoaffective disorder and had aggression, agitation, anxiety, and hit staff. Resident #1's care plan included to intervene as necessary to protect the rights and safety of others, approach/speak to him in a calm manner, divert attention., remove from situation and take to alternate location as needed. Record review of Resident #1's Progress Note dated 04/30/2024 indicated, This nurse observe the resident running down the hallway, aggressive with fist up, combative and screaming, attacking staff and residents, was separated from the staff and other residents, resident immediately removed away from residents, assisted by staff to the room to be place in bed, support is provided, assessment performed V/S (blood pressure, pulse, heart rate, respirations, and oxygen saturation):120/83,79,18,97.4,98%, no pain or discomfort, ROM completed able to move all extremities, No neuro changes, doctor, family, and DON notified, doctor orders send to ER for evaluation Author RN A. Record review of Resident #1's Progress Note dated 05/10/2024 indicated, This nurse observe the resident running down the hallway, aggressive with fist up, combative and screaming, attacking staff and resident, was separated from the staff and other residents, resident immediately removed away from residents, assisted by staff to the room to be place in bed, support provided assessment performed V/S (blood pressure, pulse, heart rate, respirations, and oxygen saturation): 124/72,83,18,97.3,96%, denies pain or discomfort, ROM completed able to move all extremities, no neuro changes, MD, Family and DON notified Author RN A. 2. Record review of a face sheet dated 06/19/2024 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities without behaviors). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was able to make herself understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #2 required partial/moderate assistance with toileting hygiene, bathing, dressing, and personal hygiene. Record review of Resident #2's care plan last reviewed 05/09/2024 indicated she was an elopement risk/wanderer as evidenced by disoriented to place, and she wandered aimlessly and was admitted to the secured unit. Record review of Resident #2's Progress Note dated 04/30/2024 indicated Resident was standing on the hallway when another pulled residents hair causing resident to fall to the ground. Head to toe assessment, resident right hand swollen V/S (blood pressure, pulse, heart rate, respirations, and oxygen saturation) obtained 120/79,68,98,18,97.3, resident assisted to w/c (wheelchair) and place at the nursing station in staff sight. Resident displayed no signs of pain, Neuro (neurological) check initiated, MD, family (no answer left voicemail message) and DON were notified. Dr. (doctor) orders send to ER for Evaluation Author RN A. Record review of Resident #2's Emergency Department discharge information dated 04/30/2024 indicated discharge diagnosis of fall and hand contusion (injury to the skin and tissue of the hand caused by trauma or impact). During an attempted interview on 06/19/2024 at 11:55 AM, Resident #2 was non-interviewable. 3. Record review of a face sheet dated 06/19/2024 indicated Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities without behaviors). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #3 was able to make himself understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 6, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #3 required partial/moderate assistance with toileting and upper body dressing, dependent for bathing, and set-up or clean-up assistance with personal hygiene. Record review of Resident #3's care plan last reviewed 05/23/2024 indicated he was an elopement risk/wanderer as evidenced by disoriented to place, impaired safety awareness, and significantly intrudes on the privacy or activities. Record review of Resident #3's Progress Note dated 05/10/2024 indicated, Resident sitting in the dining room when another resident hit him on the chest, head to toe assessment, denies pain or discomfort, resident immediately removed away from resident, support is provided, resident V/S (blood pressure, pulse, heart rate, respirations, and oxygen saturation): 119/78, 69,18,97.3, no neuro changes, MD notified, Family and DON Author RN A. During an attempted interview on 06/19/2024 at 11:38 AM, Resident #3 had inattention and was unable to answer questions appropriately. During an interview starting on 06/19/2024 at 2:23 PM, Resident #1's family member assisted with a phone interview with Resident #1. Resident #1 was asked if he remembered hitting a man while at the nursing facility. Resident #1 said he had hit a man and the man had hit him but was unable to provide further details. Resident #1 was asked if he remember an incident where he pulled a woman's hair and she had fallen. Resident #1 said he did not remember. During an attempted phone interview on 06/19/2024 at 3:33 PM, the previous Administrator did not answer the phone. During an interview on 06/19/2024 at 3:38 PM, RN A said Resident #1 was aggressive and would attack the residents and staff by punching them. RN A said she witnessed the incident with Resident #2. RN A said Resident #2 was standing in the hall and Resident #1 ran down the hallway and pulled Resident #2's hair and made her fall. RN A said Resident #2 did not have any injuries, but she was sent out to the ER for evaluation as a precaution. RN A said she witnessed the incident with Resident #3. RN A said Resident #3 was sitting in the dining room and Resident #1 walked by and hit Resident #3 on the chest. RN A said Resident #3 experienced no injuries. RN A said the previous administrator was notified of both incidents. RN A said Resident #1 hitting Resident #3 and pulling Resident #2's hair and making her fall could be considered physical abuse. RN A said it was important for incidents of abuse to be reported to ensure they were investigated and to protect the residents. During an interview on 06/19/2024 at 4:14 PM, the DON said the doctor was notified of both the incidents between Resident #1 and Resident #2 and Resident #1 and Resident #3. The DON said these incidents were not reported to HHSC because when they report it is based on a case-by-case scenario. The DON said since both incidents were witnessed and because Resident #1 had a diagnosis of dementia his actions could not be willful, therefore, they were not required to report the incidents to HHSC. During an interview on 06/19/2024 at 5:38 PM, the DON said if there was an abuse allegation, and it was not reported to HHSC it placed residents at risk for more abuse. The DON said the facility's policy regarding resident-to-resident altercations was to remove the resident from the other resident, notify the doctor, determine what happened and what led to the aggression. The DON said per the policy a resident-to-resident altercation was not considered abuse because it was not willful. During an interview on 06/19/2024 at 5:53 PM, the Administrator said he was not at the facility when the incidents between Resident #1 and Resident #2 and Resident #1 and Resident #3 occurred. The Administrator said he could not tell if based on the policy the incidents should have been reported to HHSC because he was not aware of what took place. The Administrator said if he had been the Administrator when the incidents occurred, he would have reported the incidents to ensure they were investigated thoroughly. The Administrator was asked if the resident-to-resident altercations between Resident #1 and Resident #2 and Resident #1 and Resident #3 could be considered abuse. The Administrator responded he could not respond because he did not know what had happened. Record review of the facility's policy titled, Abuse Prevention and Prohibition Program, revised 10/24/2022, indicated, .Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property .The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents . The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify .Immediately but no later than 2 hours after forming the suspicion-if alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation) .

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 2 of 5 residents (Resident #2, and Resident #3) reviewed for abuse. The facility failed to implement their policy on reporting abuse when Resident #1 pulled Resident #2's hair which caused Resident #2 to fall and be sent to the ER for evaluation on 04/30/2024. The facility failed to implement their policy on reporting abuse when Resident #1 hit Resident #3 on the chest on 05/10/2024. The facility failed to implement their abuse policy to prevent Resident #1 from pulling Resident #2's hair on 4/30/2024, and hitting Resident #3 on the chest on 5/10/2024 These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life. Findings included: Record review of the facility's policy titled, Abuse Prevention and Prohibition Program, revised 10/24/2022, indicated, .Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property .The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents . The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify .Immediately but no later than 2 hours after forming the suspicion-if alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation) . 1. Record review of a face sheet dated 06/19/2024 indicated Resident #1 was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood) and dementia in other diseases classified elsewhere with other behavioral disturbance (deterioration of memory, language, and other thinking abilities with behaviors). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was rarely/never able to make himself understood and sometimes understood others. The MDS assessment indicated Resident #1 had a short-term and long-term memory problem. The MDS assessment indicated Resident #1 did not experience hallucinations or delusions. The MDS assessment indicated Resident #1 exhibited verbal behavioral symptoms directed towards others 1 to 3 days in the 7 day look back period. The MDS assessment did not indicate Resident #1 exhibited physical or other behavioral symptoms directed towards others. The MDS assessment indicated Resident #1's behaviors did not put others at significant risk for physical injury. The MDS assessment indicated Resident #1's behaviors significantly disrupted care or living environment. The MDS assessment indicated Resident #1 required substantial/maximal assistance with toileting hygiene, bathing, lower body , and partial to moderate assistance with upper body dressing and personal hygiene. Record review of Resident #1's care plan last reviewed 06/03/2024 indicated he had a behavior problem related to dementia with psychosis, schizoaffective disorder and had aggression, agitation, anxiety, and hit staff. Resident #1's care plan included to intervene as necessary to protect the rights and safety of others, approach/speak to him in a calm manner, divert attention., remove from situation and take to alternate location as needed. Record review of Resident #1's Progress Note dated 04/30/2024 indicated, This nurse observe the resident running down the hallway, aggressive with fist up, combative and screaming, attacking staff and residents, was separated from the staff and other residents, resident immediately removed away from residents, assisted by staff to the room to be place in bed, support is provided, assessment performed V/S (blood pressure, pulse, heart rate, respirations, and oxygen saturation): 120/83,79,18,97.4,98%, no pain or discomfort, ROM completed able to move all extremities, No neuro changes, doctor, family, and DON notified, doctor orders send to ER for evaluation Author RN A. Record review of Resident #1's Progress Note dated 05/10/2024 indicated, This nurse observe the resident running down the hallway, aggressive with fist up, combative and screaming, attacking staff and resident, was separated from the staff and other residents, resident immediately removed away from residents, assisted by staff to the room to be place in bed, support provided assessment performed V/S (blood pressure, pulse, heart rate, respirations, and oxygen saturation): 124/72,83,18,97.3,96%, denies pain or discomfort, ROM completed able to move all extremities, no neuro changes, MD, Family and DON notified Author RN A. 2. Record review of a face sheet dated 06/19/2024 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities without behaviors). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was able to make herself understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #2 required partial/moderate assistance with toileting hygiene, bathing, dressing, and personal hygiene. Record review of Resident #2's care plan last reviewed 05/09/2024 indicated she was an elopement risk/wanderer as evidenced by disoriented to place, and she wandered aimlessly and was admitted to the secured unit. Record review of Resident #2's Progress Note dated 04/30/2024 indicated Resident was standing on the hallway when another pulled residents hair causing resident to fall to the ground. Head to toe assessment, resident right hand swollen V/S (blood pressure, pulse, heart rate, respirations, and oxygen saturation) obtained 120/79,68,98,18,97.3, resident assisted to w/c (wheelchair) and place at the nursing station in staff sight. Resident displayed no signs of pain, Neuro (neurological) check initiated, MD, family (no answer left voicemail message) and DON were notified. Dr. (doctor) orders send to ER for Evaluation Author RN A. Record review of Resident #2's Emergency Department discharge information dated 04/30/2024 indicated discharge diagnosis of fall and hand contusion (injury to the skin and tissue of the hand caused by trauma or impact). During an attempted interview on 06/19/2024 at 11:55 AM, Resident #2 was non-interviewable. 3. Record review of a face sheet dated 06/19/2024 indicated Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities without behaviors). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #3 was able to make himself understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 6, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #3 required partial/moderate assistance with toileting and upper body dressing, dependent for bathing, and set-up or clean-up assistance with personal hygiene. Record review of Resident #3's care plan last reviewed 05/23/2024 indicated he was an elopement risk/wanderer as evidenced by disoriented to place, impaired safety awareness, and significantly intrudes on the privacy or activities. Record review of Resident #3's Progress Note dated 05/10/2024 indicated, Resident sitting in the dining room when another resident hit him on the chest, head to toe assessment, denies pain or discomfort, resident immediately removed away from resident, support is provided, resident V/S (blood pressure, pulse, heart rate, respirations, and oxygen saturation): 119/78, 69,18,97.3, no neuro changes, MD notified, Family and DON Author RN A. During an attempted interview on 06/19/2024 at 11:38 AM, Resident #3 had inattention and was unable to answer questions appropriately. During an interview starting on 06/19/2024 at 2:23 PM, Resident #1's family member assisted with a phone interview with Resident #1. Resident #1 was asked if he remembered hitting a man while at the nursing facility. Resident #1 said he had hit a man and the man had hit him but was unable to provide further details. Resident #1 was asked if he remember an incident where he pulled a woman's hair and she had fallen. Resident #1 said he did not remember. During an attempted phone interview on 06/19/2024 at 3:33 PM, the previous Administrator did not answer the phone. During an interview on 06/19/2024 at 3:38 PM, RN A said Resident #1 was aggressive and would attack the residents and staff by punching them. RN A said she witnessed the incident with Resident #2. RN A said Resident #2 was standing in the hall and Resident #1 ran down the hallway and pulled Resident #2's hair and made her fall. RN A said Resident #2 did not have any injuries, but she was sent out to the ER for evaluation as a precaution. RN A said she witnessed the incident with Resident #3. RN A said Resident #3 was sitting in the dining room and Resident #1 walked by and hit Resident #3 on the chest. RN A said Resident #3 experienced no injuries. RN A said the previous administrator was notified of both incidents. RN A said Resident #1 hitting Resident #3 and pulling Resident #2's hair and making her fall could be considered physical abuse. RN A said it was important for incidents of abuse to be reported to ensure they were investigated and to protect the residents. During an interview on 06/19/2024 at 4:14 PM, the DON said the doctor was notified of both the incidents between Resident #1 and Resident #2 and Resident #1 and Resident #3. The DON said these incidents were not reported to HHSC because when they report it is based on a case-by-case scenario. The DON said since both incidents were witnessed and because Resident #1 had a diagnosis of dementia his actions could not be willful, therefore, they were not required to report the incidents to HHSC. During an interview on 06/19/2024 at 5:38 PM, the DON said if there was an abuse allegation, and it was not reported to HHSC it placed residents at risk for more abuse. The DON said the facility's policy regarding resident-to-resident altercations was to remove the resident from the other resident, notify the doctor, determine what happened and what led to the aggression. The DON said per the policy a resident-to-resident altercation was not considered abuse because it was not willful. During an interview on 06/19/2024 at 5:53 PM, the Administrator said he was not at the facility when the incidents between Resident #1 and Resident #2 and Resident #1 and Resident #3 occurred. The Administrator said he could not tell if based on the policy the incidents should have been reported to HHSC because he was not aware of what took place. The Administrator said if he had been the Administrator when the incidents occurred, he would have reported the incidents to ensure they were investigated thoroughly. The Administrator was asked if the resident-to-resident altercations between Resident #1 and Resident #2 and Resident #1 and Resident #3 could be considered abuse. The Administrator responded he could not respond because he did not know what had happened.

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 5 residents (Resident #2, and Resident #3) reviewed for abuse. The facility failed to protect Resident #2 from Resident #1, when Resident #1 pulled Resident #2's hair, which resulted in Resident #2's fall, and Resident #2 having to go to the ER for evaluation on 04/30/2024. The facility failed to protect Resident #3 from Resident #1, when Resident #1 hit Resident #3 on the chest on 05/10/2024. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 06/19/2024 indicated Resident #1 was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood) and dementia in other diseases classified elsewhere with other behavioral disturbance (deterioration of memory, language, and other thinking abilities with behaviors). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was rarely/never able to make himself understood and sometimes understood others. The MDS assessment indicated Resident #1 had a short-term and long-term memory problem. The MDS assessment indicated Resident #1 did not experience hallucinations or delusions. The MDS assessment indicated Resident #1 exhibited verbal behavioral symptoms directed towards others 1 to 3 days in the 7 day look back period. The MDS assessment did not indicate Resident #1 exhibited physical or other behavioral symptoms directed towards others. The MDS assessment indicated Resident #1's behaviors did not put others at significant risk for physical injury. The MDS assessment indicated Resident #1's behaviors significantly disrupted care or living environment. The MDS assessment indicated Resident #1 required substantial/maximal assistance with toileting hygiene, bathing, lower body , and partial to moderate assistance with upper body dressing and personal hygiene. Record review of Resident #1's care plan last reviewed 06/03/2024 indicated he had a behavior problem related to dementia with psychosis, schizoaffective disorder and had aggression, agitation, anxiety, and hit staff. Resident #1's care plan included to intervene as necessary to protect the rights and safety of others, approach/speak to him in a calm manner, divert attention., remove from situation and take to alternate location as needed. Record review of Resident #1's Progress Note dated 04/30/2024 indicated, This nurse observe the resident running down the hallway, aggressive with fist up, combative and screaming, attacking staff and residents, was separated from the staff and other residents, resident immediately removed away from residents, assisted by staff to the room to be place in bed, support is provided, assessment performed V/S (blood pressure, pulse, heart rate, respirations, and oxygen saturation):120/83,79,18,97.4,98%, no pain or discomfort, ROM completed able to move all extremities, No neuro changes, doctor, family, and DON notified, doctor orders send to ER for evaluation Author RN A. Record review of Resident #1's Progress Note dated 05/10/2024 indicated, This nurse observe the resident running down the hallway, aggressive with fist up, combative and screaming, attacking staff and resident, was separated from the staff and other residents, resident immediately removed away from residents, assisted by staff to the room to be place in bed, support provided assessment performed V/S (blood pressure, pulse, heart rate, respirations, and oxygen saturation): 124/72,83,18,97.3,96%, denies pain or discomfort, ROM completed able to move all extremities, no neuro changes, MD, Family and DON notified Author RN A. 2. Record review of a face sheet dated 06/19/2024 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities without behaviors). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was able to make herself understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #2 required partial/moderate assistance with toileting hygiene, bathing, dressing, and personal hygiene. Record review of Resident #2's care plan last reviewed 05/09/2024 indicated she was an elopement risk/wanderer as evidenced by disoriented to place, and she wandered aimlessly and was admitted to the secured unit. Record review of Resident #2's Progress Note dated 04/30/2024 indicated Resident was standing on the hallway when another pulled residents hair causing resident to fall to the ground. Head to toe assessment, resident right hand swollen V/S (vital signs (blood pressure, pulse, heart rate, respirations, and oxygen saturation) obtained 120/79,68,98,18,97.3, resident assisted to w/c (wheelchair) and place at the nursing station in staff sight. Resident displayed no signs of pain, Neuro (neurological) check initiated, MD, family (no answer left voicemail message) and DON were notified. Dr. (doctor) orders send to ER for Evaluation Author RN A. Record review of Resident #2's Emergency Department discharge information dated 04/30/2024 indicated discharge diagnosis of fall and hand contusion (injury to the skin and tissue of the hand caused by trauma or impact). During an attempted interview on 06/19/2024 at 11:55 AM, Resident #2 was non-interviewable. 3. Record review of a face sheet dated 06/19/2024 indicated Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities without behaviors). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #3 was able to make himself understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 6, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #3 required partial/moderate assistance with toileting and upper body dressing, dependent for bathing, and set-up or clean-up assistance with personal hygiene. Record review of Resident #3's care plan last reviewed 05/23/2024 indicated he was an elopement risk/wanderer as evidenced by disoriented to place, impaired safety awareness, and significantly intrudes on the privacy or activities. Record review of Resident #3's Progress Note dated 05/10/2024 indicated, Resident sitting in the dining room when another resident hit him on the chest, head to toe assessment, denies pain or discomfort, resident immediately removed away from resident, support is provided, resident V/S (vital signs): 119/78, 69,18,97.3, no neuro changes, MD notified, Family and DON Author RN A. During an attempted interview on 06/19/2024 at 11:38 AM, Resident #3 had inattention and was unable to answer questions appropriately. During an interview starting on 06/19/2024 at 2:23 PM, Resident #1's family member assisted with a phone interview with Resident #1. Resident #1 was asked if he remembered hitting a man while at the nursing facility. Resident #1 said he had hit a man and the man had hit him but was unable to provide further details. Resident #1 was asked if he remember an incident where he pulled a woman's hair and she had fallen. Resident #1 said he did not remember. During an attempted phone interview on 06/19/2024 at 3:33 PM, the previous Administrator did not answer the phone. During an interview on 06/19/2024 at 3:38 PM, RN A said Resident #1 was aggressive and would attack the residents and staff by punching them. RN A said she witnessed the incident with Resident #2. RN A said Resident #2 was standing in the hall and Resident #1 ran down the hallway and pulled Resident #2's hair and made her fall. RN A said Resident #2 did not have any injuries, but she was sent out to the ER for evaluation as a precaution. RN A said she witnessed the incident with Resident #3. RN A said Resident #3 was sitting in the dining room and Resident #1 walked by and hit Resident #3 on the chest. RN A said Resident #3 experienced no injuries. RN A said the previous administrator was notified of both incidents. RN A said Resident #1 hitting Resident #3 and pulling Resident #2's hair and making her fall could be considered physical abuse. RN A said it was important for incidents of abuse to be reported to ensure they were investigated and to protect the residents. During an interview on 06/19/2024 at 4:14 PM, the DON said the doctor was notified of both the incidents between Resident #1 and Resident #2 and Resident #1 and Resident #3. The DON said since both incidents were witnessed and because Resident #1 had a diagnosis of dementia his actions could not be willful. During an interview on 06/19/2024 at 5:53 PM, the Administrator said he was not at the facility when the incidents between Resident #1 and Resident #2 and Resident #1 and Resident #3 occurred. The Administrator was asked if the resident-to-resident altercations between Resident #1 and Resident #2 and Resident #1 and Resident #3 could be considered abuse. The Administrator responded he could not respond because he did not know what had happened. Record review of the facility's policy titled, Violence Between Residents, revised 2020, indicated, To protect the health and safety of residents by ensuring that altercations between residents are promptly reported, investigated, and addressed by the Facility .A. Facility Staff monitors residents for aggressive or inappropriate behavior toward other residents, family members, visitors, or Facility Staff .Report incidents, findings, and corrective measures to appropriate agencies . Record review of the facility's policy titled, Abuse Prevention and Prohibition Program, revised 10/24/2022, indicated, .Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property .The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents .

