Every finding on record at Groves Center

Based on observations, record reviews, and interviews, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR ) for four (Residents #10,#1, #54, and #5) out of 40 residents sampled. Findings include: Review of Resident #10's admission record showed an original admission date of 11/25/2025 and a readmission date of 02/12/2026. Diagnoses included depression and dementia without behavioral, psychotic, mood disturbances, or anxiety. Review of Resident #10's Level I PASARR, dated 01/30/2026, showed Section A for mental illness or suspected mental illness did not include depression. Section A contained a check mark for other with the diagnosis written as unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #10's physician orders showed an order dated 03/27/2026 for Celexa 20 milligrams to be given orally once daily for depression. Review of a psychiatric note dated 05/05/2026 showed diagnoses including anxiety with an onset date of 03/27/2026 and depression with an onset date of 02/12/2026. During an interview with the Social Services Director (SSD) on 07/22/2026 at 12:17 p.m., the SSD stated she completed the PASARRs. She reported that for new admissions she reviewed the chart to ensure the history and physical (H&P) and medical diagnoses matched the information from the discharging facility, and she completed yearly audits for current residents. Review of Resident #1's admission record revealed an admission date of 05/24/2026. Diagnoses included other generalized epilepsy and epileptic syndromes, anxiety disorder; dementia without behavioral disturbances; and major depressive disorder. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], showed medications included antianxiety, antidepressant, opioid, and anticonvulsant medications. Review of Resident #1's PASARR, dated 07/21/2026, showed Section I for PASARR screen decision-making was blank for related conditions. Section II for other indications for PASARR screen decision-making showed responses marked no for questions 1 through 7. During an interview with the SSD on 07/22/2026 at 3:41 p.m., she stated that an epilepsy diagnosis should be included on the PASARR, as well as any behaviors. Review of Resident #54's admission record showed the resident was admitted on [DATE] with diagnoses including depressive disorder. Review of Resident #54's Level I PASARR, dated 06/17/2026, showed the form did not include the diagnosis of depressive disorder. During an interview on 07/22/2026 at 3:30 p.m., the SSD stated Resident #54's Level I PASARR was incorrect and missing the diagnosis of depressive disorder. She stated the resident would require a Level II PASARR. Review of Resident #5's admission record showed the resident was admitted on [DATE] and readmitted on [DATE]. Diagnoses included other generalized epilepsy and epileptic syndromes, other seizures and adjustment disorder with mixed anxiety and depressed mood. Review of Resident #5's PASARR, dated 01/30/2026 and completed at the facility, showed only the diagnosis of adjustment disorder with mixed anxiety and depressed mood. The screening did not indicate the resident had the related condition of epilepsy. During an interview with the SSD on 07/22/2026 at 3:30 p.m., she stated Resident #5's PASARR had been updated on 07/21/2026 to include epilepsy and the resident required a Level II PASARR. Review of the policy – PASRR Requirements for Completion, effective August 2025, showed Pre admission screening will be conducted prior to admission as the PASRR process is a federally mandated pre-admission screening program (see 42 CFR 483.100) Required to be performed on all individuals prior to admission to a nursing home. The screening is reviewed by admissions for suspicion of serious mental illness and intellectual disability to ensure appropriate placement in the least constructive environment and to identify the need to provide applicants with needed specialized services. PASR screening applies to option to a Medicaid certified nursing facility and includes private pay, Medicare, and Medicaid admissions regardless of payer source. The procedure related to this policy included: 1. During the admissions process, admissions will communicate with the facility regarding prospective admissions. A Level I PASRR will be provided prior to admission to a skilled nursing facility. The facility administration will confirm that a Level I review has been completed prior to transfer to the SNF setting. 2. Determine if a serious mental illness and/ or intellectual disability or a related condition exists while reviewing the PASRR form completed by the acute care facility. (Trigger for level II completion) The guidelines instructed: Assure that sections 1-5 are completed prior to admission. If section IV (Provisional Admission) is applicable, the form is only valid if the MD has signed and dated the form. If the pre-admission screening requires a Level II evaluation(,) submit all required documents to (screening vendor) timely, so that a Level II can be completed within the required time frames.