Based on interviews and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs (without adequate behavior or side effect monitoring) for 3 of 8 (Resident # 54, Resident # 64, and Resident # 3) residents who were reviewed for psychotropic medication. 1. The facility failed to ensure Resident #54 had behavior monitoring (monitor activities and mood) for his prescribed Venlafaxine (an antidepressant used to treat major depression) for the months of May and June 2024. 2. The facility failed to ensure Resident #64 had behavior monitoring (monitor activities and mood) and side effects (unwanted undesirable effects that are possibly related to a drug) for his prescribed Lexapro (an antidepressant used to treat depression) for the months of May and June 2024. 3. The facility failed to ensure Resident #3 had behavior monitoring (monitor activities and mood) for her prescribed Duloxetine (an antidepressant; that is used to treat depression and anxiety) for the months of May and June 2024. These deficient practices could place residents at risk of not receiving the intended therapeutic benefits of their psychotropic medications. Findings included: 1. Record review of Resident #54's face sheet, dated 06/05/24, indicated Resident #54 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included depression (a common and serious medical illness that negatively affects how you feel, the way you think, and how you act), anxiety (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Insomnia (when you are not sleeping as you should), and high blood pressure. Record review of Resident #54's quarterly MDS assessment, dated 04/05/24, indicated Resident #54 understood and was understood by others. Resident #54's BIMS score was 15, which indicated he was cognitively intact. Resident #54 required assistance with bathing and independent with toileting, personal hygiene, transfer, dressing, bed mobility, and eating. The MDS indicated Resident #54 had received an antidepressant during the 7-day look-back assessment period. Record review of Resident #54's physician order dated 05/14/24 indicated an order for Venlafaxine (Effexor) 75 mg, give 1 capsule by mouth daily for diagnosis of depression. Resident #54 had a medication dose change and no order for behavior monitoring was noted. Record review of Resident #54's physician order dated 06/13/23 and discontinued 05/14/24 indicated an order for Venlafaxine (Effexor) 150 mg, give 1 capsule by mouth daily for diagnosis of depression. No order for behavior monitoring was noted. Record review of Resident #54's comprehensive care plan dated 03/13/23 indicated Resident #54 required antidepressant medication for diagnosis of Depression. Intervention for staff was to give antidepressant medications ordered by the physician and monitor/document side effects. Record review of Resident #54's MAR dated 06/01/24-06/31/24 did not indicate any behavior monitoring. Record review of Resident #54's pharmacy recommendations dated 04/01-04/12/24 indicated no behavior monitoring was noted during those visits. The pharmacy recommended the facility add behavior monitoring but they did not. 2. Record review of Resident #64's face sheet dated 06/10/24 indicated Resident #64 was a [AGE] year-old, male admitted on [DATE] and readmitted on [DATE] with diagnosis including depressive disorders (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and Dementia( forgetfulness). Record review of Resident #64's quarterly MDS assessment dated [DATE] indicated Resident #64 was usually understood and usually understood by others. The MDS indicated Resident #64 had a BIMS score of 06 which indicated moderately impaired cognition. The MDS indicated Resident #64 required total assistance for all ADLs. The MDS indicated Resident #64 had received an antidepressant during the 7-day look-back assessment period. Record review of Resident #64's care plan dated 11/15/23, indicated Resident #64 required antidepressant medication for diagnosis of Depression. Intervention for staff was to give antidepressant medications ordered by physician and monitor/document side effects. Monitor/document/report to MD prn ongoing signs and symptoms of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Record review of Resident #64's physician order dated 01/16/24 indicated an order for Lexapro, 10mg, give 1 tablet, daily for diagnosis of depressive disorders. No order for monitoring behavior or side effects was noted. Record review of Resident #64's MAR dated 06/01/24-06/31/24 did not indicate any behavior monitoring. Record review of Resident #64's MAR dated 06/01/24-06/31/24 did not indicate any side effect monitoring. Record review of Resident #64's pharmacy recommendations dated 04/01-04/12/24 and 05/01-05/05/24 indicated no behavior monitoring was noted during those visits. The pharmacy recommended the facility add behavior monitoring but they did not. 3. Record review of Resident #3's face sheet dated 06/10/24 indicated Resident #3 was a [AGE] year-old, female admitted on [DATE] and readmitted on [DATE] with diagnoses including depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act), dementia (Forgetfulness) and Diabetes. Record review of Resident #3's admission MDS assessment dated [DATE] indicated Resident #3 was sometimes understood and understood by others. The MDS indicated Resident #3 had severely impaired cognition. The MDS indicated Resident #3 required total assistance for all ADLs. The MDS indicated Resident #3 had received an antidepressant during the 7-day look-back assessment period. Record review of Resident #3's care plan dated 01/15/24, indicated Resident #3 received antidepressant medication related to major depression. The intervention was for staff to give antidepressant medications ordered by the physician. Monitor/document side effects and effectiveness. Record review of Resident #3's physician order dated 03/06/24 indicated an order for Duloxetine HCL 60MG, give 1 capsule daily for depression. No order for behavior monitoring was noted. Record review of Resident #3's MAR dated 06/01/24-06/31/24 did not indicate any behavior monitoring. Record review of Resident #3's pharmacy recommendations dated 04/01-04/12/24 and 05/01-05/05/24 indicated no behavior monitoring was noted during those visits. The pharmacy recommended the facility add behavior monitoring but they did not. During an interview on 06/05/24 at 4:06 p.m., LVN E said if a resident had psychoactive medication, then they should have side effects and behavior monitoring. He said the nurses were supposed to place an order for behavior and side effect monitoring when they received the new order. He said without proper monitoring nurses would not know if the resident was having side effects or change in mood or behavior related to the medication. During an interview on 06/05/24 at 4:09 p.m., the DON said behavior monitoring and side effects monitoring were on the MAR/TAR. She said the charge nurses were responsible for entering the behavior monitoring and/or the side effects monitoring when they did an admission or started a new medication. She said ADON #1 was responsible for ensuring nurses had inputted the behavior monitoring or side effects monitoring as needed. She said behavior monitoring was to monitor if the resident had behaviors related to what the medication was prescribed to treat. She said side effects should be monitored to see if any other interventions need to be placed or medication discontinued if causing side effects. She said failure to have behavior monitoring or side effect monitor could cause the nurses to miss a side effect or behavior. During an interview on 06/05/24 at 4:49 p.m., ADON LVN F said the nurses were supposed to write orders for side effects and behavior monitoring when they received an order for psychoactive medication. She said she was responsible as the overseer for the side effects and behavior monitor sheets. She said she had been at the facility for a month and was working on a system to ensure the monitoring was in place. She said she was learning the process of pharmacy recommendations. She said she had been trained but had not had enough time to review all residents who took psychoactive medications for side effects or behavior monitoring. She said they monitored residents to see if they had an improvement, were stable, or needed medication changes. During an interview on 06/05/24 at 5:03 p.m., the Administrator said the nurses were responsible for ensuring the side effects and behavior monitoring sheets were in place and the nurse managers were the overseers. He said without monitoring, nurses would not know if the medication had been effective or not. Record review of the facility's Psychotherapeutic Drug Management, policy dated 06/2020 indicated, To implement the most desirable and effective intervention to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and or decreasing or negatively impacting the resident's quality of life. Behavior interventions for individualized, non-pharmacological approaches to care that are provided as part of a supportive physical and psychological cycle social environment, directed towards understanding, preventing, relieving, and or accommodation accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident mental cycle or psychosocial well-being . X Nursing Responsibility: B. Will monitor psychotropic drug use daily noting any adverse effects. (i.e., EPS, Tardive dyskinesia, excessive dose, or distressed behavior). C. Will monitor the presence of target behaviors daily D. Review the use of the medication with the physician and the interdisciplinary team at least quarterly to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use .

Based on observation, interview and record review, the facility failed to ensure each resident on the secured unit met the criteria for the unit and was not provided with the access codes or other information for independent egress for 5 of 18 residents (Resident #'s 35, 23, 38, 18, and 47) reviewed for seclusion. The facility failed to ensure Resident #35 met the facility's criteria to reside on the secured unit based on her elopement risk assessment dated [DATE] indicating no risk. The facility failed to ensure Resident #23 met the facility's criteria to reside on the secured unit based on her elopement risk assessment dated [DATE] indicating she was not a risk to elope. The facility failed to ensure Resident #38 met the facility's criteria to reside on the secured unit based on his elopement assessments on 1/10/2024 indicating he was a moderate risk to elope. The facility failed to ensure Resident #18 met the facility's criteria to reside on the secured unit based on her elopement assessments on 12/29/23 and 3/04/2024 indicating she was a moderate risk to elope. The facility failed to ensure Resident #47 met the facility's criteria to reside on the secured unit based on his elopement assessments on 2/12/2024, 3/14/2024, and 6/04/2024 all indicating he was moderate risk to elope. This failure could cause residents to be placed in an environment where they would be at risk not to flourish or thrive to their optima. Findings included: 1) Record review of a face sheet dated 6/05/2024 indicated Resident #35 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of memory deficit related to a stroke, difficulty swallowing, and a speech deficit related to a stroke. Record review of the consolidated physician's orders dated 6/04/2024 indicated Resident #35 had an order dated on 3/08/2024 that indicated Resident #35 may be admitted to the secured unit for the history of exit seeking. Record review of an Elopement Risk Evaluation dated 3/07/2024 indicated Resident #35's elopement score was a 7 indicating a moderate risk of elopement. The Elopement Risk Evaluation in Section A, No Risk indicated Resident #35 was not able to make decisions regarding task of daily living (decisions consistent and reasonable) and she was able to ambulate or mobilize wheelchairs. The Elopement Risk Evaluation indicated in Section B, Moderate Risk indicated Resident #35 was cognitive impaired and had a history of leaving the community without informing staff. The Elopement Risk in Section C Imminent risk indicated physically Resident #35 failed to ambulate, propel self, wander, or intentionally or unintentionally attempted to leave the community. Section D Additional Information indicated Resident #35 was a risk for elopement related to the elopement evaluation risk score. The goal indicated Resident #35 would remain safe within facility unless accompanied by staff other authorized persons, engage in activities of choice, report to the physician potential elopements such as wandering, repeated requests to leave the facility, statements such as I'm leaving, I'm going home, attempts to leave facility elopement attempts from previous facility or hospital and supervise closely and make regular compliance rounds whenever resident was in her room. Record review of the Admission MDS dated [DATE] indicated Resident #35 was usually understood and was sometimes understood by others. The MDS indicated Resident #35's BIMS score was 12 indicating she had moderate cognitive impairment. Section E-Behavior indicated Resident #35 had not demonstrated any wandering behaviors. The MDS in section GG-Functional Abilities and Goals indicated Resident #35 had not attempted to sit to stand, chair/bed-to-chair transfer, toilet transfers, care transfers, or walking. Record review of the Comprehensive Care Plan dated 3/07/2024 and revised on 3/20/2024 indicated Resident #35 was at risk for elopement related to the elopement evaluation score and resided on the secured unit. The goal of Resident #35's care plan indicated she would remain safe within the facility unless accompanied by staff other authorized persons. The care plans interventions included to engage Resident #35 in activities, report to the physician the risk for potential elopement such as wandering, repeated requests to leave the facility, stating I'm going home, and attempts to leave the facility. The care plan interventions failed to indicate Resident #35's elopement risk assessment score would reflect a score of high/imminent to reside on the secured unit. Record review of the Quarterly MDS dated [DATE] indicated Resident #35 was usually understood and understood others. The MDS indicated Resident #35's BIMS score was 10 indicating moderate cognitive impairment. The MDs in Section E0900 Wandering-Presence and Frequency indicated no behavior of wandering was exhibited. The MDS in Section GG-Functional Abilities and Goals indicated Resident #35 required partial/moderate assistance with sit to stand, chair/bed-to-chair transfers, and toilet. transfers. The MDS indicated Resident #35 had not attempted to ambulate but had wheeled her wheelchair 150 foot with supervision or touching assistance. Record review of a Medication Administration Record dated May 2024 indicated Resident #35 received an antianxiety medication and was observed for behaviors such as agitation, anxiety, nervousness, compulsiveness, physical aggression, combativeness, excitation/irritability, verbal aggression, panicking, or other behaviors. The Medication Administration Record had no documented behaviors for the entire month of May on day shift, evening shift, or night shift. Record review of an Elopement Risk Evaluation dated 6/04/2024 (after state surveyor intervention) indicated in Section A: No Risk indicated this area was answered yes indicating Resident #35 was able to make decision regarding task of daily living (decisions consistent and reasonable). Section A indicated Resident #35 was able to ambulate or mobilize a wheelchair. Record review of the direction of this section indicated if A1 or A2 was answered yes then the assessment was complete. Record review of a Medication Administration Record dated June 2024 indicated Resident #35 received an antianxiety medication and was observed for behaviors such as agitation, anxiety, nervousness, compulsiveness, physical aggression, combativeness, excitation/irritability, verbal aggression, panicking, or other behaviors. The Medication Administration Record had no documented behaviors for June 1,2,3,4, and 5 on day shift, evening shift, or night shift. Record review of Resident #35's progress notes dated 3/07/2024 until 6/03/2024 failed to indicate Resident #35 had any elopement attempts, behaviors indicative of wanting to exit the facility, or any verbalizations of wanting to leave the facility since admission to the facility's secured unit. Record review of a Notification of a Room Change dated 6/04/2024 2:31 p.m., B.1. Reason for room change was Resident #35 no longer met the requirement to be on the secured unit. 2) Record review of a face sheet dated 6/05/2024 indicated Resident #23 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of Alzheimer's dementia, lack of coordination, need for assistance with personal care, unsteadiness to her feet, abnormalities of gait and mobility, fatigue, and reduced mobility. Record review of the Consolidated Physician's Orders dated 6/05/2024 indicated on 1/18/2024 Resident #23 was ordered to admit to the secured unit due to exit seeking behaviors. Record review of the progress notes dated 1/18/2024-6/04/2024 failed to indicate Resident #23 had episodes of elopement attempts, verbalization of the desire to leave, or wandering. Record review of an Admission MDS dated [DATE] indicated Resident #23 was usually understood, and usually understood others. The MDS indicated Resident #23's BIMS score was a 2 indicating severe cognitive impairment. The MDS in Section E0900 Wandering-Presence and Frequency indicated Resident #24 had not displayed any wandering behaviors. The MDS in Section GG-Functional Abilities and Goals indicated on admission Resident #23 required substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, and sit to stand. The MDS indicated Resident #23 was dependent for chair/bed-to-chair transfers, toilet transfer, shower transfers, and walking 10 foot was not attempted. The MDS indicated Resident #23 required substantial/maximal assistance for wheelchair mobility. Record review of a Quarterly MDS dated [DATE] indicated Resident #23 was usually understood, and usually understood others. The MDS indicated Resident #23's BIMS score was 1 indicating severe cognitive impairment. The MDS in section E0900 Wandering-Presence and Frequency indicated Resident #23 had not demonstrated any wandering behaviors. Section GG-Functional Abilities and Goals indicated Resident #23 required partial/moderate assistance with rolling left and right, sitting to lying, lying to sitting, and sitting to standing. The MDS indicated Resident #23 required substantial/maximal assistance with chair/bed-to-chair transfers and was dependent for toilet transfers. The MDS indicated Resident #23 had not attempted to ambulate. The MDS indicated Resident #23 required substantial/maximal assistance with use of a manual wheelchair for mobilization at 50 feet. Record review of the Comprehensive Care Plan dated 2/01/2024 failed to indicate Resident #23 resided on the secured unit, any goals, and any interventions. Record review of the Medication Administration Record dated May 2024 indicated Resident #23 received an anti-anxiety medication for anxiety and should be monitored closely for significant behaviors of agitation, anxiety, nervousness, compulsiveness, physical aggression, combative excitation/irritability, verbal aggression, panicking, and other. The Medication Administration Record indicated for the month of May 2024 Resident #23 had not demonstrated any behaviors. Record review of the Medication Administration Record dated June 2024 indicated Resident #23 received an anti-anxiety medication for anxiety and should be monitored closely for significant behaviors of agitation, anxiety, nervousness, compulsiveness, physical aggression, combative excitation/irritability, verbal aggression, panicking, and other. The entry indicated for June 1st ,2nd, 3rd, 4th, and 5th; Resident #23 had no behaviors demonstrated. Record review of an Elopement Risk Evaluation dated 6/04/2024 (after state surveyor intervention) indicated Resident #23 was not able to make decisions regarding task of daily living (decisions consistent and reasonable) and she was unable to ambulate or mobilize a wheelchair. The Elopement Risk Evaluation indicated Resident #23 was not at risk to elope. 3) Record review of a face sheet dated 6/04/2024 indicated Resident #38 was a 72-[NAME]-old male who admitted on [DATE], readmitted on [DATE], and most recently readmitted on [DATE] with the diagnoses of stroke, difficulty walking, and muscle weakness. Record review of the Progress Notes dated 2/03/2024 - 6/03/2024 failed to reveal documentation of Resident #38 attempting to exit the secured unit or verbalization he desired to leave the secured unit/facility. Record review of the Comprehensive Care Plan dated 6/30/2023 and revised on 6/30/2023 indicated Resident #38 was at risk for elopement and wandering as evidenced by impaired safety awareness and his residing on the secured unit. The care plan goal was Resident #38 would remain safe. The care planned intervention was distract Resident #38 from wandering by offering pleasant diversions, structed activities, food, conversation, television, and book initiated and revised on 6/30/2024. The care plan failed to indicate Resident #38's elopement risk score would have indicated he required to reside on the secured unit. Record review of an Annual MDS dated [DATE] indicated Resident #38 was understood and understood others. The MDS indicated Resident #38's BIMS was a 3 indicating he had severe cognitive impairment. The MDS in Section E0900 Wandering-Presence and Frequency indicated Resident #38 had not wandered. The MDS indicated Resident #38 was independent with sit to stand, lying to sitting on side of bed, chair/bed-to-chair transfers. The MDS indicated Resident #38 required supervision with walking 10 feet, 50 feet, and 150 feet. Record review of a Medication Administration Record dated June 2024 indicated Resident #38 received a psychotropic medication and should be closely observed for significant behaviors of hallucination, physical aggression, verbal aggression, paranoia, delusions, repetitive verbalizations, and other. The Medication Administration Record reflected Resident #38 had no behaviors demonstrated on June 1st, 2nd, 3rd, and 4th. Record review of the Consolidated Physician's Orders dated 6/04/2024 indicated on 6/10/2022 Resident #38 had a physician's order indicating he may admit to the secured unit due to exit seeking behaviors. Record review of an Elopement Risk Evaluation indicated for admission indicated on 1/10/2024 Resident #38 was not able to make decisions regarding task of daily living (decisions were consistent and reasonable). Section B Moderate Risk indicated Resident #38 was cognitively impaired and wandered aimlessly. Section C Imminent Risk and Section D Additional Information was not answered. The Elopement Risk Evaluation indicated Resident #38 was a moderate risk for elopement. Record review of an Elopement Risk Evaluation dated 4/01/2024 indicated Resident #38 was not able to make decisions regarding task of daily living (decisions were consistent and reasonable). The Elopement Risk Evaluation indicated Resident #38 was able to ambulate. Section B of the Elopement Risk Evaluation indicated Resident #38 was cognitively impaired and had a history of elopement while at home. The Section Imminent Risk and Additional Information was unanswered. The assessment scored Resident #38 as a moderate risk for elopement. 4) Record review of a face sheet dated 6/05/2024 indicated Resident #18 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of severe dementia with behavioral disturbances, and unsteadiness on feet, weakness, difficulty walking, abnormalities with gait and mobility, and reduced mobility. Record review of an Annual MDS dated [DATE] indicated Resident #18 was understood and understood others. The MDS indicated Resident #18's BIMS score was 1 indicating she had severe cognitive impairment. The MDS indicated in Section E0900 Wandering-Presence and Frequency indicated Resident #18 wandered daily. The MDS in Section E1000 Wandering-Impact indicated Resident #18 was not coded as wandering posed a significant risk of getting to a potentially dangerous place (outside of the facility) or wandered significantly to intrude on privacy or activities of others. Record review of a Quarterly MDS dated [DATE] indicated Resident #18 was understood, and usually understood others. The MDS indicated Resident #18 had a BIMS score of 1 indicating severe cognitive impairment. The MDS in Section E0900 Wandering-Presence and Frequency indicated Resident #18 wandered 1 to 3 days. The MDS in Section GG-Functional Abilities and Goals indicated Resident #18 was dependent for toileting hygiene. The MDS indicated Resident #18 was independent with sit to lying, lying to sitting on side of bed, sitting to standing. The MDS indicated Resident #18 was set up with chair/bed-to-chair transfers, toilet transfers, and walking. Record review of a Comprehensive Care Plan dated 10/27/2022 indicated Resident #18 was an elopement risk/wanderer as evidenced by a moderate risk score. The goal of the care plan indicated Resident #18 would have her safety maintained. The care plan intervention was to distract Resident #18 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and a book initiated on 6/30/2023. The Comprehensive Care Plan also included Resident #18 was at risk for feeling isolated due to being on the facility's secured unit related to dementia. The care plan interventions were to admit to the secured unit according to the physician's orders, and to assist and monitor resident for off unit activities and involve Resident #18 in daily activities designed for the secured unit. Record review of the physician's orders dated June 2024 indicated Resident #18 resided on the secured unit as of 10/27/2022. Record review of the progress notes dated 3/05/2024 -6/04/2024 there was no documentation noted of Resident #18 attempting to exit the secured unit or expressing a desire to leave the secured unit. Record review of an Elopement Risk Evaluation dated 12/29/2023 indicated Resident #18 was unable to make decisions regarding task of daily living (decisions consistent and reasonable) and she was able to ambulate or mobilize a wheelchair. Section B Moderate Risk indicated Resident #18 had cognitive impairment and wandered aimlessly. The Sections Imminent Risk and Additional Information was not answered. The Elopement Risk Evaluation indicated Resident #18 was a moderate risk to elope. Record review of an Elopement Risk Evaluation dated 3/04/2024 indicated Resident #18 was unable to make decisions regarding task of daily living (decisions consistent and reasonable) and she was able to ambulate or mobilize a wheelchair. Section B Moderate Risk indicated Resident #18 had cognitive impairment and wandered aimlessly. The Sections Imminent Risk and Additional Information was not answered. The Elopement Risk Evaluation indicated Resident #18 was a moderate risk to elope. Record review of an Elopement Risk Evaluation dated 6/04/2024 indicated Resident #18 was unable to make decisions regarding task of daily living (decisions consistent and reasonable) and she was able to ambulate or mobilize a wheelchair. Section B Moderate Risk indicated Resident #18 had cognitive impairment and wandered aimlessly. The Sections Imminent Risk indicated Resident #18 had not ambulated or propelled self, wandered, or intentionally or unintentionally attempted to leave the facility or had not verbalized a plan to elope. The Additional Information section the assessment indicated Resident #18 was at risk to elope due to the elopement risk score and would remain safe within the facility unless accompanied by staff other unauthorized persons. The Elopement Risk Evaluation indicated Resident #18 was a moderate risk to elope. Record review of the Medication Administration Record dated May 2024 indicated Resident #18 was receiving an antipsychotic