Based on observations, record reviews, and interviews, the facility failed to implement individualized non pharmacological interventions for two of two sampled residents (#79 and #10) diagnosed with dementia. This failure resulted in residents not receiving individualized approaches to prevent or reduce behavioral symptoms. Findings include: On 7/19/26 at 11:06 a.m., Resident #79 was observed lying in bed with eyes closed in a dark room without music or television playing. On 7/21/26 at 9:18 a.m. and again at 3:41 p.m., the resident was observed lying in bed with eyes closed in a room without lights or auditory stimulation such as music or television. On 7/21/26 at 3:41 p.m. Resident #79 was observed lying in bed with eyes closed, all lights in the room were off and no music or television was playing. Review of Resident #79s admission Record showed as admitted on [DATE] with diagnoses including dementia with behavioral disturbance, unspecified psychosis, major depressive disorder, mood disorder due to medical condition, and anxiety. Review of Resident #79's clinical records, revealed the discharging acute care hospital orders to the facility showed the resident's primary diagnosis was dementia with agitation. The acute care hospital's History and Physical documentation, dated 5/14/26, showed the pt [patient] brought back from facility for placement into another facility, pt not allowed to go back to the facility (pronoun) came from. The history showed the resident had a diagnosis of dementia with agitation that is sent from a facility due to inability to care for him due to episodes of agitation with aggression. Review of Resident #79's admission Minimum Data Set (MDS), dated [DATE], showed the resident was rarely/never understood, had physical behaviors on 4–6 days and verbal behaviors on 1–3 days, had adequate hearing with hearing aids, and received scheduled antipsychotic and antidepressant medications. Review of Resident #79's care plan revealed a language barrier, need for an interpreter, hearing deficits, and multiple behaviors including refusal of care, combativeness, physical aggression, profanity, and resistance to hearing aid placement. Interventions instructed staff not to corner the resident, to provide space, remove other residents, remain calm, and call for assistance. Review of Resident #79's physician/provider notes showed on 6/15/26 the physician was asked to see the resident for a change in condition, nursing reported the resident had been very agitated & aggressive. The note revealed the resident exhibited irritability and dementia resulting in the physician increasing the antipsychotic Seroquel to 25 milligram (mg) twice daily (BID) and an order for psych to evaluate. Review of Resident #79's primary care physician note on 6/17/26 showed Resident #79 was stable and clinical findings included dementia, depressed mood, and memory loss. Review of Resident #79's psychiatry note, dated 6/30/26, showed the resident was being seen for an initial evaluation by Staff L, Advanced Practitioner Registered Nurse (APRN). The APRN noted nursing had reported the resident was still adjusting to the facility and planned to go home after discharge. The resident lacked interaction with the APRN. The staff had reported the resident would flail arms in response to being touched and was resistant to care at times. The review of systems showed markedly diminished interest, restlessness/feeling keyed up, diminished emotional expression, disorganized behaviors, acted with potential for painful consequences and expansive or irritable mood. The plan was to continue with Seroquel 25 mg twice daily, Paxil 10 mg daily, Aricept 5 mg twice daily, and to start Depakote 125 mg daily. Review of Resident #79s behavior monitoring and interventions, completed and documented by Certified Nursing Assistants (CNAs) during the 30 day period of 6/23-7/22/26 showed the resident exhibited physical and verbal behaviors on 6/25, 6/27, 6/28, 7/2, 7/7, 7/14, 7/15, 7/19, and 7/21/26 (nine of the 30 days). The facility failed to provide documentation related to interventions attempted during these periods of behaviors. Review of Resident #79's Medication Administration Record (MAR) showed an order, dated 7/14/26 for Ativan 0.5 milligram (mg)/Benadryl 12.5 mg/Haldol 0.5 mg (ABH) gel – apply to alternating sites topically every 12 hours as needed for anxiety with agitation for 15 days. The MAR showed Resident #79 received four doses: on 7/17, 7/18, 7/19, and 7/20/26. Review of Resident #79's progress notes revealed the following: 7/13/26 at 2:18 a.m., Daily Skilled Note: combative mood or behavior and refused vital sign assessment. 7/13/26 at 11:34 p.m., Daily Skilled Note: cooperative (and) irritable. Alert to person and no distress noted. 7/17/26 at 3:30 p.m., Psych note: noted with a history significant for dementia with marked Behavioral disturbances evidenced by disorganized speech, thought, behaviors, disorientation, impulsiveness, noncompliance, and agitation. These symptoms continue to break through what was the last frequency and intensity and current regiment. The resident was seen in room with no acute distress. 7/17/26 at 5:29 p.m. Medication Administration note: ABH gel was administered. The note did not reveal what type of behavior(s) the resident had exhibited. Review of the CNA behavior monitoring showed on 7/17/26 the resident had not exhibited any behaviors. 7/18/26 at 10:20 p.m. Medication Administration note: ABH gel was administered. The note did not reveal what type of behavior(s) the resident had exhibited. Review of the CNA behavior monitoring showed on 7/18/26 the resident had not exhibited any behaviors. 7/19/26 at 9:51 p.m. Medication Administration note: ABH gel was administered. The note did not reveal what type of behavior(s) the resident had exhibited. Review of the CNA behavior monitoring showed on 7/19/26 at 3:52 a.m. the resident had exhibited behaviors and at 9:47 p.m. (4 minutes prior to the administration) the resident had not exhibited behaviors. 7/20/26 at 8:23 p.m. Medication Administration note: ABH gel was administered. The note did not reveal what type of behavior(s) the resident had exhibited. Review of the CNA behavior monitoring showed on 7/20/26 the resident had not exhibited behaviors. Review of Resident #79's Controlled Drug Record for ABH Gel showed the facility had received 30 doses of the medication on 7/16/26. The record showed the resident received the following doses with reviews of progress notes and MAR: 7/16/26 at 7:00 a.m.: ABH gel was administered. The review of progress notes did not show the medication was administered and the CNA behavior monitoring revealed the resident had not exhibited any behaviors on 7/16/26. 7/17/26 at 5:29 p.m. ABH gel was administered. The correlating administration note did not reveal the type of behavior the resident had exhibited and the CNA behavior monitoring did not reveal the resident had exhibited any behaviors on 7/17/26. 7/18/26 at 10:20 p.m. ABH gel was administered. The administration note did not reveal the type of behavior(s) the resident had exhibited and the CNA behavior monitoring did not reveal the resident had exhibited any behaviors on 7/18/26. 7/19/26 at 9:52 p.m. ABH gel was administered. The administration note did not reveal the type of behavior(s) the resident had exhibited and the CNA behavior monitoring did not reveal the resident had exhibited any behaviors on 7/19/26 at that time. 7/20/26 at 10:25 a.m. ABH gel was administered. The progress notes did not contain a note for this administration and the CNA behavior monitoring did not reveal the resident had exhibited any behaviors on 7/20/26. 7/20/26 at unknown time. ABH gel was administered. An administration note dated 720/26 at 8:23 p.m. (10 hours after the first administration on 7/20/26) did not show the type of behaviors the resident had exhibited and the CNA behavior monitoring showed the resident had no behaviors on that day. 7/21/26 at 10:15 a.m. ABH gel was administered. The progress notes did not contain a note for this administration and the CNA behavior monitoring revealed the resident had exhibited behaviors at 12:09 p.m., one hour and 54 minutes after the administration. In review of the above MAR and progress notes documentation showed the ABH gel was administered on seven occasions from 7/16–7/21/26. For each administration, the progress notes and CNA behavior documentation did not show correlating behaviors at or near the time of administration. An interview was conducted on 7/21/26 at 9:20 a.m. with Staff B, Licensed Practical Nurse (LPN). Staff B stated oh yah the resident had behaviors of hitting, kicking, and pulling down privacy curtain until the facility got an order for Ativan and ABH gel. The staff member reported giving the as needed (prn) gel during the shift to make sure the resident did not escalate. The staff member reported planning on giving the medication today, as well. An interview was conducted on July 21, 2026, at 10:30 a.m. with Staff B, LPN. Staff B stated she was unable to view the CNA task documentation and had to rely on aides verbally reporting resident behaviors. Staff B, LPN said CNAs can place a note on the dashboard to alert the nurse, but the CNAs are expected to inform the nurse before adding such a note. Staff B stated that when a resident exhibits behaviors, nursing should complete a progress note and review any alerts; however, she noted that no behavior-related notes were present for Resident #79. Staff B, LPN said in the past, staff notified the psychiatric provider about any behaviors, but now they use ABH and Ativan as needed. An interview was conducted on 7/21/26 at 1:44 p.m. with Staff L, APRN. Staff L stated witnessing Resident #79's combativeness and the resident would not allow for redirection. The facility administered a onetime dose of Ativan intramuscularly (IM) to calm Resident 79. The resident had been very combative, swinging and spitting. Staff L stated the resident was on an as needed (medication) right now and had wanted to taper the Seroquel, but the resident was having behaviors. Staff L stated the resident was alarming upset and had calmed down after the Ativan. Staff L stated requesting staff try to keep the music on, a combination of the Ativan and music calmed the resident down. Resident #79 is hard of hearing and when spoken to calmly Resident #79 does much better than when startled. When startled Resident #79 can become agitated. An interview was conducted on 7/21/26 at 3:27 p.m. with Staff L, APRN. Staff L, APRN stated Resident #79 had periods of calm and had conversations, then at times didn't want to be bothered and not redirectable. Staff L said when admitted the resident was irritable, didn't want to be here, wasn't aggressive just didn't want to talk to you. Staff L stated last Friday (7/17/26) the facility almost involuntarily hospitalized Resident #79 until they gave the Ativan IM. Staff L, APRN