medication and required monitoring closely for significant behaviors of hallucination, physical aggression, verbal aggression, paranoia, repetitive verbalization, or other behaviors for all of May dating May 1, 2024 - May 31, 2024. Record review of the Medication Administration Record dated June 2024 indicated Resident #18 was receiving an antipsychotic medication and required monitoring closely for significant behaviors of hallucination, physical aggression, verbal aggression, paranoia, repetitive verbalization, or other behaviors for June 1st, 2nd, 3rd, 4th, and the 5th. 5). Record review of a face sheet dated 6/05/2024 indicated Resident #47 was a [AGE] year-old-male who admitted on [DATE] and readmitted on [DATE] with diagnoses of dementia with mood disturbances and without behaviors disturbances, muscle weakness, and unsteadiness on his feet. Record review of a Comprehensive Care Plan dated 3/16/2022 and revised on 1/12/2024 indicated Resident #47 resided on the secured unit for his safety related to his diagnosis of dementia. The goal of the care plan was Resident #47 would not leave the facility unassisted. The interventions included to distract Resident #47 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and a book. The care plan also indicated to provide Resident #47 with structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Record review of the Consolidated Physician's orders dated June 2024 indicated on 3/13/2024 Resident #47 had an order to be admitted on the secured unit due to exit seeking behaviors. Record review of an Elopement Risk Evaluation dated 2/12/2024 indicated Resident #47 was not able to make decisions regarding task of daily living (decisions consistent and reasonable) and Resident #47 was able to ambulate. The Elopement Risk Evaluation Section Moderate risk indicated Resident #47 was cognitively impaired and wandered aimlessly. The Sections Imminent Risk and Additional information was not answered. The assessment indicated Resident #47 was a moderate risk for elopement. Record review of an Elopement Risk Evaluation dated 3/14/2024 indicated Resident #47 was not able to make decisions regarding task of daily living (decisions consistent and reasonable) and Resident #47 was able to ambulate. The Elopement Risk Evaluation Section Moderate risk indicated Resident #47 was cognitively impaired and wandered aimlessly. The Sections Imminent Risk and Additional information was not answered. The assessment indicated Resident #47 was a moderate risk for elopement. Record review of an Elopement Risk Evaluation dated 6/04/2024 indicated Resident #47 was not able to make decisions regarding task of daily living (decisions consistent and reasonable) and Resident #47 was able to ambulate. The Elopement Risk Evaluation Section Moderate risk indicated Resident #47 was cognitively impaired and wandered aimlessly. The Sections Imminent Risk and Additional information was not answered. The assessment indicated Resident #47 was a moderate risk for elopement. During an observation on 6/03/2024 at 10:17 a.m., Resident #23 was sitting in the dining room in her wheelchair at the dining table in the secured unit. Resident #23 was unable to be interviewed. During an observation and interview on 6/03/2024 at 10:18 a.m., Resident #35 was lying in her bed asleep on the secured unit. Resident #35 said she was just sleeping. During an observation on 6/03/2024 at 10:39 a.m., Resident #18 was sitting in her wheelchair in the dining room on the secured unit. Resident #18 said she was doing well. Resident #18 was unable to be further interviewed. During an observation on 6/03/2024 at 10:48 a.m., Resident #47 was lying in his bed on the secured unit. Resident #47 was unable to be interviewed. During an interview on 6/03/2024 at 1:50 p.m., LVN A said Resident #'s 35, 23, 18, and 47 have not attempted elopement behaviors in several months but she said Resident #47 had a history of attempting elopement but was unsure of the date. During an observation on 6/04/2024 at 10:16 a.m., Resident #23 was sitting at the dining table in the secured units dining room. During an observation and interview on 6/04/2024 at 10:18 a.m., Resident #35 said she was just resting in her bed in the secured unit. Resident #35 said she felt her needs were being met and denied abuse. During an observation and interview on 6/04/2024 at 10:22 a.m., Resident #47 was sitting in the secured units dining room having a snack. Resident #47 said his snack was good. During an observation and interview on 6/04/2024 at 10:24 a.m., Resident # 18 was sitting in her wheelchair in the dining room of the secured unit eating a snack. Resident #18 said her snack was good. During an interview on 6/04/2024 at 1:40 p.m., the DON said she was unsure why Resident #'s 23, 18, 47, and 35 remained on the secured unit when their elopement risks scores were indicative a moderate risk to elope the facility. The DON was asked to provide documentation of elopement behaviors. During an interview on 6/04/2024 at 1:51 p.m., CNA B said she was routinely providing care for the residents for the secured unit. CNA B said Resident #''s 47 had a history of going to the doors to attempt to leave but not demonstrated this behavior recently. CNA B said Resident #'s 23,18, and 35 had not attempted wandering to the doors in more than two months. During an observation and interview on 6/05/2024 at 7:49 a.m., Resident #35 was no longer on the secured unit. Resident #35 was observed in the general community. Resident #35 said she was moved, and she liked her new room. Resident #35 said the staff seemed nicer and was okay with her remaining in the bed. During an interview on 6/5/24 at 2:30 PM, RN C said She said Resident #18 went on hospice 2 weeks ago. She said Resident #18 had not tried to leave the unit or showed any desires she had wanted to leave. RN C said Resident #18 was more confused. RN C said Resident #23 had behaviors but was not able to walk. RN C said Resident #23 would not be able to leave the building. RN C said she did not feel the residents were appropriate to be in the unit if they are unable to leave the building or trying to exit seek. During an interview on 6/05/2024 at 3:49 p.m., the DON said the Elopement Risk Assessments were completed on admission and quarterly by the nurses. The DON said the Elopement Risk Assessments were reviewed on Fridays. The DON said when a resident no longer qualified for the secured unit the physician was notified for an order to come off the secured unit and the family and resident were notified. The DON said she believed the Secured Unit policy gave discretion to the Administrator to keep a resident on the secured unit although the assessment failed to meet the criteria for placement. The DON said she was unable to provide documentation of exit seeking behaviors. The DON said the Administrator could explain further. The DON said she would not want to live on the secured unit if she was a resident and had not demonstrated a need to reside on the unit. The DON said a resident could have failure to thrive issues, and a decline in socialization. During an interview on 6/05/2024 at 4:06 p.m., the Administrator said he expected the Elopement Risk Assessments and the documentation to reflect a resident's need to reside on the secured unit. The Administrator was unable to provide documentation of elopement behaviors for Resident #'s 50, 23, 18, 47, and 35. The Administrator said the DON was responsible for ensuring the resident documentation supports the residents to reside in the secured unit. The Administrator said he believed the policy for the secured unit allowed for his discretion not to move a resident from the secured unit when the assessments reflect otherwise. The Administrator said he would want to reside where he was supposed to reside if he was a resident on the secured unit with no supporting documentation to be on the unit he would not want to reside on the secured unit. Record review of a Secure Care neighborhood policy dated 8/2020 indicated the goal of the Secure Care neighborhood was to meet the individual needs of residents with dementia related illness. The Secure Care neighborhood will provide a safe environment that maximizes independence and provides an activity intensive atmosphere. Policy: l. The secure care neighborhood may be sued to keep residents who are a high risk for elopement safe from exiting the facility. The resident should have an Elopement Risk Assessment completed with a physician order completed. ll. Residents eligible for admission to the Secure Care Neighborhood will have a diagnosis of dementia or dementia related illness. Procedure: l. Resident eligible for admission for the Secure Care Neighborhood will have a diagnosis of dementia or a dementia related illness. A. The need for admission to the Secure Care neighborhood must have a physician's order. ll. The following criteria must be met in order for the resident to meet for participation in the Secure Care neighborhood program. If one of more of the criteria is not met, an exception for admission may be made only at the discretion of the administrator. Exception of admission will be made on an individual case by case basis. A. The resident must have a diagnosis of dementia or related illness. B. The resident musts be medically stable with no IV's or feeding tubes. C. If the resident expresses physical abusive and/or combative behaviors, they must be manageable through therapeutic approaches and/or low to moderate mediations. D. The resident must be alert at least 50% of the day. E. The resident must be able to assist in ADL activities including dressing, bathing, and toileting independently or with the assist of one. F. The resident must be able to participate in at least three activity programs per day which are scheduled to meet the individual needs of the residents. G. The resident must be a high-risk wander.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure 3 muffin tins were free from carbon build-up, rust, and food particles on 6/03/24. This failure could place residents at risk of foodborne illness, and food contamination. Findings included: During an observation of the facility's kitchen on 06/03/24 and interview at 11:33 AM, three muffin tins were observed at the bottom of the steam table. The three muffin tins were black, had carbon build up, rust and light-yellow food particles. The Dietary [NAME] said they had been using the muffin tins. When asked if the muffin tins appeared clean, she said No. The Dietary [NAME] said it could get in the resident's food and cause them to get sick. During an interview on 06/03/24 at 11:36 AM, the Dietary Manager said he did not believe the carbon build up or rust could get in the resident's food since it was not inside the muffin tin but on top. When demonstrated that the black buildup could be peeled off, and food particles were still inside the muffin tin he said that it could get in the resident's food, cause bacteria, and make them sick. The Dietary Manager said he tried to check the kitchen equipment as frequently as possible to ensure they were in good working order. During an interview on 06/05/24 at 3:25 PM, the Administrator said he did not expect the muffin tins to be used because it would not be beneficial to the residents and probably cause stomach issues. The Administrator said the Dietary Manager was responsible for ensuring the kitchen equipment was kept in working order. Record review of the facility's policy Equipment Operation and Sanitation revised 12/2020, indicated . To establish guidelines for safe equipment operation and sanitation . a. all equipment must be thoroughly washed and sanitized between uses in different food preparation tasks .

Based on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 nurse medication carts and 2 of 23 residents reviewed in sample (Residents #69 and #43). 1. The facility failed to ensure Resident #69 did not have prescribed medication Prostat AWC oral liquid (medication used to aid in wound healing) left at bedside on 06/04/24. 2. LVN D failed to ensure the 400 hall nurse medication cart was locked when it was left unattended on 06/04/24 when she went to wash her hands. 3. The facility failed to ensure LVN D properly secured Resident #43's insulin pen inside the nurse's medication cart on 06/04/24. These failures could place residents at risk of injury. Findings included: 1.Record review of Resident #69's face sheet dated 06/04/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of partial traumatic amputation of left foot, Dementia (a disease in which causes a decline in a person's cognitive ability to perform day to day activities, Schizophrenia (mental disorder characterized by episodes of psychosis generally misperceptions of real life), Diabetes Mellitus (disease in which it causes too much sugar in the blood), and weakness. Record review of Resident #69's quarterly MDS dated [DATE] indicated he had a BIMS score of 8 which meant he had moderately impaired cognition. The MDS also indicated he required maximal assistance with toileting, transfers, dressing, and bathing, and he was independent with eating. Record review of Resident #69's care plan dated 04/24/24 indicated he had wounds to his bilateral feet that he was being seen by outpatient wound care with interventions for Resident #69 to have no complications to his right and left feet, and to have Prostat AWC (medication used to aid in wound healing) 30ml twice a day until they were healed. Record review of Resident #69's order summary report dated 06/04/24 indicated he had an order as followed: 1.Prostat AWC Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30 ml by mouth two times a day for wound healing until all wounds are healed with a start date of 05/18/24 and no end date. Record review of Resident #69's administration record dated June 2024 indicated Medication Aide G administered the Prostat AWC liquid (medication used to aid in wound healing) to Resident #69 on 06/04/24 at 8:00 AM dose, when it was found at Resident #69's bedside. During an observation and interview on 06/04/24 at 08:23 AM Resident #69 was sitting on the side of his bed eating his breakfast and showed the surveyor his wound healing medication that was left at his bedside for him to take. He said he did not like taking the medication until he ate. During an observation and interview on 06/04/24 at 08:33 AM the MDS Nurse came into Resident #69's room while he had his Prostat AWC liquid (medication used to aid in wound healing) in a 30ml medicine cup and said he should not have his medication at his bedside and that the medication aide should have stood there while the resident took his medicine. The MDS Nurse said the importance of the staff standing at bedside until a resident completely took their medications, was to ensure the resident took the medication and prevented a wandering resident from getting medication and taking it. During an interview on 06/04/24 at 08:57 AM Medication Aide G said she gave Resident #69 his 08:00 Am medication. She said that while she was giving him his medication, she was distracted by another resident and forgot to ensure Resident #69 took his medications. Medication Aide G said she was responsible for ensuring residents took their medications prior to her leaving the bedside. She said the failure could have placed Resident #69 at risk for not taking his medication or possibly allowed another resident to get the medication and take it. During an interview on 06/05/24 at 04:02 PM the DON said no medications should have been left at Resident #69's bedside. She said she expected the nurses and Medication Aides to be watching all medications being administered. The DON said the failure placed a risk for other residents taking the medications and placed the facility at risk for not following doctor orders. The DON said she was responsible for ensuring the med aides and nurse were administering medications correctly. During an interview on 06/05/24 at 04:31 PM the Administrator said he expected the staff to remain with residents and observe the residents take medications. He said the failure placed a risk for Resident #69 not taking his medication as ordered or risk for another resident to get the medication and take. 46928 2. Record review of Resident #43's face sheet dated 06/05/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] and readmitted [DATE]. Resident #43 had diagnoses type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), cerebral infarction (stroke), chronic kidney disease (a condition characterized by a gradual loss of kidney function), and atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow). Record review of Resident #43's comprehensive care plan dated 02/18/23 indicated Resident #43 had diabetes and used diabetic medications. The care plan interventions indicated to administer diabetic medications as ordered. Record review of Resident #43's annual MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated he had a BIMS score of 9, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #43 received insulin injections 7 out of the 7 day look back period. Record review of Resident #43's order summary report dated 06/05/24, indicated he had an order for Fiasp FlexTouch (fast acting insulin indicated to improve glycemic control in patients with diabetes) 100 unit/ml per sliding scare before meals for diabetes with a start date of 04/29/24. Record review of Resident #43's nurse administration record dated 06/01/24-06/30/24, indicated he received Fiasp 100unit/ml per sliding scale three times a day. During an observation and interview on 06/04/24 at 10:31 AM, LVN D entered Resident #43's bathroom to wash her hands. LVN D left the 400-hall nurse's medication cart unlocked. LVN D obtained Resident #43's blood sugar and administered his insulin. LVN D placed Resident #43's Fiasp Flexpen on top of the nurse medication cart and went inside Resident #43's bathroom to wash her hands. LVN D left the nurse medication cart unlocked. LVN D failed to properly secure Resident #43's insulin pen and the nurse medication cart when she them out of her view. LVN D said she was responsible for ensuring the cart was locked and medications secured when leaving the cart and medications unattended. LVN D said someone passing by could have gotten the insulin or the medications inside the cart. During an interview on 06/05/24 at 03:02 PM, ADON F said she expected medications to be properly secured inside the medication cart and the medications cart to be locked when leaving them unattended. ADON F said the person administering medications was responsible for ensuring medications and carts were properly secured. ADON F said by not properly securing medications, residents or people passing by could get the medications. During an interview on 06/05/24 at 3:24 PM, the DON said she expected the medication cart to be always locked and medications to be properly secured inside the cart. The DON said the staff administering medications was responsible for ensuring medications were properly secured. The DON said by leaving medications on top of the cart or the cart unlocked, anyone passing by could get the medications. During an interview on 06/05/24 at 3:25 PM, the Administrator said he expected the medication carts to always remain locked. The Administrator said he expected medications to be properly secured and not left on top of the medication cart. The Administrator said by leaving medications on top of the cart or the cart unlocked, residents passing by could get the medications. The Administrator said the person administering medications was responsible for properly securing the medications. Record review of the facility's undated policy Medication-Administration indicated . Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner, or as consistent with state law . The licensed nurse must know the following information about any medication they are administering. A. The drug's name. B. The drug's route of administration. C. The drug's action. D. the Drug's indication for use and desired outcome. E. The drug's usual dosage. F. The drug's side effects and adverse effects. G. Any precautions and special considerations .VIII. Medications will not be left at bedside .When a medication is held for any reason, the Licensed Nurse will initial the appropriate area on the MAR and circle his/her initials. The Licensed Nurse will document the reason the medication was held on the back of the MAR. Record review of the facility's policy Storage of Medications revised 08/2020 indicated . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access .

Based on observation, interview, and record review, the facility failed to ensure that its medication error rates were not 5 percent or greater. There were 3 errors out of the 58 opportunities, resulting in a 5.17 percent medication error rate involving 2 out of 5 residents reviewed for medication errors. (Residents #6 and #35) 1. The facility failed to ensure Resident #6's MiraLAX (laxative) was administered as ordered on 06/04/24. 2. The facility failed to ensure Resident #35's fluticasone (nasal spray that treats allergy symptoms) and guaifenesin (medication used to relieve chest congestion) were administered as ordered on 06/04/24. These failures could place residents at risk of not receiving the therapeutic outcomes and possible negative outcomes. Findings included: 1. Record review of Resident #6's face sheet dated 06/05/24, indicated a [AGE] year-old female who admitted to the facility on [DATE], and readmitted on [DATE]. Resident #6 had diagnoses of type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow), weakness, and hypertension (high blood pressure). Record review of Resident #6's annual MDS assessment dated [DATE], indicated was able to make herself understood and understood others. The MDS assessment indicated Resident #6 had a BIMS of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #6 did not refuse care or had constipation. Record review of Resident #6's comprehensive care plan dated 05/17/24, did not indicate she had constipation issues or was receiving MiraLAX. Record review of Resident #6's order summary report dated 06/05/24, indicated she had an order for MiraLAX powder 17 GM/scoop give 17 grams by mouth in the morning for constipation with an order start date of 10/19/2021. Record review of Resident #6's medication administration record dated 06/01/24- 06/30/24 indicated she had received MiraLAX 17 on 06/04/24. During an observation of the medication administration on 06/04/24 at 08:07 AM, MA G did not administer the MiraLAX as ordered to Resident #6. During an interview on 06/05/24 at 09:30 AM, MA G said Resident #6 did not like to take her MiraLAX daily and usually took it every other day. MA G said she thought she had signed the medication out as given but she should have struck it out and marked out as drug refused. MA G said since she was moving so fast, she accidently marked it as given. MA G said by Resident #6 was at risk for constipation by not administering the MiraLAX. 2. Record review of Resident #35's face sheet dated 06/05/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysphagia (difficulty swallowing), dementia (memory loss), essential hypertension (high blood pressure), and chronic kidney disease (a condition characterized by a gradual loss of kidney function). Record review of Resident #35's comprehensive care plan dated 03/13/24 did not indicate Resident #35 was receiving fluticasone for allergic rhinitis or guaifenesin for cough. Record review of Resident #35's quarterly MDS assessment dated [DATE], indicated she understood others and usually was able to make herself understood. The MDS assessment indicated he had a BIMS score of 10, which indicated her cognition was moderately impaired. Record review of Resident #35's order summary report dated 06/05/24, indicated she had the following orders: *Fluticasone propionate nasal suspension 50mcg /act: 2 sprays in both nostrils in the morning for allergic rhinitis with a start date of 03/08/24. *Guaifenesin ER (extended release) 600mg tablet: give one tablet by mouth every 12 hours as needed for cough with an order start date of 03/08/24. Record review of Resident #35's medication administration record dated 06/01/24-06/30/24, indicated Resident #35 received fluticasone 50mcg/act 2 sprays each nostril and guaifenesin 600mg 1 tablet by mouth on 06/04/24. During an observation of the medication administration on 06/04/24 at 08:33 AM, MA G did not administer Resident #35's guaifenesin tablet and only administered one spray of fluticasone to each nostril. MA G failed to administer Resident #35's guaifenesin and fluticasone as ordered. During an interview on 06/05/24 at 09:30 AM, MA G said Resident #35 should have received 2 sprays of fluticasone to each nostril and 1 tablet of guaifenesin during the medication pass on 06/04/24. MA G said they did not have the guaifenesin tablets available at the facility and had told medical records that the medication needed to be ordered. MA G said she should have marked the guaifenesin as not administered and notified the nurse that medication was not available. MA G said Resident #35 was at risk for stuffy nose and congestion since medications were not administered as ordered. MA G said the medications rights were as follows: the right dose, the right time, the right medication, the right patient, and the right route. MA G said she had been checked off on medication administration. MA G said she was in a hurry and to nervous but should have had paid better attention to the medication administration record. During an interview on 06/05/24 at 3:02 PM, ADON F said she expected medications to be administered as ordered. ADON F said Resident #6's MiraLAX should have been administered unless Resident #6 had refused. ADON said medications refused should have been marked as refused and not administered. ADON F said Resident #35's fluticasone and guaifenesin should have been administered as ordered. ADON F said if a medication was not available, staff should notify medical records staff and the nurse so medication could have been reordered. ADON F said medications not administered should not have been documented as given. ADON F said Resident #6 was at risk for constipation and Resident #35 was at risk for allergy problems. ADON F said MA G was responsible for administrating medications as ordered. During an interview on 06/05/24 at 03:24 PM, the DON said she expected medications to be administered as ordered. The DON said Resident #6 refusal of MiraLAX should have been documented as refused and not administered. The DON said Resident #35 should have received 2 sprays of fluticasone and 1 tablet of guaifenesin as ordered. The DON said MA G was responsible for ensuring medications were administered as ordered. The DON said Resident #35 was at risk for medications not being effective and congestion. During an interview on 06/05/24 at 03:25 PM, the Administrator said he expected medications to be administered per the physician's orders. The Administrator said residents were at risk for adverse effects for not receiving medications as ordered. The Administrator said MA G was responsible for administering medications as ordered by the physician. The Administrator said the DON and ADON were responsible for ensuring the medication aides were checked off on medication administration. Record review of the facility's undated policy Medication-Administration indicated . Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner, or as consistent with state law . The licensed nurse must know the following information about any medication they are administering. A. The drug's name. B. The drug's route of administration. C. The drug's action. D. the Drug's indication for use and desired outcome. E. The drug's usual dosage. F. The drug's side effects and adverse effects. G. Any precautions and special considerations .When a medication is held for any reason, the Licensed Nurse will initial the appropriate area on the MAR and circle his/her initials. The Licensed Nurse will document the reason the medication was held on the back of the MAR.

Based on observation, interview, and record review, the facility failed to ensure adequate monitoring of cigarettes to prevent accidents or hazards for 1 of 3 residents reviewed (Resident #54) and the facility failed to ensure 1 of 1 unit environment remained free of accident hazards for 1 of 18 residents (Resident #38) reviewed for accidents and hazards. 1. The facility did not ensure Resident # 54 did not have his cigarettes which were left out on his bedside table. 2. The facility failed to ensure Resident #38's personal disposable razor was disposed of or stored properly after use to prevent accidents. These failures could place residents at risk for injury. Findings included: 1.Record review of Resident #54's face sheet, dated 06/05/24, indicated Resident #54 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included anxiety (a feeling of fear, dread, and uneasiness), Insomnia (when you are not sleeping as you should), depression(sadness), and high blood pressure. Record review of Resident #54's quarterly MDS assessment, dated 01/26/24, indicated Resident #54 understood and was understood by others. Resident #54's BIMS score was 15, which indicated he was cognitively intact. Resident #54 required assistance with bathing and independent with toileting, personal hygiene, transfer, dressing, bed mobility, and eating. Record review of Resident # 54's Smoking assessment dated [DATE] indicated Resident #54 was a smoker. It indicated he required minimal supervision while smoking and his smoking material should have been kept at the nurses' station. Record review of Resident #54's comprehensive care plan dated 03/13/23 indicated he was a smoker. The intervention was for the staff to keep his smoking material at the nurses' station. During an observation on 06/03/24 at 10:00 a.m., cigarettes were observed on Resident #54's bedside table. During an interview on 06/03/24 at 12:10 p.m., Resident #54 said he kept his cigarettes and lighter. He said unknown staff were aware he kept his cigarettes and lighter. He said he signed himself out to smoke and it was too much of a hassle to ask for his cigarettes and lighter each time he signed out on pass. During an interview on 06/05/24 at 4:06 p.m., LVN E said he does not know how Resident #54 gets his cigarettes. He said he does ask Resident #54 for his lighter and cigarettes when he returns from outside or out on pass. He said cigarettes and lighters should be kept at the nurse's station. He said another resident could get the cigarettes and lighter if left out and cause a fire. During an interview on 06/05/24 at 4:09 p.m., the DON said she was unaware Resident #54 had his cigarettes on him. She said she was aware Resident #54 signed himself out to smoke. She said the nurses should ensure they collect all smoking material of all residents who had smoked during smoking times and residents who had signed back in from out on pass. She said it was their policy for residents to smoke in designated areas and for all smoking material to be kept in a box at the nurses' station. She said if Resident #54 had his smoking material and left them out it could be a potential fire hazard. During an interview on 06/05/24 at 4:49 p.m., ADON, LVN F said Resident #54's cigarettes and lighter should be at the nurses' station like all other residents who smoke. She said whoever took the residents out to smoke should receive all smoking material back from the residents and the nurses should receive all smoking material back when the resident(s) signed back in from out on pass. She said failure to keep smoking material at the nurses' station could result in burns. During an interview on 06/05/24 at 5:03 p.m., the Administrator said all residents who smoked should have their smoking material locked up at the nurses' station. He said Resident #54 had been non-compliant with following the smoking policy and they had issued him a 30-day notice. The Administrator said he still expected Resident #54 to have his smoking material locked up at the nurses' station for safety. 33249 2. Record review of a face sheet dated 6/04/2024 indicated Resident #38 was a [AGE] year-old male who admitted on [DATE], readmitted on [DATE], and most recently readmitted on [DATE] with the diagnoses of stroke and dementia. Record review of an Annual MDS dated [DATE] indicated Resident #38 was understood and understood others. The MDS indicated Resident #38's BIMS score was a 3 indicating he had severe cognitive impairment. The MDS indicated Resident #38 was independent with personal hygiene which included shaving. Record review of the Comprehensive Care Plan dated 4/27/2022 indicated Resident #38 had a stroke. The goal of the care plan was Resident #38 would be able to communicate needs daily and be free from complications related to a stroke. The interventions of this care plan were to monitor and document the resident's abilities for ADLs and assist Resident #38 as needed and allow Resident #38 to do what he could do for himself. During an observation on 6/03/2024 at 10:19 a.m., Resident #38 was sitting in his recliner. Resident #38 has his television remote and a disposable personal razor sitting in his window on the ledge. During an observation, and interview on 6/04/2024 at 10:30 a.m., Resident #38 had a disposable razor sitting on the ledge of the window next to his recliner. LVN A said when asked about the razor said, Resident #38 you know you need to give the razor back to us when you finish using it. LVN A was asked does Resident #38 have a diagnosis of dementia, and she agreed. LVN A said Resident #38 should not have kept the razor and stored the razor in his window ledge. LVN A said the unit had residents who wandered and could have an injury from obtaining the razor. During an interview on 6/05/2024 at 3:49 p.m., the DON said a razor should be placed in a sharps container once used. The DON said the unit staff were responsible for ensuring the proper discarding of used razors. The DON said this was monitored with every 2-hour rounds by the nursing staff. The DON said a resident could obtain the opened, used razor and injure themselves. During an interview on 6/05/2024 at 4:20 p.m., the Administrator said storing a disposable razor in the window ledge was not the appropriate place to store a razor. The Administrator said the storing of an open and used razor in the window ledge posed a safety risk. The Administrator said the secured unit staff were responsible for ensuring sharps were stored properly. Record review of the facility policy titled, Smoking, dated November 2023, indicated, It is the policy to respect the resident choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers #8. All smoking materials will be stored in a secure area to ensure they are kept safe. Record review of a Sharps Disposal policy dated 6/2020 indicated, The purpose of the policy was to ensure nursing staff discarded contaminated sharps in designated containers. l. Nursing staff using sharps discard them as soon as feasible into designated containers.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1's safety while smoking. Resident #1 was allowed to sit on a public roadway in a space used by cars to parallel park where he could have been injured in a vehicle and pedestrian accident. An IJ was identified on 4/09/2024 at 3:45 PM. The IJ template was provided to the facility on [DATE] at 4:49 PM. While the IJ was removed on 4/10/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision. The findings included: Record review of a face sheet dated 4/10/2024 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] with the diagnoses which included: difficulty walking, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, abnormal posture, history of falls and encephalopathy (a disease that affects brain structure or function causing altered mental state and confusion). Record review of the Quarterly MDS dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated Resident #1's BIMS score was 15 indicating he had no cognitive deficits. The MDS in Section GG Functional Abilities and Goals indicated Resident #1 required set up with showers and personal hygiene. The MDS indicated Resident #1 required supervision or touching assistance with sit to stand, chair/bed-to-chair transfers, and toilet transfers. The MDS indicated Resident #1 was unable to walk 10 feet due to his medical condition or safety. Record review of a comprehensive care plan dated 3/15/2023 indicated Resident #1 was a smoker. The care plan goal was Resident #1 would smoke in designated areas without occurrence of injury. The care plan interventions for Resident #1 were performing the smoking assessment according to facility policy, explaining where designated smoking areas were and smoking times, monitoring when smoking to assure Resident #1's safety, and to keep all smoking material at the nurse's station. The comprehensive care plan also indicated Resident #1 was at risk to fall related to his gait/balance problems and use of psychoactive drugs. The goal of the care plan was Resident #1 would not sustain serious injury through the next review. The interventions included to ensure the call light was within reach and educate the resident on safety reminders. Record review of the consolidated physician's orders dated April 2024 indicated Resident #1 was administered Gabapentin (anticonvulsant medication used to treat pain) 300 milligrams at 8:00 AM, Xanax (anti-anxiety) 0.5 milligrams at 9:00 AM, Cyclobenzaprine (muscle relaxer) 10 milligrams at 9:00 AM, and Oxycodone 10 milligrams at 7:30 AM (narcotic pain medication). Record review of a Safe Smoking Evaluation dated 3/14/2023 indicated Resident #1 smoked, knew the locations of designated smoking areas, could go to the smoking areas independently, independently light his own smoking materials safely, could extinguish smoking materials completely and in the appropriate receptacles, and dispose of ashes or another tobacco-related residue. The assessment indicated Resident #1 did not have shaking when smoking, did not fall asleep while smoking, had not had past incidents with smoking materials, no visible burn marks on clothing, and no dexterity issues. The Summary of the Safe Smoking Evaluation reflected Resident #1 was safe to smoke with minimal supervision, and all smoking materials would be kept at the nurse's station. Record review of a Smoking by Residents policy dated November 2023 indicated on 11/22/2023 Resident #1 signed a copy indicating when clothing was found to have cigarette burn holes the smoker must wear an apron to protect themselves from burns regardless of whether the resident was assessed as independent for smoking. All smoking materials will be stored in a secure area to ensure they were kept safe. Smoking sessions would be supervised by facility staff members. The policy indicated the first, second, third offense rules and the discharge process after found smoking when smoking privileges were removed. Record review of a smoking notice violation dated 2/26/2024 indicated Resident #1 was provided a first offense regarding non-compliance with the smoking rules/policy. The smoking policy indicated in Section XlV. Response to resident non-compliance with smoking rules included: A. First Offense: a written letter issued to the resident and/or family regarding non-compliance. B. Second Offense: a written letter issued to the resident and /or family referencing the first offense letter and advising that a third offense results in the loss of smoking privileges. C. Third Offense: A written letter issued to the resident and/or family outlining the non-compliant behavior. At this time the resident loses their smoking privileges. D. Residents observed smoking following revocation of smoking privileges is issued a 30-day notice of discharge if their non-compliant behavior endangers other individuals (e.g. continuing to smoke in areas where oxygen is in use). The clinical/behavioral status of the resident endangering other individuals at the facility will be documented by an associated physician in accordance with Policy no._AD_04-Transfers and Discharge. Record review of a smoking notice violation dated 3/11/2024 indicated Resident #1 was provided a letter to inform him of his second offense regarding non-compliance with the smoking rules/policy. The violation indicated Resident #1 was observed smoking outside of smoke times on March 9, 2024, at 5:45 a.m. The letter again indicated Resident #1 received a copy of the policy. Record review of the Resident Out on Pass Log Version 1.0 indicated Resident #1's last signed out on pass time was on 4/08/2024. In the section of accompanied by was written 9:00 - 1130 the log failed to specify if the time was morning or night. The pre-printed log in the categories listed did not indicate the time Resident #1 signed himself out, the licensed nurse's initials, the expected time of return, the time of return and then again, the licensed nurse's initials. The log had no sign out date for 4/09/2024. During an observation as the surveyors themselves were looking for a parking space on 4/09/2024 at 9:00 a.m., revealed Resident #1 was noted to be sitting on the left side of the roadway that was in the front of the nursing facility. Resident #1 was sitting in his wheelchair in front of a passenger car facing the roadway while smoking his cigarette. Resident #1 was facing the facility sitting in front of a parked vehicle closest to the front passenger side. Resident #1 had an entire car length between him and the next paralleled parked SUV. The surrounding area behind Resident #1 was the roadside curb, brush, and residential fencing. The were not any public sidewalks available for use by a pedestrian. During an observation and interview on 4/09/2024 at 10:10 a.m., the DON was asked where the surveyor could find Resident #1. The surveyor informed the DON Resident #1 was not in his room. The DON asked Resident #1's nurse, RN A, the whereabouts of Resident #1 and she asked, Did you check his restroom? The surveyor indicated the bathroom had not been checked for his presence. The DON opened and looked at the Resident Sign Out Logbook then closed the book. The DON walked to the front door and viewed out the glass doors as though she was looking for someone. The DON said Resident #1 went outside, across the street at his leisure to smoke. RN A returned from Resident #1's room to the DON and surveyor and indicated Resident #1 was not in his restroom. The nurse opened the secured glass doors, walked down the facility driveway, and found Resident #1. Resident #1 was sitting in the roadway smoking. The area Resident #1 was seated was facing the roadway more closely to the passenger side of a red colored passenger car. Resident #1 had an entire car length space to his right just behind a large SUV. Resident #1 was found to be smoking sitting directly on the roadway, with a curb, brush, and residential fencing boundary present directly behind his wheelchair. Resident #1 was sitting in an area in which there were no sidewalks provided off the roadway. Resident #1 was assisted back inside the facility by RN A. During an interview on 4/09/2024 at 10:17 a.m., Resident #1 said he had been smoking across the street because he was not allowed to smoke on the premises due to his 30-day letter. Resident #1 said he had not signed himself out but left out of the building on his signature from 4/08/2024. Resident #1 said he felt safe outside in the street because he sat close to the curb. Resident #1 said he smoked early in the mornings between 5:30 a.m. and 6:00 a.m. when the air was freshest, and he said he felt as though he could breathe better. During an interview on 4/09/2024 at 10:57 a.m., RN A said she was Resident #1's nurse. RN A said 4/08/2024 was her first day outside the secured unit assignment having been assigned to Resident #1. RN A was unsure how Resident #1 had his cigarettes and was found outside the facility. RN A said it was very important for the CNAs, or other staff to let her know when a resident was leaving the facility. RN A said she was not aware where Resident #1 was until she started looking for him. During an interview on 4/09/2024 at 11:07 a.m., Resident #1 said he had a package of cigarettes and a lighter on his person but was not allowed to smoke on the premises. During an interview on 4/09/2024 at 11:17 a.m., the local Ombudsman said she was assisting Resident #1 with his discharge appeals process. The Ombudsman said she was aware Resident #1 smoked outside, and he had his own smoking materials. During an interview on 4/09/2024 at 12:51 p.m., Resident #1 said there were so many residents sitting in the foyer of the facility he could not get to the sign out book this morning. Resident #1 said the Receptionist opened the door for him this morning. Resident #1 said he did not have the code to the front door. Resident #1 said he usually stayed outside on the street about an hour at a time smoking, drinking his coffee, and looking at his iPad. During an interview on 4/09/2024 at 12:52 p.m., the SW said she was aware Resident #1 smoked outside across the street. The SW said due to Resident #1's smoking habits his smoking privileges on the premises had been removed. The SW said when Resident #1 signed out essentially he was out on pass. The SW said Resident #1 should have signed out to smoke for safety. The SW said the nurse should have documented Resident #1 was out on pass. During an interview on 4/09/2024 at 1:13 p.m., the Receptionist said she had been employed at the facility for almost 2 weeks. The Receptionist said she was told she could let Resident #1 and one other resident go outside. The Receptionist said since she had been told Resident #1 could go outside, she just allowed him to exit the building. The Receptionist said she was unable to recall who said Resident #1 could exit the building to smoke. During an interview on 4/09/2024 at 1:17 p.m., the DON said when she looked out the front door of the facility, she just overlooked Resident #1 because she did not see him as he was closer to the parked car. The DON said she had spoken to Resident #1 about sitting closer to the curb when sitting in the street to smoke. The DON said Resident #1 should have signed himself out, then he could be let out. The DON said she was told Resident #1 smoked across the street because he was non-compliant with the rules to be able to smoke at the facility during designated smoke times. During an interview on 4/06/2024 at 4:06 a.m., the Administrator said Resident #1 smoked outside across the street because his smoking privileges had been taken away because he had been caught smoking outside the policy. The Administrator said Resident #1 should not have had cigarettes on his person, but the Administrator said every time the cigarettes and lighters were taken up Resident #1 obtained Th. The Administrator said the street was a busy residential street with employees and resident family's coming and goings. Record review of a Smoking by Resident policy dated November 2023 indicated the purpose of the policy was to respect resident choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers. The policy indicated smoking was not allowed anywhere inside the facility, the facility permits smoking only in the areas designated by the Facility's Safety Committee, the facility discourages smoking by residents and ensures that those residents who choose to smoke do so safely, residents who want to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke independently in these areas .Procedures V. Residents will be allowed to smoke in designed smoking areas only X. All Smoking sessions will be supervised by Facility Staff members XXIV. Response to resident non-compliance with smoking rules include A. First Offense: A letter issued to the resident and/or family regarding non-compliance. B. Second Offense: A written letter issued to the resident and/or family referencing the first offense letter and advising that a third offense results in the loss of smoking privileges. C. Third offense: A written letter issued to the resident and/or family outlining the non-compliant behavior. At this time the resident loses their smoking privileges. D. Residents observed smoking following revocation of smoking privileges is issued a 30-day notice of discharge if their non-compliant behavior endangers other individuals. The clinical/behavioral status of the resident endangering other individuals at the Facility will be documented by an associated physician in accordance with policy no. AD-04-Transfer and Discharge. Record review of an Out on Pass policy and procedure dated 8/2020 indicated the purpose was to provide resident with the opportunity to participate in family and community life in ways that support well-being and optimal functioning. Policy . It is the policy of the facility to meet residents' physical psychosocial needs to go out on pass. The Facility will make reasonable efforts to ensure the resident safety and uphold resident rights. l When a resident request to go out on pass, the interdisciplinary Team will assess the resident's ability to participate in activities outside the facility, while taking into consideration the resident's decision-making capacity, physical disabilities, and ability to take medications without supervision V. Licensed Nurses A. Prior to the resident leaving on pass, a Licensed Nurse will assess the residents physical and mental status .VI. The Resident/Responsible Person A. The resident/responsible person is encouraged to give the facility reasonable notice when anticipating going out on pass. B. The resident/responsible person will verbally notify a Licensed nurse prior to going out on pass and will sign out and back in on Resident Out on Pass Log. The Administrator and Regional Director was notified an IJ was identified on 4/09/2024 at 4:35 p.m. The IJ template was provided to the facility on [DATE] at 4:49 p.m. The Facility's plan of removal was accepted on 4/10/2024 at 3:20 p.m. and included the following: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes. F689 On 4/9/24 during a complaint survey at [facility name and address]. HHSC surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility allegedly failed to provide supervisory services. When Resident #1 exited facility without signing self out on pass to sit on public street between two parked cars while he smoked. The notification of the alleged immediate jeopardy states as follows: Resident #1 was allowed to exit the building without signing out and sit on the public street between 2 parked cars while he smoked. Identify responsible staff/ what action taken. 1. Director of Nurses and Administrator educated by the Regional Nurse Consultant on the facility policy for signing out on pass completed on 4/9/24. 2. All Staff education on out on pass process started by the DON on 4/9/24 and completed on 4/10/24, no staff will resume assignment without being in serviced. 3. All new hires will be educated on this process by DON/Designee prior to starting work. This will be ongoing. 4. Resident #1 will be provided a safe designated smoking area located on property available to resident at all times. In-Service conducted. 1. Director of Nurses and Administrator educated by the Regional Nurse Consultant on the facility policy for signing out on pass completed on 4/9/24. 2. All Staff education on out on pass process started by the DON on 4/9/24 and completed on 4/10/24, no staff will resume assignment without being in serviced. 3. All new hires will be educated on this process by DON/Designee prior to starting work. This will be ongoing. Implementation of Changes Director of Nurses and Administrator were educated on the facility policy for signing out on pass completed on 4/9/24. All Staff education on out on pass process started by the DON on 4/9/24 and completed on 4/10/2024, no staff will resume assignment without being in serviced. Smoke assessment completed on all smokers in the facility, as well as education on smoke schedule and designated area. Residents who smoke that are determined to be safe to smoke will be assessed for any additional accommodations that may be needed to ensure resident safety. All residents with BIMS of 11 (mildly impaired cognition) and below will not be allowed to sign out on pass without supervision. Facility will be respectful of resident's right to come and go from the facility by ensuring residents who are able to do so will sign in and out of the facility. Should a resident require a ride to a destination, facility will make attempt to accommodate said request. Residents who are deemed safe to go out on pass will be educated of potential safety concerns and IDT note will be placed in resident's chart. After an audit by the facility administrator no other residents are found to be signing out on pass to smoke off property or go elsewhere without facility assistance or support. All new hires will be educated on this process by DON/Designee prior to starting work. This will be ongoing. All re-education and assessments were initiated by the Regional Nurse Consultant for the DON/ Administrator. The changes were implemented effective on 4/9/24 and re-education is ongoing. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on out on pass policy prior to resuming work by Administrator/DON/Designee. Facility Smoking Policy/Smoking assessments were reviewed with no changes required. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 4/9/24 and conducted an Ad HOC QAPI regarding ensuring patient safety by properly signing out on pass prior to exiting facility. The Medical Director was notified about the immediate Jeopardy on 4/9/24, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 4/9/24. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of Process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 4/9/24. On 4/10/2024 the surveyor confirmed the facility had implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interview with the Administrator on 4/10/2024 at 5:00 p.m., indicated safer smoking arrangement for Resident #1 was implemented while completing the appeals process regarding the 30-day notice and sign out on pass process. Interview with the DON on 4/10/2024 at 5:16 p.m. indicated safer smoking arrangements for Resident #1 while completing the appeals process regarding the 30-day notice and the sign out on pass process. Record review of the off Cycle (Ad hoc) QA Meeting Document, dated 4/09/2024 indicated an action plan was initiated and discussed for a safer smoking option for Resident #1, and the signing out process Record review of the Administrator and DON's training provided by the Regional Nurse Consultant dated 4/09/2024 regarding the facility's Out on Pass policy. The Out on Pass Policy dated 08/2020 indicated when a resident wished to go out on pass the interdisciplinary team would assess the resident's ability to participate in activities outside the facility, while taking into consideration the resident's decision-making capacity, physical disabilities, and ability to take medications without supervision lll. If the resident's use of the out on pass order conflicts with the resident's plan of care or jeopardizes the resident's safety, the Nursing Staff will notify the Attending Physician and Psychiatrist of the need to review the resident's status prior to the staff allowing the resident to leave the facility on a pass. IV. The order for a pass out of the facility may be discontinued by the Attending Physician or Psychiatrist at any time. Record review of the Out on Pass Book Monitoring Tool indicated the book was reviewed on 4/10/2024 with no concerns noted. Record review of the resident list of BIMS of 12 and higher tool dated 4/09/2024 indicated Resident #1 was on the list. Record review of the resident list of who sign out on pass to go smoke dated 4/09/2024 indicated Resident #1 was the only Resident who could sign himself out to smoke. Record review of In-Service Training Report dated 4/09/2024 revealed all staff were provided education on residents going out on pass and the sign in and out book. Record review of In-Service Training Report dated 4/10/2024 revealed all staff were provided education regarding the smoking policy and smoking times. Record review of the undated Out on Pass Monitoring Tool indicated a listing with the date, resident name, BIMs, smoking evaluation, accompanied/self, sign in/and out, and auditor's signature. Record review of the BIMS scores was considered cognitively intact of the residents who smoked and who could sign themselves out was 8 including Resident #1. Record review of the Smoking Assessments of the 10 residents who smoked indicated 8 required minimal supervision and two required direct supervision while smoking. During an observation on 4/10/2024 at 5:00 p.m., indicated Resident #1's smoking area was to the right of the front door of the facility. The area had a small table, proper ash trays, and proper trash can, and a fire extinguisher was available. During an interview on 4/10/2024 from 3:20 p.m. - 5:30 p.m., the Administrator, DON, MDS, AD, Maintenance Supervisor, Laundry Supervisor, SW, Staffing Coordinator, Medical Records, Transportation, Director of Nutrition, Housekeeping/Laundry Supervisor, Receptionist, RN A, CNAs B, F, K, O, LVN D, E, H, L and Q, Dietary aide P, Housekeeping M, and Laundry N could all explain the signing in/out process, including which residents could sign themselves out and the criteria to sign oneself out of the facility. The staff could explain the smoking processes and explained Resident #1 was the only individual who smoked outside of the main designated area. On 4/10/2024 at 5:25 p.m., the Administrator was informed the IJ was removed however, the facility remained out of compliance at a potential for harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 18 residents (Resident #64) reviewed for pain management. The facility did not provide Resident #68 with her available and ordered pain medication during an episode of acute pain on 12/6/21. As a result, Resident #68 suffered severe pain for at least an approximate hour. This failure could place residents at risk for unnecessary pain, discomfort and decreased quality of life. Findings included: Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #64 understood others and made herself understood. The MDS indicated Resident #64 did not have cognitive impairment (BIMS of 15). The MDS indicated she had mild depression (PHQ-9 of 6). The MDS indicated Resident #64 had no behavior of rejecting care. The MDS indicated she required supervision only to for ADLS including bed mobility, transfers, walking with her walker, dressing, eating, toilet use and personal hygiene. The MDS indicated Resident #1 was independent with bathing. The MDS indicated she was never incontinent of bowel or bladder. The MDS indicated Resident #64 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated she had not received PRN (as needed) pain medication or non-medication intervention for pain relief during the 5-day look back period. The MDS indicated during the 5-day look back period Resident #64 had not had pain at any time. The MDS indicated she had received an opioid (a medication primarily used for pain relief) daily during the 7-day look back period. Record review of the active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the care plan reviewed on 11/17/21 indicated Resident #64 had history of seeking pain medication. The care plan interventions included administer medications as ordered and monitor/document for effectiveness; anticipate the resident's needs; and assist the resident to develop more appropriate methods of coping . During an interview and observation on 12/5/21 at 10:55 a.m., Resident #64 was walking down the hall with her walker. Resident #64 said she was having trouble getting her pain medication when she needed it. Resident #64 said she was not hurting today. During an observation and interview on 12/6/21 at 10:30 a.m., Resident #64 was laying in her bed grimacing and rubbing her left hip. She moaned then said her hip and back were hurting. Resident #64 rated the pain at a 10 on 0-10 pain scale (0 being no pain at all 10 being severe pain). She said she had already asked for pain medication and was told by CMA X she could not have anything for pain until 12:00 p.m. During an interview at 12/6/21 at 10:46 a.m., LVN B said she believed Resident #64 was on a scheduled pain regimen. LVN B said Resident #64 had been administered scheduled pain medication at 6:00 a.m. and would receive the medication again at 12:00 p.m. LVN B said scheduled pain medications were administered by the CMAs. She said follow up pain assessments were not triggered in the EMR for scheduled pain medications. but if a resident reported pain when a scheduled pain medications,. but if a resident reported pain when a scheduled pain medication was given, then a follow up assessment should be completed . She clarified; the CMA should let the nurse know if a resident continued to have pain after a scheduled pain medication was administered and the nurse would assess the resident's pain at that time. LVN B said if a resident had a PRN (as needed) pain medication available it would be administered by the nurse. LVN B said CMA X had not reported Resident #64 had continued pain after the administration of scheduled pain medication. LVN B indicated if the resident continued to have pain after the administration of the prn pain medication, the nurse would notify the physician. During an observation on 12/6/21 at 11:10 a.m., Resident #64's call light was on. An unidentified housekeeper walked into the room. During an interview on 12/6/21 at 11:11 a.m., The unidentified housekeeper said Resident #64 told her she needed a pain pill and a muscle relaxer. The housekeeper said she would tell the nurse. During an observation on 12/6/21 at 11:12 a.m., CMA X entered Resident #64's room and told Resident #64 you have 30 more minutes. During an interview on 12/6/21 at 11:13 a.m., CMA X said Resident #64 told him she had [MEDICATION(S)] that could be administered. CMA X said he did not think Resident #64 had [MEDICATION(S)] and believed she just [MEDICATION(S)]. CMA X said he was going to check and see if Resident #64 had any new pain medications . During an observation on 12/6/21 at 11:15 a.m., the ADON knocked on Resident #64's door but did not enter the room. The ADON then went to the end of the hall and talked to CMA X. During an observation and interview on 12/6/21 at 11:19 a.m,, Resident #64 was laying in her bed on her right side. She moved back and forth in a rocking motion while on her right side. She was tearful and said the pain was getting worse. Resident #64 said CMA X told her he would have to check if she had any new pain medications available. Resident #64 said she told CMA X she had [MEDICATION(S)]. She said CMA X told her she could have [MEDICATION(S)] and a muscle relaxer in 30 minutes. During an observation on 12/6/21 at 11:20 a.m., the ADON entered Resident #64's room. The ADON did not have any medication with him. During an observation on 12/6/21 at 11:22 a.m., the ADON exited the room and went to the medication cart CMA X had just placed outside of Resident #64's room. During an interview on 12/6/21 at 12:04 p.m., Resident #64 said the pain had gotten better and she just wanted to sleep. Record review of Resident #64's MAR for 12/5/21-12/6/21 indicated she had not been administered her [MEDICATION(S)] since 8:30 p.m. on 12/5/21. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #64's pain assessments on 12/6/21 indicated the following pain levels (on pain scale of 0-10) on the following times; *at 12:00 a.m.-0; *at 6:00 a.m.-0; *at 7:57 a.m.-5; *at 12:00 p.m.-NA; *at 2:26 p.m.-0; *at 6:00 p.m.-0; *at 7:05 p.m.-0; and *at 7:07 p.m.-0. During an interview on 12/8/21 at 10:13 a.m., RN G said she was the nurse for Resident #64 on 12/6/21 on the 6am to 2pm shift. RN G said Resident #64 was being managed by a pain management clinic and was to have back surgery. She said Resident#64 did have [MEDICATION(S)] ordered by her pain management physician in addition to her scheduled [MEDICATION(S)] since 12/3/21. RN G said when she received the order for the [MEDICATION(S)], she contacted Resident #64's primary physician and reviewed her medications with him. RN G said at that time Resident #64's primary physician agreed with the [MEDICATION(S)] administration and she put the order in the EMR system. RN G said the [MEDICATION(S)] would not display on the CMAs medication list for Resident #64 because it was a PRN (as needed) medication and would only display on the nurse's medication list because the nurse would have to administer the medication. RN G said the process was if a Resident had scheduled pain medication, it could be administered by a CMA. But if a resident continued to have pain the CMA was to notify the nurse and the nurse would check the nursing MAR/physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN G said she was not notified Resident #64 had unrelieved pain on 12/6/21. RN G said had she been notified she would have administered her the [MEDICATION(S)]. During an interview on 12/8/21 at 3:52 p.m., NAIT U said Resident #64 complained of pain at least 3 times before 10:00 a.m. on 12/6/21. NAIT U said she notified RN G of Resident #64's pain every time Resident #64 complained of pain before 10:00 a.m. During an interview on 12/8/21 at 4:43 p.m., CMA W said if a scheduled pain medication is administered and a Resident reports they are having pain; the CMA should follow up between 30 minutes to an hour after the pain medication administration to ensure the pain has been relieved. CMA W said if the resident reported they still had pain; the CMA should notify the nurse. During an interview on 12/8/21 at 5:02 p.m., the ADON said Resident #64 did not report pain to him on 12/6/21. During an interview on 12/8/21 at 5:05 p.m., the DON said she expected nurses to administer pain medication as ordered and expected CMAs to report unrelieved pain to nurses. The DON said if a Resident reports pain with scheduled pain medication the nurse should follow up and assess if the resident was still having unrelieved pain approximately an hour after the administration of the medication. The DON said the system in place to ensure resident pain was managed was to review resident charts for the follow up pain assessment. During an interview on 12/8/21 at 5:20 p.m., the Administrator said he expected staff to administer pain medication as ordered and expected CMAs to report unrelieved pain to nurses. He said the system in place to ensure pain management needs were met was the daily clinical morning meeting where new clinical issues were discussed. The Administrator said this system was dependent on staff communicating resident issues, which would include unrelieved pain. During an interview on 12/7/21 11:00 a.m., the DON was asked to provide a facility policy and procedure for pain management. This facility policy and procedure was not provided at the time of exit.

Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 10 residents reviewed for accidents. (Resident #1) The facility did not supervise Resident #1, who had a history of [REDACTED]. Resident #1 fell and broke her hip which required hospitalization and surgical intervention. This failure could place residents who require supervision at risk for accidents and injury. Findings included: A face sheet dated 02/11/20 indicated Resident #1 was [AGE] years old, admitted 10/02/18 and had [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had severely impaired cognition and required extensive assistance of 1 staff for transfers and locomotion on the unit and used a walker as a mobility device. The MDS indicated she had 1 fall without injury and 1 fall with injury since the previous assessment. A care plan dated 01/17/19 indicated Resident #1 was at risk for falls related to poor cognition and poor balance with interventions including staff to monitor safety and monitor resident for attempts to ambulate without assistance and intervene as needed. A care plan dated 01/19/19 indicated Resident #1 was at risk for falls. The care plan included the additional information that Resident #1 fell on [DATE] which resulted in skin tears to her left wrist and elbows requiring sutures and had a fall with no injuries on 01/30/20. A hospital history and physical dated 01/31/20 indicated Resident #1 sustained a fall with hip pain, was found to have a [MEDICAL CONDITION] and was admitted to the local hospital for further care. The hospital radiology report dated 01/31/20 indicated Resident #1 sustained an acute comminuted (break or splinter of the bone into more than 2 fragments) proximal femur (top of the femur closest to the hip) fracture with increased varus angulation (turned inward toward the body). A hospital progress note dated 02/04/20 indicated Resident #1 had a left hip repair surgery, was treated with postoperative blood loss [MEDICAL CONDITION] and received two units of transfused blood. A typed description of incident summary dated 1/31/20 completed by the administrator indicated at 1:47 a.m., LVN C heard yelling on the unit and found Resident #1 lying on her right side in the dining room floor next to her wheel chair. The summary indicated the resident was holding her left hip and complained of pain to her right hip. LVN C noted slight shortening to Resident #1's left lower leg. The summary indicated at time of incident both CNAs noted to be off the unit as well as the nurse, leaving unit unattended. One on one coaching and write ups completed by administrator and ADON at 3:45 a.m. A provider investigation report dated 01/31/20 at 8:09 p.m. indicated Resident #1 was independently ambulating in the dining room when (LVN C) heard Resident #1 request help and found the resident on the floor in the secure unit dining room and complained of pain to her left hip at 3:24 a.m. A handwritten statement dated 01/31/20 by LVN G indicated she heard someone yelling out for help and she and CNA H went to the unit and found Resident #1 lying on the floor by the table closest to the dining room door. The statement indicated Resident #1 was on her right side, her wheel chair was locked by the table and was approximately 5 feet away from the resident. The statement indicated Resident #1 complained of left hip pain and had a small abrasion on her left hip. The statement indicated the charge nurse (LVN C) was notified and there were no aides or staff on the hall at the time of the fall. A handwritten statement dated 01/31/20 by CNA H indicated she was at the nursing station when she heard yelling coming from hall 2 (the secure unit). The statement indicated CNA H immediately ran to the unit and Resident #1 was on the floor in the fetal position on her right side and the resident said the left side of her hip hurt. The statement indicated LVN G and CNA H were there to assist Resident #1. The statement indicated There was no aide on the hall at all. A corrective action memo dated 01/31/20 signed by LVN C indicated LVN C received a written warning because she was in the middle of verbal hostility, used profanity while dealing with concerns on the unit, and was witnessed throwing a resident's wound vac (a device used for wound healing) across the room without properly removing it off the resident. LVN C wrote she was trying to stop (CNA A and CNA B) from being hostile, I did not take off wound vac, I did not use profanity. On 02/11/20 at 1:34 p.m., a voicemail message was left at the facility provided number for LVN C providing surveyor contact information and requesting a return call. LVN C did not return the call. A corrective action memo dated 01/31/20 signed by CNA A and the administrator indicated CNA A received a written warning, suspension and termination because she was in the middle of verbal hostility, used profanity while dealing with concerns on the unit and did not notify the charge nurse of leaving the unit unattended resulting in the injury of a resident. During an interview on 02/11/20 at 1:36 p.m., CNA A said Resident #1 was sitting up in her wheel chair in the dining room the morning she fell because she refused to go to bed. She said she did not think Resident #1 would get up from her wheelchair, but the resident fell out of her wheel chair when she left the secure unit on her break. CNA A said she knew 2 staff were required on the secure unit but thought she could take her break as long as the other staff was present. CNA A said she did not know CNA B took her break at the same time she took hers. She said she did not notify LVN C, the charge nurse, she was taking her break. She said she should have notified the charge nurse she was taking a break and felt terrible Resident #1 got hurt. A corrective action memo dated 01/31/20 signed by CNA B indicated CNA B received a written warning, suspension and termination because she was in the middle of verbal hostility, used profanity while dealing with concerns on the unit, and did not notify the charge nurse of leaving the unit unattended resulting in the injury of a resident. During an interview on 02/11/20 at 2:03 p.m., CNA B said she told CNA A she was going on break when she left out of the secure unit the morning Resident #1 fell . She said she did not notify LVN C, who was the charge nurse. CNA B said she knew there was supposed to be 2 staff on the secure unit at all times but thought it was all right since she left CNA A there. She said she should have notified the charge nurse she was going on break. CNA B said Resident #1 had a history of [REDACTED]. During an interview on 02/11/20 at 11:44 a.m., RN F said Resident #1 had a fall with skin tears that required sutures in early (MONTH) 2020 and was known to be a high fall risk. She said the resident required supervision because she was cognitively impaired and would try to get up without assistance and would fall. During an interview on 02/11/20 at 11:18 a.m., LVN D said the secure unit staffing protocol was 2 staff supervised residents at all times. LVN D said Resident #1 was a high fall risk and should have been supervised to prevent her fall. During an interview on 02/11/20 at 11:39 a.m., CNA [NAME] said the DON told her during her orientation 2 staff were required to be on the secure unit at all times and she had to notify her charge nurse for break so that she would be relieved by a replacement staff. CNA [NAME] said she did not think this always happened and it resulted in Resident #1's injury. During an interview on 02/11/20 at 10:28 a.m., the DON said Resident #1 was at high risk for falls and had a history of [REDACTED]. The DON said CNA A and CNA B were assigned to work on the unit the night Resident #1 fell . He said the unit had a mandatory staffing policy of 2 staff on the unit at all times. He said CNA A and CNB B violated the policy when they took their break at the same time. He said CNA A and CNA B were fired for abandonment of duties and the charge nurse, LVN C, was written up for improper oversight of CNA A and CNA B. During an interview on 02/11/20 at 10:34 a.m., the administrator said there was supposed to be 2 staff on the secure unit at all times. She said if 1 staff left on break, another staff or the charge nurse was to relieve them and be physically present on the secure unit. The administrator said she did not know if it was an actual policy, but it was the procedure the facility followed since she started work in (MONTH) 2019.

Based on interview and record review, the facility failed to develop and implement written policy to report to the state agency within 2 hours of an event causing serious bodily harm for 1 of 1 resident reviewed for neglect. (Resident #1) The facility did not report to the state agency within 2 hours when CNA A and CNA B went on break at the same time, leaving Resident #1 unsupervised. Resident #1 fell and broke her hip which required hospitalization and surgical intervention. This failure could place residents at risk for abuse, neglect and exploitation. Findings included: An Abuse-Reportable Events policy dated 05/2017 indicated it is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person.7. Reporting a. All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies required by regulation. A face sheet dated 02/11/20 indicated Resident #1 was [AGE] years old, admitted 10/02/18 and had [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had severely impaired cognition and required extensive assistance of 1 staff for transfers and locomotion on the unit and used a walker as a mobility device. The MDS indicated she had 1 fall without injury and 1 fall with injury since the previous assessment. A care plan dated 01/17/19 indicated Resident #1 was at risk for falls related to poor cognition and poor balance with interventions including staff to monitor safety and monitor resident for attempts to ambulate without assistance and intervene as needed. A care plan dated 01/19/19 indicated Resident #1 was at risk for falls. The care plan included the additional information that Resident #1 fell on [DATE] which resulted in skin tears to her left wrist and elbows requiring sutures and had a fall with no injuries on 01/30/20. A hospital history and physical dated 01/31/20 indicated Resident #1 sustained a fall with hip pain, was found to have a [MEDICAL CONDITION] and was admitted to the local hospital for further care. The hospital radiology report dated 01/31/20 indicated Resident #1 sustained an acute comminuted (break or splinter of the bone into more than 2 fragments) proximal femur (top of the femur closest to the hip) fracture with increased varus angulation (turned inward toward the body). A hospital progress note dated 02/04/20 indicated Resident #1 had a left hip repair surgery, was treated with postoperative blood loss [MEDICAL CONDITION] and received two units of transfused blood. A typed description of incident summary dated 1/31/20 completed by the administrator indicated at 1:47 a.m., LVN C heard yelling on the unit and found Resident #1 lying on her right side in the dining room floor next to her wheel chair. The summary indicated the resident was holding her left hip and complained of pain to her right hip. LVN C noted slight shortening to Resident #1's left lower leg. The summary indicated at time of incident both CNAs noted to be off the unit as well as the nurse, leaving unit unattended. One on one coaching and write ups completed by administrator and ADON at 3:45 a.m. A provider investigation report dated 01/31/20 at 8:09 p.m. indicated Resident #1 was independently ambulating in the dining room when (LVN C) heard Resident #1 request help and found the resident on the floor in the secure unit dining room and complained of pain to her left hip at 3:24 a.m. A handwritten statement dated 01/31/20 by LVN G indicated she heard someone yelling out for help and she and CNA H went to the unit and found Resident #1 lying on the floor by the table closest to the dining room door. The statement indicated Resident #1 was on her right side, her wheel chair was locked by the table and was approximately 5 feet away from the resident. The statement indicated Resident #1 complained of left hip pain and had a small abrasion on her left hip. The statement indicated the charge nurse (LVN C) was notified and there were no aides or staff on the hall at the time of the fall. A handwritten statement dated 01/31/20 by CNA H indicated she was at the nursing station when she heard yelling coming from hall 2 (the secure unit). The statement indicated CNA H immediately ran to the unit and Resident #1 was on the floor in the fetal position on her right side and the resident said the left side of her hip hurt. The statement indicated LVN G and CNA H were there to assist Resident #1. The statement indicated There was no aide on the hall at all. A corrective action memo dated 01/31/20 signed by CNA A and the administrator indicated CNA A received a written warning, suspension and termination because she was in the middle of verbal hostility, used profanity while dealing with concerns on the unit and did not notify the charge nurse of leaving the unit unattended resulting in the injury of a resident. During an interview on 02/11/20 at 1:36 p.m., CNA A said Resident #1 was sitting up in her wheel chair in the dining room the morning she fell because she refused to go to bed. She said she did not think Resident #1 would get up from her wheelchair, but the resident fell out of her wheel chair when she left the secure unit on her break. CNA A said she knew 2 staff were required on the secure unit but thought she could take her break as long as the other staff was present. CNA A said she did not know CNA B took her break at the same time she took hers. She said she did not notify LVN C, the charge nurse, she was taking her break. She said she should have notified the charge nurse she was taking a break and felt terrible Resident #1 got hurt. A corrective action memo dated 01/31/20 signed by CNA B indicated CNA B received a written warning, suspension and termination because she was in the middle of verbal hostility, used profanity while dealing with concerns on the unit, and did not notify the charge nurse of leaving the unit unattended resulting in the injury of a resident. During an interview on 02/11/20 at 2:03 p.m., CNA B said she told CNA A she was going on break when she left out of the secure unit the morning Resident #1 fell . She said she did not notify LVN C, who was the charge nurse. CNA B said she knew there was supposed to be 2 staff on the secure unit at all times but thought it was all right since she left CNA A there. She said she should have notified the charge nurse she was going on break. CNA B said Resident #1 had a history of [REDACTED]. During an interview on 02/11/20 at 10:28 a.m., the DON said Resident #1 was at high risk for falls and had a history of [REDACTED]. The DON said CNA A and CNA B were assigned to work on the unit the night Resident #1 fell . He said the unit had a mandatory staffing policy of 2 staff on the unit at all times. He said CNA A and CNB B violated the policy when they took their break at the same time. He said CNA A and CNA B were fired for abandonment of duties and the charge nurse, LVN C, was written up for improper oversight of CNA A and CNA B. During an interview on 02/11/20 at 10:34 a.m., the administrator said there was supposed to be 2 staff on the secure unit at all times. She said if 1 staff left on break, another staff or the charge nurse was to relieve them and be physically present on the secure unit. The administrator said she did not know if it was an actual policy, but it was the procedure the facility followed since she started work in (MONTH) 2019. During an interview on 02/11/20 at 2:45 p.m., the administrator said she thought she had 24 hours to report the incident to the state despite the actual harm.