stated the facility staff started playing music in Resident #79's room and the resident calmed down and was tapping foot. Staff L, APRN said recommending the staff to have music playing and the Assistant Director of Nursing (ADON) was excited about it. An interview was conducted on 7/21/26 at 5:16 p.m. with the Activity Aide, AA. The AA stated Resident #79 was offered coloring last Thursday (7/16/26) and had only offered activities that one time. Resident #79 does not come out of his room. An interview was conducted on 7/21/26 at 5:25 p.m. with Staff K, CNA. Staff K, CNA stated only working with Resident #79 one time but did assist other CNAs when Resident #79 was in the previous room. Staff K stated the Resident #79 has one good side, left side, for hearing and wears hearing aids sometimes which help with behaviors. Staff K stated when the resident was told what the staff were going to do Resident #79 let them. Sometimes Resident #79 would stop us and we would have to return later. Staff K stated she would stop and wait, talk to the resident, leave the resident if said stop, to calm down offering snacks and the resident will ask for soda. Staff K stated she would take the resident to the dining room for activities in the morning if the resident wanted to. During an interview on 7/22/26 at 1:50 p.m., the Director of Nursing (DON) explained that communication between staff and providers occurred in person, and providers were contacted by phone as needed. The DON stated that aides were expected to report any behaviors to the floor nurse and document them in the task section as well as in the Stop and Watch (alert) portion of the electronic record. Staff could enter any concerns into Stop and Watch, including refusal of care or behaviors, which would generate alerts for the nurses. These alerts also appeared on the dashboards of the unit managers and the DON, who reviewed them during morning meetings. According to the DON, once nurses receive communication from an aide about behavior, the nurse would address it immediately by contacting either psychiatry or the primary provider and notifying both the DON and the unit manager. Staff are to document behaviors in progress notes to reflect any changes and could also document a change in condition. The DON reported that the facility had attempted numerous interventions for Resident #79 prior to initiating medications, including having staff work in pairs, ensuring the resident had hearing aids, and playing music. The DON added that she was aware of when Staff L had been present and would need to verify whether Ativan had been administered. 2. On 7/19/26 at 9:40 a.m., Resident #10 was observed lying in bed with the head and foot of the bed elevated approximately 30 degrees. The resident was covered with a blanket over her face and appeared to be sleeping. On 7/19/2026 at 3:01 p.m., a telephone interview was conducted with the Resident #10's resident representative (RR). The RR stated Resident #10 had recent cognitive decline, was hard of hearing, and benefited from seeing her family member who also resided in the facility. The RR stated informing staff at the facility on numerous occasions of Resident #10's hearing deficit and stated she had placed a sign to remind staff of Resident #10's hearing deficit. On 7/19/2026 at 3:34 p.m., an observation was made of Resident #10 screaming incomprehensible words in her room while staff walked past the doorway without entering to assess or intervene. On 7/20/2026 at 12:48 p.m., an interview was conducted with Resident #10's family friend. The family friend stated coming to see both Resident #10 and her family member who resides in the facility as well. The family friend stated visiting two to three times a week. He stated Resident #10 did go see her family member last Wednesday, but it had been two weeks before that. Resident #10's family friend stated both Resident #10 and her family member had a great visit. The family friend stated Resident #10 loves to watch TV and visit her son. Resident #10's family friend stated it would be nice if she could socialize more. On 7/20/2026 at 4:18 p.m., an interview was conducted with Staff D, LPN. Staff D, LPN stated Resident #10 cried out daily, often yelling mommy, and stated they did not consistently document these episodes because they were considered normal for her. Staff were unaware of the resident's hearing deficit or family member residing in the facility. On 7/21/2026 at 4:30 p.m., an interview was conducted with Staff M, LPN. Staff M, LPN was at her medication cart down the 400 hallways and Resident #10 could be heard audibly crying out illegible high pitched rhythmic yelling. Staff M, LPN stated Resident #10 does this every day, that's just her. Staff M, LPN stated she was unaware Resident #10's family member was a resident in the facility. Staff M, LPN stated she was not aware of Resident #10's hearing deficit but stated she felt the resident can hear when she wants. Staff M, LPN stated she would put a progress note in today but does not usually as Resident #10 does this all the time and it is just her. On 7/21/2026 at 5:49 p.m., an interview was conducted with Staff K, CNA. Staff K, CNA stated she was familiar with Resident #10's family member residing in the facility and stated he has told her how happy he is when he sees her. On 7/22/2026 at 9:05 a.m., a telephone interview was conducted with Resident #10's primary APRN for psychiatric services. The APRN stated he will review progress notes both from her primary physician and the nurses' notes for behavioral concerns. The APRN stated he would review any new medications ordered and acknowledged he was titrating Resident #10's antipsychotic medication, Depakote, for her mood behaviors. The APRN stated he had checked her Depakote levels more for toxicity than for therapeutic levels. The APRN stated he could titrate the Depakote for effect if needed. The APRN stated he was aware of Resident #10's family friend visitor as well as her family member residing in the facility. The APRN stated both seem to have a calming effect for Resident #10. The APRN stated he is all for non-pharmacological interventions and a change of scenery would be beneficial for Resident #10. The APRN stated he did not believe Resident #10 was anti-social and added he had thought about implementing a plan for the two to see each other more often. On 7/22/2026 at 10:50 a.m., an interview was conducted with the Clinical Reimbursement Director (CRD). The CRD stated relying on daily reports and staff communication to update care plans and was unaware of the resident's hearing deficit. She stated she could add a communication related care plan and would seek guidance on including the family member as an intervention. The CRD stated the nurses could update the care plans as well. The CRD stated she does not generally look at hospice notes but does interview family during care plan meetings for the resident in order to individualize the care plan. The CRD stated she was unaware of Resident #10's hard of hearing diagnosis but could add a care plan for communication. The CRD stated she was aware of Resident #10's family member residing as well in the facility but did not know how to incorporate this into her care plan but she would ask her regional consultant for guidance. On 7/21/2026 at 2: 00 p.m., an observation was made in Resident #10's room with the Nursing Home Administrator (NHA) and a Chief Clinical Officer. Resident #10 was observed with her feet hanging over the right side of the bed. Resident #10 was anxious and crying, stating she was scared. The NHA reassured the resident by holding her hand and calming her down with soft words. The NHA utilized her cell phone to call the resident's RR to add an additional aspect to calming the resident. The resident calmed down and appeared comforted in talking with the RR. The resident demeanor changed and allowed the NHA to reposition her feet and denied pain. A record review of Resident #10's Task for Behavior Monitoring and Interventions for the month of June 2026 showed no behaviors identified. On 7/22/2026 at 1:51 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the staff would contact the primary physician or psychiatric services either by phone or directly in person especially if there was a change in condition or behavior. The DON stated she has been educating staff to be more sensitive in identifying behaviors and to report it. The DON stated Resident #10 non- interventions for her behavior would include talking in a calm voice and/or holding her hand. Review of Resident #10's admission Record showed an original admit date of 11/25/2025 and a re-readmit date of 2/12/2026 with diagnoses to include but not limited to need for assistance with personal care, depression unspecified, unspecified dementia unspecified severity without behavioral, psychotic or mood disturbance and anxiety, cognitive communication deficit. A record review of Resident #10's most recent psychiatric progress note dated 6/12/2026 showed an ICD-10 CM billing code for anxiety disorder that is directly caused by a known physical or medical health condition. A review of Resident #10's care plan showed a focus area for Activities with a newly added intervention to take Resident #10 to visit her family member to help deescalate behaviors. A record review of the facility's policy and procedure titled Dementia Management effective date of October 2021 showed the following policy statement: The interdisciplinary team will evaluate the resident/patient to identify the cause(s) of the inappropriate behavior(s) that are often associated with the diagnosis of dementia. Non-pharmacological interventions will be attempted prior to initiating pharmacological interventions. Procedure 1. Review and evaluate the following. Areas to review include, but are not limited to: admission Data Collection and Initial Plan of Care and/or Monthly Return and prn (as needed) data collection. Social Services Assessment/Discharge Evaluations Physician progress note Consultations Hospital Records Triggered RAPs (Resident Assessment Protocol): Cognitive loss/dementia 4. Determine resident/patient and/or family goals for inclusion in the Interdisciplinary Plan of Care (IPOC). 5. Schedule as IPOC or Standards of Care meeting to discuss data and identify interdisciplinary interventions. 