Based on interview and record review, the facility failed to ensure supervision and monitoring was provided to prevent physical harm for 1 of 10 residents reviewed for neglect. (Resident #1) The facility did not supervise Resident #1, who had a history of [REDACTED]. Resident #1 fell and broke her hip which required hospitalization and surgical intervention. This failure could place residents who require supervision at risk for accidents and injury. Findings included: A face sheet dated 02/11/20 indicated Resident #1 was [AGE] years old, admitted 10/02/18 and had [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had severely impaired cognition and required extensive assistance of 1 staff for transfers and locomotion on the unit and used a walker as a mobility device. The MDS indicated she had 1 fall without injury and 1 fall with injury since the previous assessment. A care plan dated 01/17/19 indicated Resident #1 was at risk for falls related to poor cognition and poor balance with interventions including staff to monitor safety and monitor resident for attempts to ambulate without assistance and intervene as needed. A care plan dated 01/19/19 indicated Resident #1 was at risk for falls. The care plan included the additional information that Resident #1 fell on [DATE] which resulted in skin tears to her left wrist and elbows requiring sutures and had a fall with no injuries on 01/30/20. A hospital history and physical dated 01/31/20 indicated Resident #1 sustained a fall with hip pain, was found to have a [MEDICAL CONDITION] and was admitted to the local hospital for further care. The hospital radiology report dated 01/31/20 indicated Resident #1 sustained an acute comminuted (break or splinter of the bone into more than 2 fragments) proximal femur (top of the femur closest to the hip) fracture with increased varus angulation (turned inward toward the body). A hospital progress note dated 02/04/20 indicated Resident #1 had a left hip repair surgery, was treated with postoperative blood loss [MEDICAL CONDITION] and received two units of transfused blood. A typed description of incident summary dated 1/31/20 completed by the administrator indicated at 1:47 a.m., LVN C heard yelling on the unit and found Resident #1 lying on her right side in the dining room floor next to her wheel chair. The summary indicated the resident was holding her left hip and complained of pain to her right hip. LVN C noted slight shortening to Resident #1's left lower leg. The summary indicated at time of incident both CNAs noted to be off the unit as well as the nurse, leaving unit unattended. One on one coaching and write ups completed by administrator and ADON at 3:45 a.m. A provider investigation report dated 01/31/20 at 8:09 p.m. indicated Resident #1 was independently ambulating in the dining room when (LVN C) heard Resident #1 request help and found the resident on the floor in the secure unit dining room and complained of pain to her left hip at 3:24 a.m. A handwritten statement dated 01/31/20 by LVN G indicated she heard someone yelling out for help and she and CNA H went to the unit and found Resident #1 lying on the floor by the table closest to the dining room door. The statement indicated Resident #1 was on her right side, her wheel chair was locked by the table and was approximately 5 feet away from the resident. The statement indicated Resident #1 complained of left hip pain and had a small abrasion on her left hip. The statement indicated the charge nurse (LVN C) was notified and there were no aides or staff on the hall at the time of the fall. A handwritten statement dated 01/31/20 by CNA H indicated she was at the nursing station when she heard yelling coming from hall 2 (the secure unit). The statement indicated CNA H immediately ran to the unit and Resident #1 was on the floor in the fetal position on her right side and the resident said the left side of her hip hurt. The statement indicated LVN G and CNA H were there to assist Resident #1. The statement indicated There was no aide on the hall at all. A corrective action memo dated 01/31/20 signed by LVN C indicated LVN C received a written warning because she was in the middle of verbal hostility, used profanity while dealing with concerns on the unit, and was witnessed throwing a resident's wound vac (a device used for wound healing) across the room without properly removing it off the resident. LVN C wrote she was trying to stop (CNA A and CNA B) from being hostile, I did not take off wound vac, I did not use profanity. On 02/11/20 at 1:34 p.m., a voicemail message was left at the facility provided number for LVN C providing surveyor contact information and requesting a return call. LVN C did not return the call. A corrective action memo dated 01/31/20 signed by CNA A and the administrator indicated CNA A received a written warning, suspension and termination because she was in the middle of verbal hostility, used profanity while dealing with concerns on the unit and did not notify the charge nurse of leaving the unit unattended resulting in the injury of a resident. During an interview on 02/11/20 at 1:36 p.m., CNA A said Resident #1 was sitting up in her wheel chair in the dining room the morning she fell because she refused to go to bed. She said she did not think Resident #1 would get up from her wheelchair, but the resident fell out of her wheel chair when she left the secure unit on her break. CNA A said she knew 2 staff were required on the secure unit but thought she could take her break as long as the other staff was present. CNA A said she did not know CNA B took her break at the same time she took hers. She said she did not notify LVN C, the charge nurse, she was taking her break. She said she should have notified the charge nurse she was taking a break and felt terrible Resident #1 got hurt. A corrective action memo dated 01/31/20 signed by CNA B indicated CNA B received a written warning, suspension and termination because she was in the middle of verbal hostility, used profanity while dealing with concerns on the unit, and did not notify the charge nurse of leaving the unit unattended resulting in the injury of a resident. During an interview on 02/11/20 at 2:03 p.m., CNA B said she told CNA A she was going on break when she left out of the secure unit the morning Resident #1 fell . She said she did not notify LVN C, who was the charge nurse. CNA B said she knew there was supposed to be 2 staff on the secure unit at all times but thought it was all right since she left CNA A there. She said she should have notified the charge nurse she was going on break. CNA B said Resident #1 had a history of [REDACTED]. During an interview on 02/11/20 at 11:44 a.m., RN F said Resident #1 had a fall with skin tears that required sutures in early (MONTH) 2020 and was known to be a high fall risk. She said the resident required supervision because she was cognitively impaired and would try to get up without assistance and would fall. During an interview on 02/11/20 at 11:18 a.m., LVN D said the secure unit staffing protocol was 2 staff supervised residents at all times. LVN D said Resident #1 was a high fall risk and should have been supervised to prevent her fall. During an interview on 02/11/20 at 11:39 a.m., CNA [NAME] said the DON told her during her orientation 2 staff were required to be on the secure unit at all times and she had to notify her charge nurse for break so that she would be relieved by a replacement staff. CNA [NAME] said she did not think this always happened and it resulted in Resident #1's injury. During an interview on 02/11/20 at 10:28 a.m., the DON said Resident #1 was at high risk for falls and had a history of [REDACTED]. The DON said CNA A and CNA B were assigned to work on the unit the night Resident #1 fell . He said the unit had a mandatory staffing policy of 2 staff on the unit at all times. He said CNA A and CNB B violated the policy when they took their break at the same time. He said CNA A and CNA B were fired for abandonment of duties and the charge nurse, LVN C, was written up for improper oversight of CNA A and CNA B. During an interview on 02/11/20 at 10:34 a.m., the administrator said there was supposed to be 2 staff on the secure unit at all times. She said if 1 staff left on break, another staff or the charge nurse was to relieve them and be physically present on the secure unit. The administrator said she did not know if it was an actual policy, but it was the procedure the facility followed since she started work in (MONTH) 2019.

Based on observation, interview and record review, the facility failed to ensure that one (Resident #29) of twelve residents reviewed for pain management received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure Resident #29 received the necessary treatment and care when he began displaying signs of severe pain after an x-ray on 09/01/18 reflected no fracture. Staff noted an increase in Resident #29's pain and discomfort, including not being able to tolerate assistance with ADLs, for several days following his fall, but no steps were taken to address his pain. On 09/07/18 Resident #29's hip was found to be red, swollen, and warm to the touch, but staff did not obtain an order for [REDACTED].#29 had a fracture of his left femur were available at 4:29 AM on 09/09/18, but Resident #29 was not sent to the hospital until over 20 hours later at approximately 1:45 AM on 09/09/18. Resident #29 required surgery to repair the fracture to his femur. These failures placed residents at risk of extended periods of unaddressed pain and discomfort, decreased quality of care, and lack of prompt medical attention. Findings included: Review of Resident #29's Minimum Data Set (MDS) Significant Change in Status Assessment, dated 09/24/18, reflected Resident #29 was an [AGE] year-old male who was re-admitted to the facility on [DATE]. The MDS assessment indicated Resident #29 had severe cognitive impairment and required extensive assistance from one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS assessment indicated Resident #29 used a wheelchair and was always incontinent of bladder and bowel. The MDS assessment revealed Resident #29's active [DIAGNOSES REDACTED]. The MDS assessment indicated Resident #29 did not have a recent history of falls and he had no pain present. Review of Resident #29's Care Plan, dated 01/11/19, reflected he required pain management due to chronic pain. His interventions were to administer medications as ordered, anticipate the need for pain relief and respond immediately to any complaint of pain. His care plan also addressed his high risk for falls due to balance problems and [DIAGNOSES REDACTED]. The fall care area reflected he had a fall with major injury on 09/01/18. Record review of Resident #29's nurses' notes revealed the following entries on the identified dates and times: 09/01/18 at 10:00 AM: called to room by CNA. Res (resident) noted to be lying on floor on abd. (abdomen) res voice low. res stated he was ok (okay). assisted res onto back and examined for injuries. Able to move all extremities. Staff times 2 assisted res to bed. res appeared as if he'd had [MEDICAL CONDITION]. [MEDICATION NAME] 1 mg given IM (intramuscular) rt (right) ventrogluteal. Neuro checks started. Temp (temperature) 98, pulse 74, resp (respiration) 20, b/p (blood pressure) 135/75. (Signed by RN I) 09/01/18 at 6:00 PM: res c/o (complained of) lt (left) hip, ankle, knee, and foot pain. (physician) called and new order noted for lt hip, knee, ankle, and foot x-ray. (x-ray company) called and x-rays ordered. (Signed by RN I) 09/01/18 at 11:00 PM: x-ray here to do x-rays of res. (Signed by RN I) 09/03/18 at 7:37 PM: Resident up in chair for first part of shift. After supper got CNA because resident said he did not feel well. No signs of distress, skin warm and dry to touch . (Signed by LVN J ) No additional nurses' notes related to increased pain or injuries for Resident #29 were noted from 09/04/18 until 09/09/18. 09/09/18 at 2:35 AM: Res x-ray result came out to be positive for [MEDICAL CONDITION] at the neck of the femur, called (physician) and he told this nurse to send Res out to the hospital, Res wife was contacted and Res was taken to the hospital by EMS (Emergency Medical Services) crew @ (at) 0145. (1:45 AM) Signed by LVN M 09/13/18 at 6:18 PM: Resident returned from hospital via facility van with staff .27 staples to Left Hip Review of Resident #29's radiology report dated 09/01/18 reflected: The left hip joint is intact. No fracture or dislocation is seen Review of Resident #29's radiology report dated 09/08/18, reflected the x-ray was conducted on 09/07/18 and was read by the radiologist on 09/08/18 at 4:29 AM. The radiology report revealed: There is a fracture involving neck of femur with increased lateral displacement. The remainder of the femur is intact. Conclusion: Recent proximal left femur fracture as described. Lateral displacement of fracture increased from 09/01/18 . There was no time stamp of when the facility received these results. Review of Resident #29's eMAR, for the period of 09/1/18 through 09/30/18, revealed MA N documented Resident #29 reported his pain was a 10 on a scale of 0 to 10 during the 6:00 PM medication pass of his routine pain medication from 09/04/18 through 09/07/18. Prior to this time frame, Resident #29's pain level from 09/01/18 to 09/04/18, was documented as 0/10, 2/10, 4/10, 5/10 and one occasion of 8/10 on 09/02/18. The eMAR did not have a legend for the 0-10 pain scale. Review of the facility's 24-hour reports, dated 09/01/18 through 09/09/18, reflected no additional information regarding Residents #29's condition was noted. The report mostly consisted of nurses' notes. Review of Resident #29's hospital records, dated 09/09/18 through 09/13/18, reflected he arrived at the hospital on [DATE] at 2:11 AM. The records reflected Location of injuries- left hip. Chief complaint: Fall. The injury occurred one week ago at a nursing home .Resident appeared to be in pain and in apparent distress . Resident #29 underwent left hip surgery and was discharged back to the facility on [DATE]. In an interview with the DON on 02/27/19 at 12:15 PM, he said he was not employed at the facility at the time of Resident #29's incident. The DON stated after reviewing Resident #29's records he believed there was a delay in care and treatment that was due to the first set of negative x-rays . In an interview on 02/28/19 at 12:25 PM with LVN L, she acknowledged that she was Resident #29's charge nurse on 09/03/18 through 09/07/18 during the 6:00 AM-2:00 PM shift . LVN L said she recalled Resident #29 had fallen during the weekend of 09/01/18 and x-rays were obtained, which were negative for a fracture. LVN L said she recalled around 09/07/18 Resident #29 complained of pain to his hip and was noted to have facial grimacing . LVN L said she also recalled Resident #29's left leg appeared shorter than his right upon her assessment. LVN L said she reached out to Resident #29's responsible party and his physician, who was unavailable at the time , she said his physician was on an airplane or a conference. She said her shift ended before the physician returned her phone call, and she left the pending issue for the next shift to address but she was unable to recall which nurse she informed. She said by the next day, new x-rays had been obtained. In an interview on 02/28/19 at 2:30 PM the Medical Director (MD) stated he was Resident #29 primary care physician in (MONTH) (YEAR). The MD said he expected facility staff to use their professional judgment when a resident fell and was having pain. He said this should include assessing the resident, obtaining x-rays, and sending the resident to the hospital for further evaluation as needed. The MD stated once x-ray results were received, he expected to be notified of the results. He stated he had an answering service in case he was not available . In an interview on 03/01/19 at 2:05 PM the ADM revealed he had no knowledge of the incident as he was not employed by the facility when the incident occurred . In an interview on 03/07/19 at 7:19 PM Resident #29's family member stated Resident #29 was in severe pain, and she believed he was having more [MEDICAL CONDITION] the days following the fall on 09/01/18, due to the pain . She said Resident #29 was in tears when the injured areas were touched. The family member said the facility did not send him to the hospital until 09/09/18 at 1:30 AM. She said even the hospital staff asked why it took so long to send him out after a positive x-ray result. The family member stated it was her opinion that staff were just not paying attention to his pain and injury. She said Resident #29 did have routine pain medication; however, it was not effective after his fall. She said she told several staff something was wrong. The family member stated Resident #29 did not want to get out of bed, but staff kept getting him up. In an interview on 03/15/19 at 4:36 PM LVN J confirmed she was Resident #29's charge nurse on 09/03/18 through 09/07/18 during the 2:00 PM-10:00 PM shift. She said in the days following his fall on 09/01/18 CNAs reported Resident #29 exhibited signs of pain and distress, including hollering, cursing and facial grimacing, when staff attempted to transfer him. LVN J stated this was unusual for him. She said Resident #29 refused to get up from bed for meals and regular showers, both of which he usually enjoyed. LVN J said she did not report this change in condition to Resident #29's physician since she attributed the pain to him being sore after his fall on 09/01/18. She said Resident #29 received his routine pain medication as ordered, which seemed to be effective until his next dose. LVN J said she did not suspect something else was wrong until 09/07/18 when CNA O reported Resident #29's left hip/thigh was swollen, red , and warm to the touch towards the end of her shift, close to 2 PM. LVN J said she called Resident #29's physician and he ordered the second set of x-rays . LVN J was not sure if she was present when the results of the x-ray were received, but she recalled by 09/10/18, Resident #29 was in the hospital. LVN J said she was not aware of Resident #29 reporting that his pain was a 10 on a scale of 0 to 10 to the MA administering his routine pain medication. She said she was not notified of Resident #29's high pain scale by the MA. LVN J stated if she had been notified of his high pain levels, she would have assessed him prior to 09/07/18, and called his physician about his increased pain to see if new orders were needed. In an interview on 03/15/19 at 2:36 PM CNA O stated she recalled working with Resident #29 following his fall on 09/01/18. She said Resident #29 was in pain for two days after his fall on 09/01/18, and she felt something was still wrong. She said Resident #29 liked to get up for meals and socialize; however, after his fall , he refused to get out of bed. CNA O said when staff attempted to assist him, he would holler out and complain of pain. She said it was unusual for Resident #29 to complain of pain, and she reported it to LVN J . CNA O was not sure how many times or when exactly she reported these issues to LVN J. CNA O said Resident #29's appetite was not as good as usual, and he was only eating about 50 percent of his meals whereas he usually ate 100 percent. CNA O stated Resident #29 was also sleeping more than usual after his fall on 09/01/18. In an interview on 03/15/19 at 3:15 PM CNA Q stated she was one of the aides assisting Resident #29 from 09/03/18 through 09/05/18. She said after Resident #29's fall on 09/01/18 he began hollering during ADL care, and he told her not to touch his hip. CNA Q stated she had reported this behavior to LVN J as it was unusual for him but she did not recall when she reported this change of condition. In an interview on 03/15/19 at 3:21 PM MA N confirmed she administered Resident #29's medications from 09/04/18 through 09/07/18 during the 2-10 PM shift. She said he received routine pain medication, [MEDICATION NAME] (narcotic pain medication) every six hours. She said the eMAR prompted her to document his pain level during the 6:00 PM medication pass. She said the 0-10 pain scale meant zero was no pain and ten was severe pain. She said Resident #29 told her his hip was hurting him badly and he had facial grimacing, so she documented his pain as a 10 on the eMAR. MA N said she followed up with Resident #29 after she administered the medication to see if his pain subsided, and he would report feeling better or would be asleep. She said Resident #29 rarely reported severe pain prior to his fall on 09/01/18, and usually only reported moderate pain levels. MA N said she reported Resident #29's increased pain levels to LVN J , but she did not recall when exactly. She said she also noticed Resident #29 did not get up in his wheelchair a lot after his fall on 09/01/18, which was unusual for him. Review of the facility's Care and Standards Policy, undated, reflected Purpose: To ensure all residents receive necessary care and services that are evidence-based and in accordance with accepted professional clinical standards of practice. Policy: All residents shall receive necessary care and services to assist them in attaining or maintaining the highest practicable level of physical, mental, and psychosocial well-being in accordance with a comprehensive assessment and plan of care. Care is documented in the medical record according to state and/or federal regulations. Review of the facility's Pain Management Policy, dated (MONTH) (YEAR), reflected It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life .Residents with unrelieved pain will be evaluated by the nurse and the physician notified. Pain interventions will be adjusted accordingly and may include non-pharmacological measures .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #1) of two residents reviewed for adequate supervision. The facility failed to supervise Resident #1 after escorting her off the secured unit to an activity. The facility was unaware Resident #1 eloped until an individual from the community returned to resident to the facility approximately one hour and 50 minutes after activity ended. The resident had wandered approximately 1000 feet from the facility. The resident sustained [REDACTED]. An IJ was identified on 03/07/17. While the IJ was removed on 03/08/17, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope pattern due to the facility requiring more time to train all staff and monitor their plan of removal. This failure placed the 24 residents at risk for elopement which could result in serious injury, harm or death of the resident. Findings included: Resident #1's Admission Record Sheet, dated 02/23/17, revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1's Elopement Risk Assessment, dated 02/16/17 and e-signed by the Director of Nursing, preliminary data, reflected Resident #1 resided on the secured unit. This assessment did not identify Resident #1's level of elopement risk. Resident #1's admission care plan, dated 02/16/17, revealed she was independent with transferring. She had occasional disorientation/forgetfulness. Behavior problems marked were wanders and wants to leave was written in and added next to the box marked wanders. Mobility/ambulation was marked assist one, cane. Resident #1's MDS assessment dated [DATE], revealed she was severely cognitively impaired with a BIMS score of 7 (a score of 0-7 indicated severe cognitive impairment). She was not able to identify the correct year or month but was able to identify the correct day of the week. She wandered daily and was ambulatory with a cane. Review of the facility's Provider Investigation Report, dated 03/01/17, reflected that on 02/22/17 at 1:15 PM, CNA A escorted Resident #1, along with four other residents, off the secured unit (Hall 2). Resident #1 and three other residents were led to an activity (church) held in the main dining room. CNA A then went on break for 10 minutes followed by returning to the secured unit. Approximately one hour later, the activity ended and CNA A went to escort the residents back to the secured unit. CNA A escorted two female residents and another staff member (not identified) assisted one male resident, but not Resident #1. The Provider Investigation Report further noted Resident #1 was not wearing a wander guard bracelet at the time of the incident. It noted at or around 4:00 p.m., an individual from the community came and asked if Resident #1 was a resident of the facility. The individual said he and his wife met Resident #1 45 minutes ago outside their house. He said as they talked, they realized she (Resident #1) might be a resident of the nursing home. It noted the DON conducted an assessment of Resident #1 and there was no evidence of physical or emotion harm as a result of the incident. The Provider Investigation Report's Statement Summary reflected that after the incident, LVN B asked Resident #1 to retrace her steps on how she got out. LVN B took Resident #1 by the arm and Resident #1 took her on a walk that re-traced her steps. She first went to the dining room, where church was held. The resident and LVN B talked about church and what the preacher had said. LVN B asked Resident #1 to show her where she went when church was over. Resident #1 proceeded to walk from the dining room to the front door and placed her hands on the door to get out. The Interview on 03/02/17 at 2:45 PM with the Administrator revealed he had used video surveillance to verify times. He stated Resident #1 went out the front door. He stated he spoke with the gentleman who returned Resident #1 to the facility, just after 4:00 PM. He stated he looked at the clock when they sat down in his office and knew it took a few minutes for him to be located in the facility before he met him. The Administrator stated the front door was set for a long delay before it relocked after opening. Observation of main entry door 03/02/17 at 11.45 AM revealed the door had a coded entry/exit system. Resident #1 was observed on 03/02/17 at 11:55 AM and on 03/07/17 at 3:15 PM. She resided on the secured unit. She had no bruises or abrasions to her face, neck or lower arms and hands. During the observation 03/07/17, she was observed to stand and walk about the dining room without staff assistance. Observation on 03/07/17 at 5:00 PM of the distance from the facility to where Resident #1walked to which revealed approximately 1000 feet which was around the block, out of sight of the facility. An interview with CNA A was conducted on 03/02/17 at 12:15 PM. On 02/22/17, she was working on the secured unit by herself, as a CNA 6:00 AM to 2:00 PM, she stated there were usually two CNAs on the unit. She stated residents from the secured unit left the unit quite a bit for activities. She stated on 02/22/17, she took five residents off the unit. One of the five residents went to sit outside with a nurse. She took four residents, including Resident #1 to the dining room for church service. She stated she saw the preacher getting everyone together in the dining room. She did not see any staff when she left the four residents in the dining room. She stated she then went to clock out for her lunch break and took a 30 minute lunch break. When she came back inside through the back door she did not see the preacher in the dining room. She stated she got two female residents to lead them back to the secured unit, but not Resident #1. She stated another staff member led a male resident back to the secured unit. She stated she did not notice Resident #1 in the dining room. She stated she went back to work on the secured unit and worked a double shift on 2:00 PM to 10:00 PM. She was not aware Resident #1 was not on the secured unit until Resident #1 was returned to the unit later. She stated Resident #1 and the resident who had been sitting out front were brought back into the secured unit at the same time. An interview was conducted with the Activity Director on 03/02/17 at 10:40 AM. She stated on 02/22/17, she left around noon. She stated she informed staff on Halls 1, 3, and 4 so they could help residents to the dining room for the church service which started at 1:30 PM. She stated she did not remember if she informed staff on the secured unit that she was leaving early. She stated the Administrator was aware she was leaving early. An interview with the DON on 03/02/17 at 11:20 AM revealed the Activity Director left early on 02/22/17 and there was no one to supervise the activity in the dining room. An interview was conducted with the DON on 03/02/17 at 9:15 AM. She stated Resident #1 was on the secured unit because she was an elopement risk. On the day of her elopement Resident #1 was at church in the dining room. She was a recent admission and had been at the facility maybe two days. On 03/02/17 at 9:50 AM, she stated the facility practice and what usually happened was the CNAs from the secured unit took residents to the activity and the Activity Director was in the activity to supervise and monitor residents. If there was any problem with a resident, the Activity Director could go and get a CNA or any staff member who was outside the secured unit. Interview with the Administrator on 03/02/17 at 2:45 PM, revealed he initiated use of the sign out sheets on the secured unit on 02/23/17 and he audited the sign out sheets. He would sample a resident name and location from the sign out sheet and then go to locate that resident and staff member in the location named. He also conducted a reverse audit. When he observed a resident from the secured unit outside the unit he checked the sign out sheet to verify that resident had been signed out. Review of the Front Door Training/Mag Lock/Hall 2 Sign Out in-service conducted with the staff on 02/23 /17, revealed Residents on Hall 2 will need to be signed out and signed in. Hall 2 residents will have an orange wrist band so that all staff can identify high risk residents when they are off the unit for any reason. The facility's Abuse Prevention Program policy dated 06/16/16, reflected our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Investigating Allegations of Neglect Policy dated 06/10/16, reflected Policy Statement, all reported incidents of neglect are promptly and thoroughly investigated. Policy Interpretation and Implementation: 1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition. 