6. Review and revise goals and interventions as indicated 7. Communicate interventions and goals with the care giving team. 8. Complete a new MDS (Minimum Data Set) if the dementia diagnoses indicates significant change A record review of the facility's policy and procedure titled, Behavior Management Program Overview effective October 2021 showed the following policy statement: The facility promotes the utilization of a behavior management program based on individual resident needs. The facility Behavior Management Program is provided by the interdisciplinary team and recognizes that behaviors exhibited by residents require appropriate identification, data collection, intervention, management and evaluation to assist the resident in obtaining their highest practicable level of functioning. The interdisciplinary team works in partnership with the resident/resident representative to establish effective interventions and goals. Non pharmacological interventions are the first choice in management of behavioral symptoms. Psychoactive medications are used after non-pharmacological interventions have been attempted without success. The lowest possible effective dose of psychoactive medication will be prescribed for documented clinical symptoms. Dose management is reviewed by the Interdisciplinary Team (IDT) and in conjunction with physician and pharmacist recommendations. Clinical contraindications to dose reduction are documented Side effects of the psychoactive medication are monitored by observations and documented on the eMAR (electronic Medication Administration Record) Procedure: 3. Review potential causes of behavioral symptoms with the IDT. Potential causes include, but are not limited to: Illness/conditions (i.e., pain, constipation, Alzheimer's disease) Cognitive status problems (i.e., confused) Mood and/or relationship problems (i.e., grief, placement adjustment) Environmental conditions (i.e., noise, crowding) Current treatment/management procedures (i.e., how are behaviors currently being addressed) Medication side effects 4. Identify and implement interventions based on identified triggers and possible causes of behaviors. 5. Discuss the resident/resident representative goal(s) for managing the resident's behaviors for inclusion of the care plan. 7. Identify individual specific behavior symptoms goals and interventions. 8. Communicate resident centered interventions to staff. 9. Monitor the frequency of the behavior(s) and the effectiveness of the interventions. 10. Review side effects from the medication, notify practitioner if needed. 11. Review and revise the care plan and Kardex as needed.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored according to accepted professional standards. The facility did not ensure one treatment cart (outside 300/400 hall) of two carts observed was locked and inaccessible to unauthorized personnel, visitors, or residents; and did not ensure crushed and unidentifiable medications were not left at bedside for one resident #13) of four residents observed; and did not ensure medications were not left lying on the hallway floor of a resident living area. These failures had the potential to result in unsafe medication administration, medication diversion, and improper storage conditions.Findings included: An observation on 8/29/26 at 9:05 a.m. revealed one treatment cart parked across from the nursing station on the 300/400 hall, positioned against the half wall shared with the dining area, was unlocked and unattended. The nurses assigned to the 300 and 400 hallways were observed at the ends of their respective halls with their medication carts, and one aide was observed on the 400 hall near the nurse's area. The second drawer of the unlocked cart contained prescribed lotions and ointments. Staff A, Manager on Duty, walked by after escorting the survey team to the conference room and stated no the cart was not to be unlocked.During an observation on 8/29/26 at 9:31 a.m., Resident #13 was lying in bed and did not respond to verbal introduction. The resident was wearing a nasal cannula delivering 2 liters per minute of oxygen, and a bottle of liquid nutrition was infusing at 65 milliliters per hour. A plastic opaque water cup was observed on the bedside dresser, located on the same side of the bed as the nutrition pump and near the head of the bed. The cup contained a white, cream, and peach colored powdery substance that covered the bottom of the cup, and a white plastic spoon was resting inside it.An interview and observation conducted with Staff B, Licensed Practical Nurse (LPN), on 8/29/26 at 9:34 a.m. revealed Staff B stated the substance looked possibly like medications. Staff B returned to the medication cart, reviewed the resident's available medications, and noted the resident had a peach colored Hydralazine ordered, and stated they did not leave medications in a resident's room.Record review of Resident #13's admission Record showed the resident was admitted on [DATE] with diagnoses that included non traumatic intracerebral hemorrhage in the cerebellum, acute respiratory failure with hypoxia, hemiplegia unspecified affecting the left nondominant side, obstructive hydrocephalus, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side.A review of Resident #13's admission Minimum Data Set (MDS), dated [DATE], showed the Brief Interview for Mental Status (BIMS) was not conducted, as the resident was rarely or never understood. The staff assessment for mental status showed the resident had short and long term memory problems and severely impaired daily decision making. The swallowing and nutritional status section showed the resident received nutrition through a feeding tube.Review of Resident #13's Medication Administration Audit Report for 8/29/26 showed the resident received, via gastrostomy tube (G tube), one 10 milligram tablet of metoclopramide at 12:57 a.m., and at 5:21 a.m. received one 10 milligram tablet of metoclopramide and one 40 milligram tablet of isosorbide dinitrate. The report showed Staff B documented administering the following medications and fluids via G tube at 8:26 a.m.: lansoprazole delayed release disintegrating 30 milligram tablet; 200 milliliters of free water; oxycodone 5 milligram tablet; losartan potassium 25 milligram tablet; hydralazine 50 milligram tablet; Jardiance 25 milligram tablet; G tube flush with 300 milliliters of water; glipizide 5 milligram tablet; clonidine 0.1 milligram tablet; aspirin enteric coated delayed release 81 milligram tablet; doxazosin 4 milligram tablet; amlodipine besylate 10 milligram tablet; baclofen 5 milligram tablet; and labetalol 200 milligram tablet. Review of the physician orders for Resident #13 showed staff were to Dilute each crushed/sprinkles/powdered med with at least 15 mL of water and rinse the cup with 5 to 15 mL to ensure all residue is out of the cup.An observation on 8/29/26 at 9:48 a.m. revealed a white oval caplet lying on the 400 hallway floor underneath a blue Geri chair parked between rooms [ROOM NUMBERS]. Staff C, Licensed Practical Nurse (LPN), observed the caplet and stated no it should not be there.During an interview on 8/29/26 at 2:25 p.m., the Director of Nursing (DON) stated medications were not allowed to be left at the bedside unless the resident had been evaluated and approved for self administration. The DON stated Resident #13 did not have an order for self administration, that pills observed on the floor should be picked up, and that treatment carts were supposed to be locked.Review of the policy, Storage of Medication, dated 01/26, showed medications and biologicals were to be stored properly according to manufacturer or pharmacy recommendations to maintain integrity and support safe, effective drug administration. The policy stated medication supplies were accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. The policy also stated that in order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications, such as medication aides, were allowed access to medication carts, and that medication rooms, cabinets, and medication supplies were to remain locked when not in use or attended by authorized staff.

Based on observations, record reviews, and interviews the facility failed to notify the resident representative of one (#79) of three sampled residents of the administration of a one-time dose of an injectable anti-anxiety medication for stabilization and the implementation of a topical gel containing three psychotropic medications.Findings include: On 7/19/26 at 11:06 a.m., Resident #79 was observed lying in bed with eyes closed. During lunch the same day, the resident's meal tray was observed sitting on the over bed table positioned next to the resident while the resident continued to lie in bed with eyes closed. The room remained dark and silent. Review of Resident #79's admission record showed the resident was admitted on [DATE] with diagnoses including, but not limited to, unspecified psychosis not due to a substance or known physiological condition, dementia and other behavioral disturbances, mood disorder due to known physiological condition with mixed features, moderate recurrent major depressive disorder, and anxiety disorder. The record identified one family member as the responsible party, healthcare proxy, and care/financial power of attorney (POA), and another family member also listed as a care/financial POA Review of Resident #79's Minimum Data Set (MDS) dated [DATE] revealed Resident #79 was severely cognitively impaired. Review of the physician orders showed an order dated 7/14/26 for Ativan 2 mg/mL, to inject 0.5 mL intramuscularly every 12 hours as needed for anxiety with agitation and behaviors, for 5 days. The physician also ordered on 7/14/26, a topical compound containing 0.5 mg Ativan, 12.5 mg Benadryl, and 0.5 mg Haldol (ABH) to be applied to alternating sites every 12 hours as needed for anxiety with agitation, for 15 days. Review of Resident #79's Medication Administration Record (MAR) showed the resident had not received any intramuscular Ativan doses. The MAR documented topical ABH gel administration on 7/17, 7/18, 7/19, and 7/20/26. The resident's controlled drug record showed ABH doses were administered on 7/16, 7/17, 7/18, 7/19, 7/20 (twice), and 7/21/26. Review of Resident #79's primary care physician and psychiatry/psychology notes revealed no entry dated 7/13 or 7/14/26 corresponding with the ordering of the ABH gel. Review of Resident #79's nursing progress notes dated 7/13-7/15/26 did not show documentation that the responsible party or either POA was notified of, or educated about, the ordered intramuscular Ativan or topical ABH gel prior to administration. During an interview on 7/21/26 at 1:44 p.m., Staff L, psychiatry Advanced Registered Nurse Practitioner (ARNP), reported witnessing Resident #79 being combative and unable to be redirected. Staff L stated the facility administered intramuscular Ativan. The ARNP reported Resident #79 became calmer with the Ativan and the playing of music. Staff L stated they did not speak to the family on 7/14/26, and that either the Assistant Director of Nursing (ADON) or Director of Nursing (DON) typically contacted the family. During an interview on 7/22/26 at 1:50 p.m., the DON stated she had not reached out to the family regarding the ABH gel or the intramuscular Ativan orders. She stated the nursing progress notes should contain the information regarding obtaining consent for administration of intramuscular Ativan and/or topical ABH from the resident/resident representative.