2. Neglect also means the failure to protect the resident from abuse, neglect or exploitation. 3. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. Interview with the Administrator on 03/02/17 at 2:45 PM revealed he was the only staff member who audited the sign out sheets; therefore the audit was not conducted seven days a week. On 03/07/17 at 8:50 AM, the Adminstrator, the DON and ADON were unavailable therfore the Bookkeeper was notified an IJ had been identified and a plan of removal was requested at that time. Review of the plan of removal, accepted on 03/08/17 at 10:00 AM, reflected the following: Implementation of Changes: A list of residents with an elopement risk has been completed. Facility compiled a list of residents with an elopement risk who have the potential to be affected the most. All residents have the potential to be affected. This information was obtained from the elopement risk assessment that the nurses completed upon admission, readmission, change in condition, and quarterly in point click care (EHR). All elopement risk assessments were updated on 03/07/17 and completed by the DON and ADON. CNAs that are assigned to these residents are conducting rounds every 2 hours, and at the beginning and end of their shifts. They are conducting the rounds that were conducted. They are documenting the rounds that were conducted on a rounds sheet that is on a clipboard at the nurses' station. A local door alarm representative was contacted and verified the door was in proper working condition on 02/23/17. Adjustment to the timed delay was adjusted from 15 seconds to 5 seconds. The adjustment was made to limit the time the doors unlocked after the code is entered into the keypad. Facility dedicated an additional staff on 02/22/17 to monitor the doors until the door alarm company verified proper working condition on 02/23/17. The wander risk assessment book was updated with a current photograph and a brief physical description of the residents with exit seeking behaviors in general population and those that reside on the secure unit on 02/28/17 by the DON. Pictures of all residents are in the electronic record system and available to be printed out when needed for identification. All residents will be monitored by nursing staff for their location every two hours. Increased staffing on the secured by one staff member on the secured unit on 03/02/17. The staffing pattern for the secured unit is two staff members dedicated to the unit on 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM. This is in addition to staff members that support the unit as well (activity, administrative nursing, housekeeping, administrative staff, etc.). CNA A and LVN B were verbally counseled on 02/22/17 by the DON regarding the need to improve communication between charge nurse and aide. Also, making rounds on the residents every two hours. All staff was in-serviced regarding the lock delay system on the front door to lock after five seconds on 03/07/17 by the Administrator. All staff will be in-serviced by nursing administration and/or the Administrator on 03/07/17 (or before reporting for duty) on elopement risk to include but not limited to; use of wander risk assessment book, identifying potential wander risk residents and reporting wandering residents. This in-service will include behavior management, exit seeking, and verbal expressions of exit seeking All nursing staff will be in-serviced on 03/07/17 by nursing administration and/or Administrator (or before reporting for duty) on making rounds and documenting the location of residents every two hours. All staff were in-serviced on 03/07/17 (or before reporting for duty) by nursing administration and/or Administrator on signing all residents in and out for visitations and appointments, etc. The secured unit will have an additional sign out sheet for when those residents are removed from the unit for activities, appointments, visitations, etc. These sheets will assist in locating residents during needed times such as missing resident or emergency. All staff will be in-serviced by nursing administration and/or Administrator on 03/07/17 (or before reporting for duty) on resident supervision policy, missing resident policy, and abuse/neglect/exploitation policy. Administrator and/or nursing administration will conduct elopement drills (code orange) on each shift beginning on the 6:00 AM to 2:00 PM shift on 03/07/17. All staff members will be required to be in-serviced and/or participate in a code orange drill prior to reporting for duty. All staff will be required to be in-serviced by nursing administration and/or Administrator prior to reporting for duty beginning 03/07/17. Staff members are being called in for these mandatory in-services. Those staff members that are unable to attend will be informed that they may not report for duty until they have been in-serviced. Nursing administration and/or Administrator will meet staff prior to their shifts and/or at agreed-upon times to ensure proper in-servicing prior to being on duty. HR staff will verify all staff is in-serviced by matching in-service sign in sheets to active employee roll. Elopement drills were conducted on 03/07/17 for all staff and all shifts by the Administrator and/or nursing administration. Nursing staff was in-serviced on 03/07/17 by nursing administration and/or Administrator on conducting a head count every two hours for all residents. Nursing administration includes the DON, ADON, and MDS coordinator. Administrator, administrative nurses, and interdisciplinary team will implement the following changes: Documentation of all resident locations every two hours. Effective 03/07/17. Signing residents in and out of both the secured unit and general population. Effective 03/07/17. Monitoring the effectiveness of the change in delayed timing on front door magnetic locks. Effective 03/07/17. In-servicing all existing and on-boarding staff members on the above-mentioned in-services prior to providing resident care and during their orientation period. Policies on documenting resident locations, signing in/out of both secured unit and facility will be updated to reflect these changes Facility administrator and/or designee will monitor for compliance through daily review of sign in/out sheets, incidents and accidents and through daily rounds beginning 03/07/17. During monthly visits the medical director will review the elopement prevention plan and provide feedback beginning 03/07/17. To verify the facility implement their plan of removal the following was conducted: Interviews on 03/08/17 with LVN B, Laundry Staff C, Housekeeper D, CNA E, CNA F, LVN G, CNA H, LVN I, CNA J, LVN K, CNA L, and CNA M, representing staff from all three shifts were interviewed regarding the in-service and training they received on the facility's elopement protocol. They were each able to state they were trained in elopement risk/assessment tool, behavior management, supervision, missing resident, abuse/neglect, rounds, door locks, elopement drills and sign out/in sheets. An interview with the Administrator on 03/08/17 at 3:45 PM revealed 24 residents resided in the facility that wandered or exhibited a behavior of exiting seeking.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #1) of two residents reviewed for adequate supervision. The facility failed to supervise Resident #1 after escorting her off the secured unit to an activity. The facility was unaware Resident #1 eloped until an individual from the community returned to resident to the facility approximately one hour and 50 minutes after activity ended. The resident had wandered approximately 1000 feet from the facility. The resident sustained [REDACTED]. An IJ was identified on 03/07/17. While the IJ was removed on 03/08/17, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope pattern due to the facility requiring more time to train all staff and monitor their plan of removal. This failure placed the 24 residents at risk for elopement which could result in serious injury, harm or death of the resident. Findings included: Resident #1's Admission Record Sheet, dated 02/23/17, revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1's Elopement Risk Assessment, dated 02/16/17 and e-signed by the Director of Nursing, preliminary data, reflected Resident #1 resided on the secured unit. This assessment did not identify Resident #1's level of elopement risk. Resident #1's admission care plan, dated 02/16/17, revealed she was independent with transferring. She had occasional disorientation/forgetfulness. Behavior problems marked were wanders and wants to leave was written in and added next to the box marked wanders. Mobility/ambulation was marked assist one, cane. Resident #1's MDS assessment dated [DATE], revealed she was severely cognitively impaired with a BIMS score of 7 (a score of 0-7 indicated severe cognitive impairment). She was not able to identify the correct year or month but was able to identify the correct day of the week. She wandered daily and was ambulatory with a cane. Review of the facility's Provider Investigation Report, dated 03/01/17, reflected that on 02/22/17 at 1:15 PM, CNA A escorted Resident #1, along with four other residents, off the secured unit (Hall 2). Resident #1 and three other residents were led to an activity (church) held in the main dining room. CNA A then went on break for 10 minutes followed by returning to the secured unit. Approximately one hour later, the activity ended and CNA A went to escort the residents back to the secured unit. CNA A escorted two female residents and another staff member (not identified) assisted one male resident, but not Resident #1. The Provider Investigation Report further noted Resident #1 was not wearing a wander guard bracelet at the time of the incident. It noted at or around 4:00 p.m., an individual from the community came and asked if Resident #1 was a resident of the facility. The individual said he and his wife met Resident #1 45 minutes ago outside their house. He said as they talked, they realized she (Resident #1) might be a resident of the nursing home. It noted the DON conducted an assessment of Resident #1 and there was no evidence of physical or emotion harm as a result of the incident. The Provider Investigation Report's Statement Summary reflected that after the incident, LVN B asked Resident #1 to retrace her steps on how she got out. LVN B took Resident #1 by the arm and Resident #1 took her on a walk that re-traced her steps. She first went to the dining room, where church was held. The resident and LVN B talked about church and what the preacher had said. LVN B asked Resident #1 to show her where she went when church was over. Resident #1 proceeded to walk from the dining room to the front door and placed her hands on the door to get out. The Interview on 03/02/17 at 2:45 PM with the Administrator revealed he had used video surveillance to verify times. He stated Resident #1 went out the front door. He stated he spoke with the gentleman who returned Resident #1 to the facility, just after 4:00 PM. He stated he looked at the clock when they sat down in his office and knew it took a few minutes for him to be located in the facility before he met him. The Administrator stated the front door was set for a long delay before it relocked after opening. Observation of main entry door 03/02/17 at 11.45 AM revealed the door had a coded entry/exit system. Resident #1 was observed on 03/02/17 at 11:55 AM and on 03/07/17 at 3:15 PM. She resided on the secured unit. She had no bruises or abrasions to her face, neck or lower arms and hands. During the observation 03/07/17, she was observed to stand and walk about the dining room without staff assistance. Observation on 03/07/17 at 5:00 PM of the distance from the facility to where Resident #1walked to which revealed approximately 1000 feet which was around the block, out of sight of the facility. An interview with CNA A was conducted on 03/02/17 at 12:15 PM. On 02/22/17, she was working on the secured unit by herself, as a CNA 6:00 AM to 2:00 PM, she stated there were usually two CNAs on the unit. She stated residents from the secured unit left the unit quite a bit for activities. She stated on 02/22/17, she took five residents off the unit. One of the five residents went to sit outside with a nurse. She took four residents, including Resident #1 to the dining room for church service. She stated she saw the preacher getting everyone together in the dining room. She did not see any staff when she left the four residents in the dining room. She stated she then went to clock out for her lunch break and took a 30 minute lunch break. When she came back inside through the back door she did not see the preacher in the dining room. She stated she got two female residents to lead them back to the secured unit, but not Resident #1. She stated another staff member led a male resident back to the secured unit. She stated she did not notice Resident #1 in the dining room. She stated she went back to work on the secured unit and worked a double shift on 2:00 PM to 10:00 PM. She was not aware Resident #1 was not on the secured unit until Resident #1 was returned to the unit later. She stated Resident #1 and the resident who had been sitting out front were brought back into the secured unit at the same time. An interview was conducted with the Activity Director on 03/02/17 at 10:40 AM. She stated on 02/22/17, she left around noon. She stated she informed staff on Halls 1, 3, and 4 so they could help residents to the dining room for the church service which started at 1:30 PM. She stated she did not remember if she informed staff on the secured unit that she was leaving early. She stated the Administrator was aware she was leaving early. An interview with the DON on 03/02/17 at 11:20 AM revealed the Activity Director left early on 02/22/17 and there was no one to supervise the activity in the dining room. An interview was conducted with the DON on 03/02/17 at 9:15 AM. She stated Resident #1 was on the secured unit because she was an elopement risk. On the day of her elopement Resident #1 was at church in the dining room. She was a recent admission and had been at the facility maybe two days. On 03/02/17 at 9:50 AM, she stated the facility practice and what usually happened was the CNAs from the secured unit took residents to the activity and the Activity Director was in the activity to supervise and monitor residents. If there was any problem with a resident, the Activity Director could go and get a CNA or any staff member who was outside the secured unit. Interview with the Administrator on 03/02/17 at 2:45 PM, revealed he initiated use of the sign out sheets on the secured unit on 02/23/17 and he audited the sign out sheets. He would sample a resident name and location from the sign out sheet and then go to locate that resident and staff member in the location named. He also conducted a reverse audit. When he observed a resident from the secured unit outside the unit he checked the sign out sheet to verify that resident had been signed out. Review of the Front Door Training/Mag Lock/Hall 2 Sign Out in-service conducted with the staff on 02/23 /17, revealed Residents on Hall 2 will need to be signed out and signed in. Hall 2 residents will have an orange wrist band so that all staff can identify high risk residents when they are off the unit for any reason. The facility's Abuse Prevention Program policy dated 06/16/16, reflected our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Investigating Allegations of Neglect Policy dated 06/10/16, reflected Policy Statement, all reported incidents of neglect are promptly and thoroughly investigated. Policy Interpretation and Implementation: 1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition. 2. Neglect also means the failure to protect the resident from abuse, neglect or exploitation. 3. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. Interview with the Administrator on 03/02/17 at 2:45 PM revealed he was the only staff member who audited the sign out sheets; therefore the audit was not conducted seven days a week. On 03/07/17 at 8:50 AM, the Adminstrator, the DON and ADON were unavailable therfore the Bookkeeper was notified an IJ had been identified and a plan of removal was requested at that time. Review of the plan of removal, accepted on 03/08/17 at 10:00 AM, reflected the following: Implementation of Changes: A list of residents with an elopement risk has been completed. Facility compiled a list of residents with an elopement risk who have the potential to be affected the most. All residents have the potential to be affected. This information was obtained from the elopement risk assessment that the nurses completed upon admission, readmission, change in condition, and quarterly in point click care (EHR). All elopement risk assessments were updated on 03/07/17 and completed by the DON and ADON. CNAs that are assigned to these residents are conducting rounds every 2 hours, and at the beginning and end of their shifts. They are conducting the rounds that were conducted. They are documenting the rounds that were conducted on a rounds sheet that is on a clipboard at the nurses' station. A local door alarm representative was contacted and verified the door was in proper working condition on 02/23/17. Adjustment to the timed delay was adjusted from 15 seconds to 5 seconds. The adjustment was made to limit the time the doors unlocked after the code is entered into the keypad. Facility dedicated an additional staff on 02/22/17 to monitor the doors until the door alarm company verified proper working condition on 02/23/17. The wander risk assessment book was updated with a current photograph and a brief physical description of the residents with exit seeking behaviors in general population and those that reside on the secure unit on 02/28/17 by the DON. Pictures of all residents are in the electronic record system and available to be printed out when needed for identification. All residents will be monitored by nursing staff for their location every two hours. Increased staffing on the secured by one staff member on the secured unit on 03/02/17. The staffing pattern for the secured unit is two staff members dedicated to the unit on 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM. This is in addition to staff members that support the unit as well (activity, administrative nursing, housekeeping, administrative staff, etc.). CNA A and LVN B were verbally counseled on 02/22/17 by the DON regarding the need to improve communication between charge nurse and aide. Also, making rounds on the residents every two hours. All staff was in-serviced regarding the lock delay system on the front door to lock after five seconds on 03/07/17 by the Administrator. All staff will be in-serviced by nursing administration and/or the Administrator on 03/07/17 (or before reporting for duty) on elopement risk to include but not limited to; use of wander risk assessment book, identifying potential wander risk residents and reporting wandering residents. This in-service will include behavior management, exit seeking, and verbal expressions of exit seeking All nursing staff will be in-serviced on 03/07/17 by nursing administration and/or Administrator (or before reporting for duty) on making rounds and documenting the location of residents every two hours. All staff were in-serviced on 03/07/17 (or before reporting for duty) by nursing administration and/or Administrator on signing all residents in and out for visitations and appointments, etc. The secured unit will have an additional sign out sheet for when those residents are removed from the unit for activities, appointments, visitations, etc. These sheets will assist in locating residents during needed times such as missing resident or emergency. All staff will be in-serviced by nursing administration and/or Administrator on 03/07/17 (or before reporting for duty) on resident supervision policy, missing resident policy, and abuse/neglect/exploitation policy. Administrator and/or nursing administration will conduct elopement drills (code orange) on each shift beginning on the 6:00 AM to 2:00 PM shift on 03/07/17. All staff members will be required to be in-serviced and/or participate in a code orange drill prior to reporting for duty. All staff will be required to be in-serviced by nursing administration and/or Administrator prior to reporting for duty beginning 03/07/17. Staff members are being called in for these mandatory in-services. Those staff members that are unable to attend will be informed that they may not report for duty until they have been in-serviced. Nursing administration and/or Administrator will meet staff prior to their shifts and/or at agreed-upon times to ensure proper in-servicing prior to being on duty. HR staff will verify all staff is in-serviced by matching in-service sign in sheets to active employee roll. Elopement drills were conducted on 03/07/17 for all staff and all shifts by the Administrator and/or nursing administration. Nursing staff was in-serviced on 03/07/17 by nursing administration and/or Administrator on conducting a head count every two hours for all residents. Nursing administration includes the DON, ADON, and MDS coordinator. Administrator, administrative nurses, and interdisciplinary team will implement the following changes: Documentation of all resident locations every two hours. Effective 03/07/17. Signing residents in and out of both the secured unit and general population. Effective 03/07/17. Monitoring the effectiveness of the change in delayed timing on front door magnetic locks. Effective 03/07/17. In-servicing all existing and on-boarding staff members on the above-mentioned in-services prior to providing resident care and during their orientation period. Policies on documenting resident locations, signing in/out of both secured unit and facility will be updated to reflect these changes Facility administrator and/or designee will monitor for compliance through daily review of sign in/out sheets, incidents and accidents and through daily rounds beginning 03/07/17. During monthly visits the medical director will review the elopement prevention plan and provide feedback beginning 03/07/17. To verify the facility implement their plan of removal the following was conducted: Interviews on 03/08/17 with LVN B, Laundry Staff C, Housekeeper D, CNA E, CNA F, LVN G, CNA H, LVN I, CNA J, LVN K, CNA L, and CNA M, representing staff from all three shifts were interviewed regarding the in-service and training they received on the facility's elopement protocol. They were each able to state they were trained in elopement risk/assessment tool, behavior management, supervision, missing resident, abuse/neglect, rounds, door locks, elopement drills and sign out/in sheets. An interview with the Administrator on 03/08/17 at 3:45 PM revealed 24 residents resided in the facility that wandered or exhibited a behavior of exiting seeking.

Based on observations, interviews, and record reviews, the administrator failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (Resident #1) of two residents reviewed for adequate supervision. The administrator failed to oversee and assist with the implementation of effective policies and procedures on adequate supervision for residents who have been identified for risk of elopement. An IJ was identified on 03/07/17. While the IJ was removed on 03/08/17, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope pattern due to the facility requiring more time to train all staff and monitor their plan of removal. These failures affected one resident and placed an additional 24 residents at risk for elopement which could result in serious injury, harm or death of the resident. Findings included: Resident #1's Admission Record Sheet, dated 02/23/17, revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1's Elopement Risk Assessment, dated 02/16/17 and e-signed by the Director of Nursing, preliminary data, reflected Resident #1 resided on the secured unit. This assessment did not identify Resident #1's level of elopement risk. Resident #1's admission care plan, dated 02/16/17, revealed she was independent with transferring. She had occasional disorientation/forgetfulness. Behavior problems marked were wanders and wants to leave was written in and added next to the box marked wanders. Mobility/ambulation was marked assist one, cane. Resident #1's MDS assessment dated [DATE], revealed she was severely cognitively impaired with a BIMS score of 7 (a score of 0-7 indicated severe cognitive impairment). She was not able to identify the correct year or month but was able to identify the correct day of the week. She wandered daily and was ambulatory with a cane. Review of the facility's Provider Investigation Report, dated 03/01/17, reflected that on 02/22/17 at 1:15 PM, CAN A escorted Resident #1, along with four other residents, off the secured unit (Hall 2). Resident #1 and three other residents were led to an activity (church) held in the main dining room. CAN A then went on break for 10 minutes followed by returning to the secured unit. Approximately one hour later, the activity ended and CAN A went to escort the residents back to the secured unit. CAN A escorted two female residents and another staff member (not identified) assisted one male resident, but not Resident #1. Interview on 03/02/17 at 2:45 PM with the Administrator revealed he had used video surveillance to verify times. He stated Resident #1 went out the front door. He stated he spoke with the gentleman who returned Resident #1 to the facility, just after 4:00 PM. He stated he looked at the clock when they sat down in his office and knew it took a few minutes for him to be located in the facility before he met him. The Administrator stated the front door was set for a long delay before it relocked after opening. (Note: This is the Mag Lock error referred to in the facility's Investigation Report dated 03/01/17). On 03/07/17 at 8:50 AM, the Bookkeeper was notified an IJ had been identified and a plan of removal was requested at that time. An interview with CNA A was conducted on 03/02/17 at 12:15 PM. On 02/22/17, she was working on the secured unit by herself, as a CNA 6:00 AM to 2:00 PM, she stated there were usually two CNAs on the unit. She stated residents from the secured unit left the unit quite a bit for activities. She stated on 02/22/17, she took five residents off the unit. One of the five residents went to sit outside with a nurse. She took four residents, including Resident #1 to the dining room for church service. She stated she saw the preacher getting everyone together in the dining room. She did not see any staff when she left the four residents in the dining room. She stated she then went to clock out for her lunch break and took a 30 minute lunch break. When she came back inside through the back door she did not see the preacher in the dining room. She stated she got two female residents to lead them back to the secured unit, but not Resident #1. She stated another staff member led a male resident back to the secured unit. She stated she did not notice Resident #1 in the dining room. She stated she went back to work on the secured unit and worked a double shift on 2:00 PM to 10:00 PM. She was not aware Resident #1 was not on the secured unit until Resident #1 was returned to the unit later. She stated Resident #1 and the resident who had been sitting out front were brought back into the secured unit at the same time. An interview was conducted with the Activity Director on 03/02/17 at 10:40 AM. She stated on 02/22/17, she left around noon. She stated she informed staff on Halls 1, 3, and 4 so they could help residents to the dining room for the church service which started at 1:30 PM. She stated she did not remember if she informed staff on the secured unit that she was leaving early. She stated the Administrator was aware she was leaving early. An interview with the DON on 03/02/17 at 11:20 AM revealed the Activity Director left early on 02/22/17 and there was no one to supervise the activity in the dining room. An interview was conducted with the DON on 03/02/17 at 9:15 AM. She stated Resident #1 was on the secured unit because she was an elopement risk. On the day of her elopement Resident #1 was at church in the dining room. She was a recent admission and had been at the facility maybe two days. On 03/02/17 at 9:50 AM, she stated the facility practice and what usually happened was the CNAs from the secured unit took residents to the activity and the Activity Director was in the activity to supervise and monitor residents. If there was any problem with a resident, the Activity Director could go and get a CNA or any staff member who was outside the secured unit. The facility's Abuse Prevention Program policy dated 06/16/16, reflected our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Investigating Allegations of Neglect Policy dated 06/10/16, reflected Policy Statement, all reported incidents of neglect are promptly and thoroughly investigated. Policy Interpretation and Implementation: 1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition. 2. Neglect also means the failure to protect the resident from abuse, neglect or exploitation. 3. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. Interview with the Administrator on 03/02/17 at 2:45 PM revealed he was the only staff member who audited the sign out sheets; therefore the audit was not conducted seven days a week. Review of the plan of removal, accepted on 03/08/17 at 10:00 AM, reflected the following: Implementation of Changes: A list of residents with an elopement risk has been completed. Facility compiled a list of residents with an elopement risk who have the potential to be affected the most. All residents have the potential to be affected. This information was obtained from the elopement risk assessment that the nurses completed upon admission, readmission, change in condition, and quarterly in point click care (EHR). All elopement risk assessments were updated on 03/07/17 and completed by the DON and ADON. CNAs that are assigned to these residents are conducting rounds every 2 hours, and at the beginning and end of their shifts. They are conducting the rounds that were conducted. They are documenting the rounds that were conducted on a rounds sheet that is on a clipboard at the nurses' station. A local door alarm representative was contacted and verified the door was in proper working condition on 02/23/17. Adjustment to the timed delay was adjusted from 15 seconds to 5 seconds. The adjustment was made to limit the time the doors unlocked after the code is entered into the keypad. Facility dedicated an additional staff on 02/22/17 to monitor the doors until the door alarm company verified proper working condition on 02/23/17. The wander risk assessment book was updated with a current photograph and a brief physical description of the residents with exit seeking behaviors in general population and those that reside on the secure unit on 02/28/17 by the DON. Pictures of all residents are in the electronic record system and available to be printed out when needed for identification. All residents will be monitored by nursing staff for their location every two hours. Increased staffing on the secured by one staff member on the secured unit on 03/02/17. The staffing pattern for the secured unit is two staff members dedicated to the unit on 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM. This is in addition to staff members that support the unit as well (activity, administrative nursing, housekeeping, administrative staff, etc.). CNA A and LVN B were verbally counseled on 02/22/17 by the DON regarding the need to improve communication between charge nurse and aide. Also, making rounds on the residents every two hours. All staff was in-serviced regarding the lock delay system on the front door to lock after five seconds on 03/07/17 by the Administrator. All staff will be in-serviced by nursing administration and/or the Administrator on 03/07/17 (or before reporting for duty) on elopement risk to include but not limited to; use of wander risk assessment book, identifying potential wander risk residents and reporting wandering residents. This in-service will include behavior management, exit seeking, and verbal expressions of exit seeking All nursing staff will be in-serviced on 03/07/17 by nursing administration and/or Administrator (or before reporting for duty) on making rounds and documenting the location of residents every two hours. All staff were in-serviced on 03/07/17 (or before reporting for duty) by nursing administration and/or Administrator on signing all residents in and out for visitations and appointments, etc. The secured unit will have an additional sign out sheet for when those residents are removed from the unit for activities, appointments, visitations, etc. These sheets will assist in locating residents during needed times such as missing resident or emergency. All staff will be in-serviced by nursing administration and/or Administrator on 03/07/17 (or before reporting for duty) on resident supervision policy, missing resident policy, and abuse/neglect/exploitation policy. Administrator and/or nursing administration will conduct elopement drills (code orange) on each shift beginning on the 6:00 AM to 2:00 PM shift on 03/07/17. All staff members will be required to be in-serviced and/or participate in a code orange drill prior to reporting for duty. All staff will be required to be in-serviced by nursing administration and/or Administrator prior to reporting for duty beginning 03/07/17. Staff members are being called in for these mandatory in-services. Those staff members that are unable to attend will be informed that they may not report for duty until they have been in-serviced. Nursing administration and/or Administrator will meet staff prior to their shifts and/or at agreed-upon times to ensure proper in-servicing prior to being on duty. HR staff will verify all staff is in-serviced by matching in-service sign in sheets to active employee roll. Elopement drills were conducted on 03/07/17 for all staff and all shifts by the Administrator and/or nursing administration. Nursing staff was in-serviced on 03/07/17 by nursing administration and/or Administrator on conducting a head count every two hours for all residents. Nursing administration includes the DON, ADON, and MDS coordinator. Administrator, administrative nurses, and interdisciplinary team will implement the following changes: Documentation of all resident locations every two hours. Effective 03/07/17. Signing residents in and out of both the secured unit and general population. Effective 03/07/17. Monitoring the effectiveness of the change in delayed timing on front door magnetic locks. Effective 03/07/17. In-servicing all existing and on-boarding staff members on the above-mentioned in-services prior to providing resident care and during their orientation period. Policies on documenting resident locations, signing in/out of both secured unit and facility will be updated to reflect these changes Facility administrator and/or designee will monitor for compliance through daily review of sign in/out sheets, incidents and accidents and through daily rounds beginning 03/07/17. During monthly visits the medical director will review the elopement prevention plan and provide feedback beginning 03/07/17. To verify the facility implement their plan of removal the following was conducted: Interviews on 03/08/17 with LVN B, Laundry Staff C, Housekeeper D, CNA E, CNA F, LVN G, CNA H, LVN I, CNA J, LVN K, CNA L, and CNA M, representing staff from all three shifts were interviewed regarding the in-service and training they received on the facility's elopement protocol. They were each able to state they were trained in elopement risk/assessment tool, behavior management, supervision, missing resident, abuse/neglect, rounds, door locks, elopement drills and sign out/in sheets. An interview with the Administrator on 03/08/17 at 3:45 PM revealed 24 residents resided in the facility that wandered or exhibited a behavior of exiting seeking.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #1) of two residents reviewed for adequate supervision. The facility failed to supervise Resident #1 after escorting her off the secured unit to an activity. The facility was unaware Resident #1 eloped until an individual from the community returned to resident to the facility approximately one hour and 50 minutes after activity ended. The resident had wandered approximately 1000 feet from the facility. The resident sustained [REDACTED]. An IJ was identified on 03/07/17. While the IJ was removed on 03/08/17, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope pattern due to the facility requiring more time to train all staff and monitor their plan of removal. This failure placed the 24 residents at risk for elopement which could result in serious injury, harm or death of the resident. Findings included: The facility's Abuse Prevention Program policy dated 06/16/16, reflected our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Investigating Allegations of Neglect Policy dated 06/10/16, reflected Policy Statement, all reported incidents of neglect are promptly and thoroughly investigated. Policy Interpretation and Implementation: 1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition. 2. Neglect also means the failure to protect the resident from abuse, neglect or exploitation. 3. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. Resident #1's Admission Record Sheet, dated 02/23/17, revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1's Elopement Risk Assessment, dated 02/16/17 and e-signed by the Director of Nursing, preliminary data, reflected Resident #1 resided on the secured unit. This assessment did not identify Resident #1's level of elopement risk. Resident #1's admission care plan, dated 02/16/17, revealed she was independent with transferring. She had occasional disorientation/forgetfulness. Behavior problems marked were wanders and wants to leave was written in and added next to the box marked wanders. Mobility/ambulation was marked assist one, cane. Resident #1's MDS assessment dated [DATE], revealed she was severely cognitively impaired with a BIMS score of 7 (a score of 0-7 indicated severe cognitive impairment). She was not able to identify the correct year or month but was able to identify the correct day of the week. She wandered daily and was ambulatory with a cane. Review of the facility's Provider Investigation Report, dated 03/01/17, reflected that on 02/22/17 at 1:15 PM, CNA A escorted Resident #1, along with four other residents, off the secured unit (Hall 2). Resident #1 and three other residents were led to an activity (church) held in the main dining room. CNA A then went on break for 10 minutes followed by returning to the secured unit. Approximately one hour later, the activity ended and CNA A went to escort the residents back to the secured unit. CNA A escorted two female residents and another staff member (not identified) assisted one male resident, but not Resident #1. The Provider Investigation Report further noted Resident #1 was not wearing a wander guard bracelet at the time of the incident. It noted at or around 4:00 p.m., an individual from the community came and asked if Resident #1 was a resident of the facility. The individual said he and his wife met Resident #1 45 minutes ago outside their house. He said as they talked, they realized she (Resident #1) might be a resident of the nursing home. It noted the DON conducted an assessment of Resident #1 and there was no evidence of physical or emotion harm as a result of the incident. The Provider Investigation Report's Statement Summary reflected that after the incident, LVN B asked Resident #1 to retrace her steps on how she got out. LVN B took Resident #1 by the arm and Resident #1 took her on a walk that re-traced her steps. She first went to the dining room, where church was held. The resident and LVN B talked about church and what the preacher had said. LVN B asked Resident #1 to show her where she went when church was over. Resident #1 proceeded to walk from the dining room to the front door and placed her hands on the door to get out. The Interview on 03/02/17 at 2:45 PM with the Administrator revealed he had used video surveillance to verify times. He stated Resident #1 went out the front door. He stated he spoke with the gentleman who returned Resident #1 to the facility, just after 4:00 PM. He stated he looked at the clock when they sat down in his office and knew it took a few minutes for him to be located in the facility before he met him. The Administrator stated the front door was set for a long delay before it relocked after opening. Observation of main entry door 03/02/17 at 11.45 AM revealed the door had a coded entry/exit system. Resident #1 was observed on 03/02/17 at 11:55 AM and on 03/07/17 at 3:15 PM. She resided on the secured unit. She had no bruises or abrasions to her face, neck or lower arms and hands. During the observation 03/07/17, she was observed to stand and walk about the dining room without staff assistance. Observation on 03/07/17 at 5:00 PM of the distance from the facility to where Resident #1walked to which revealed approximately 1000 feet which was around the block, out of sight of the facility. An interview with CNA A was conducted on 03/02/17 at 12:15 PM. On 02/22/17, she was working on the secured unit by herself, as a CNA 6:00 AM to 2:00 PM, she stated there were usually two CNAs on the unit. She stated residents from the secured unit left the unit quite a bit for activities. She stated on 02/22/17, she took five residents off the unit. One of the five residents went to sit outside with a nurse. She took four residents, including Resident #1 to the dining room for church service. She stated she saw the preacher getting everyone together in the dining room. She did not see any staff when she left the four residents in the dining room. She stated she then went to clock out for her lunch break and took a 30 minute lunch break. When she came back inside through the back door she did not see the preacher in the dining room. She stated she got two female residents to lead them back to the secured unit, but not Resident #1. She stated another staff member led a male resident back to the secured unit. She stated she did not notice Resident #1 in the dining room. She stated she went back to work on the secured unit and worked a double shift on 2:00 PM to 10:00 PM. She was not aware Resident #1 was not on the secured unit until Resident #1 was returned to the unit later. She stated Resident #1 and the resident who had been sitting out front were brought back into the secured unit at the same time. An interview was conducted with the Activity Director on 03/02/17 at 10:40 AM. She stated on 02/22/17, she left around noon. She stated she informed staff on Halls 1, 3, and 4 so they could help residents to the dining room for the church service which started at 1:30 PM. She stated she did not remember if she informed staff on the secured unit that she was leaving early. She stated the Administrator was aware she was leaving early. An interview with the DON on 03/02/17 at 11:20 AM revealed the Activity Director left early on 02/22/17 and there was no one to supervise the activity in the dining room. An interview was conducted with the DON on 03/02/17 at 9:15 AM. She stated Resident #1 was on the secured unit because she was an elopement risk. On the day of her elopement Resident #1 was at church in the dining room. She was a recent admission and had been at the facility maybe two days. On 03/02/17 at 9:50 AM, she stated the facility practice and what usually happened was the CNAs from the secured unit took residents to the activity and the Activity Director was in the activity to supervise and monitor residents. If there was any problem with a resident, the Activity Director could go and get a CNA or any staff member who was outside the secured unit. Interview with the Administrator on 03/02/17 at 2:45 PM, revealed he initiated use of the sign out sheets on the secured unit on 02/23/17 and he audited the sign out sheets. He would sample a resident name and location from the sign out sheet and then go to locate that resident and staff member in the location named. He also conducted a reverse audit. When he observed a resident from the secured unit outside the unit he checked the sign out sheet to verify that resident had been signed out. Review of the Front Door Training/Mag Lock/Hall 2 Sign Out in-service conducted with the staff on 02/23 /17, revealed Residents on Hall 2 will need to be signed out and signed in. Hall 2 residents will have an orange wrist band so that all staff can identify high risk residents when they are off the unit for any reason. Interview with the Administrator on 03/02/17 at 2:45 PM revealed he was the only staff member who audited the sign out sheets; therefore the audit was not conducted seven days a week. On 03/07/17 at 8:50 AM, the Adminstrator, the DON and ADON were unavailable therfore the Bookkeeper was notified an IJ had been identified and a plan of removal was requested at that time. Review of the plan of removal, accepted on 03/08/17 at 10:00 AM, reflected the following: Implementation of Changes: A list of residents with an elopement risk has been completed. Facility compiled a list of residents with an elopement risk who have the potential to be affected the most. All residents have the potential to be affected. This information was obtained from the elopement risk assessment that the nurses completed upon admission, readmission, change in condition, and quarterly in point click care (EHR). All elopement risk assessments were updated on 03/07/17 and completed by the DON and ADON. CNAs that are assigned to these residents are conducting rounds every 2 hours, and at the beginning and end of their shifts. They are conducting the rounds that were conducted. They are documenting the rounds that were conducted on a rounds sheet that is on a clipboard at the nurses' station. A local door alarm representative was contacted and verified the door was in proper working condition on 02/23/17. Adjustment to the timed delay was adjusted from 15 seconds to 5 seconds. The adjustment was made to limit the time the doors unlocked after the code is entered into the keypad. Facility dedicated an additional staff on 02/22/17 to monitor the doors until the door alarm company verified proper working condition on 02/23/17. The wander risk assessment book was updated with a current photograph and a brief physical description of the residents with exit seeking behaviors in general population and those that reside on the secure unit on 02/28/17 by the DON. Pictures of all residents are in the electronic record system and available to be printed out when needed for identification. All residents will be monitored by nursing staff for their location every two hours. Increased staffing on the secured by one staff member on the secured unit on 03/02/17. The staffing pattern for the secured unit is two staff members dedicated to the unit on 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM. This is in addition to staff members that support the unit as well (activity, administrative nursing, housekeeping, administrative staff, etc.). CNA A and LVN B were verbally counseled on 02/22/17 by the DON regarding the need to improve communication between charge nurse and aide. Also, making rounds on the residents every two hours. All staff was in-serviced regarding the lock delay system on the front door to lock after five seconds on 03/07/17 by the Administrator. All staff will be in-serviced by nursing administration and/or the Administrator on 03/07/17 (or before reporting for duty) on elopement risk to include but not limited to; use of wander risk assessment book, identifying potential wander risk residents and reporting wandering residents. This in-service will include behavior management, exit seeking, and verbal expressions of exit seeking All nursing staff will be in-serviced on 03/07/17 by nursing administration and/or Administrator (or before reporting for duty) on making rounds and documenting the location of residents every two hours. All staff were in-serviced on 03/07/17 (or before reporting for duty) by nursing administration and/or Administrator on signing all residents in and out for visitations and appointments, etc. The secured unit will have an additional sign out sheet for when those residents are removed from the unit for activities, appointments, visitations, etc. These sheets will assist in locating residents during needed times such as missing resident or emergency. All staff will be in-serviced by nursing administration and/or Administrator on 03/07/17 (or before reporting for duty) on resident supervision policy, missing resident policy, and abuse/neglect/exploitation policy. Administrator and/or nursing administration will conduct elopement drills (code orange) on each shift beginning on the 6:00 AM to 2:00 PM shift on 03/07/17. All staff members will be required to be in-serviced and/or participate in a code orange drill prior to reporting for duty. All staff will be required to be in-serviced by nursing administration and/or Administrator prior to reporting for duty beginning 03/07/17. Staff members are being called in for these mandatory in-services. Those staff members that are unable to attend will be informed that they may not report for duty until they have been in-serviced. Nursing administration and/or Administrator will meet staff prior to their shifts and/or at agreed-upon times to ensure proper in-servicing prior to being on duty. HR staff will verify all staff is in-serviced by matching in-service sign in sheets to active employee roll. Elopement drills were conducted on 03/07/17 for all staff and all shifts by the Administrator and/or nursing administration. Nursing staff was in-serviced on 03/07/17 by nursing administration and/or Administrator on conducting a head count every two hours for all residents. Nursing administration includes the DON, ADON, and MDS coordinator. Administrator, administrative nurses, and interdisciplinary team will implement the following changes: Documentation of all resident locations every two hours. Effective 03/07/17. Signing residents in and out of both the secured unit and general population. Effective 03/07/17. Monitoring the effectiveness of the change in delayed timing on front door magnetic locks. Effective 03/07/17. In-servicing all existing and on-boarding staff members on the above-mentioned in-services prior to providing resident care and during their orientation period. Policies on documenting resident locations, signing in/out of both secured unit and facility will be updated to reflect these changes Facility administrator and/or designee will monitor for compliance through daily review of sign in/out sheets, incidents and accidents and through daily rounds beginning 03/07/17. During monthly visits the medical director will review the elopement prevention plan and provide feedback beginning 03/07/17. To verify the facility implement their plan of removal the following was conducted: Interviews on 03/08/17 with LVN B, Laundry Staff C, Housekeeper D, CNA E, CNA F, LVN G, CNA H, LVN I, CNA J, LVN K, CNA L, and CNA M, representing staff from all three shifts were interviewed regarding the in-service and training they received on the facility's elopement protocol. They were each able to state they were trained in elopement risk/assessment tool, behavior management, supervision, missing resident, abuse/neglect, rounds, door locks, elopement drills and sign out/in sheets. An interview with the Administrator on 03/08/17 at 3:45 PM revealed 24 residents resided in the facility that wandered or exhibited a behavior of exiting seeking.