Based on interviews and record reviews, the facility failed to follow through on a resident's request to transfer to another skilled nursing facility, which resulted in no referrals being sent and no documented follow up, for one (Resident #92) out of one resident reviewed who had expressed a desire to transfer to another facility.Findings include: A record review showed Resident #92 was readmitted to the facility on [DATE] with diagnoses including, but not limited to, paraplegia, major depressive disorder, and adjustment disorder. A review of the minimum data set (MDS), dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. During an interview conducted on 7/19/2026 at 9:58 A.M., Resident #92 stated he wanted to transfer to a skilled nursing facility in [NAME], Florida, to be closer to his family. The resident stated he had spoken with the facility about transferring and had not received any follow up information. A review of the care plan initiated on 3/17/2020 showed an intervention instructing staff to ask the resident if he desired to talk to someone about the possibility of leaving the facility. A review of Resident #92's progress notes from April 2026 through July 2026 revealed no documentation that addressed Resident #92's request to transfer to a facility closer to family. During an interview conducted on 7/21/2026 at 1:55 P.M., the Social Services Director (SSD) stated she had spoken with the resident on several occasions about transferring to another facility so he could be closer to his family. The SSD stated she had not sent any referrals to other facilities. During an interview conducted on 7/21/2026 at 2:41 P.M., the Nursing Home Administrator (NHA) stated she did not know whether the SSD had sent referrals. The NHA stated referrals were sent in March other facilities but stated she did not know whether the facilities denied the referrals, placed the resident on a waiting list, or accepted him. The NHA was unaware if any follow up had occurred. A review of the facility's policy titled Resident Rights, effective 2025, showed the facility was required to promote resident self determination and ensure access to persons and services inside and outside the facility. The policy required the facility to protect and promote each resident's rights.

Based on interviews and record review, the facility failed to ensure a resident's wish for advanced directives to not be resuscitated were honored for one (Resident #2) out of eight residents reviewed for advanced directives. This had the potential for staff to initiate unwanted resuscitative measures.Findings include: A review of Resident #2's admission record showed Resident #2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, muscle wasting and atrophy and acute and chronic respiratory failure. A review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #2 was cognitively intact. Durning an interview on [DATE] at 9:15 A.M. Resident #2 stated not wanting staff to intervene in the event of an emergency. Resident #2 said he did not want cardiopulmonary resuscitation (CPR) performed or to be sent to the hospital. A record review of Resident #2's physician orders for [DATE] revealed an order for DNR [Do Not Resuscitate] with no directions specified. The order was active and had a start date of [DATE]. A review of Resident #2's paper medical chart showed a physician order written on [DATE] indicating Resident #2 was a Full Resuscitation meaning CPR should be performed. A review of Resident #2's care plan, initiated on [DATE], revealed an advanced directive focus with a goal stating: Resident's wishes and directions will be carried out in accordance with their advanced directives on an ongoing basis through the next review date. An interview was conducted on [DATE] at 12:10 P.M. with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN said if a resident coded, she would go to review the paper medical chart for any advanced directives. Staff C, LPN said Resident #2 was a full-code, and she would initiate CPR if resident was found unresponsive. An interview was conducted on [DATE] at 12:15 P.M. with Staff B, LPN. Staff B, LPN said if a resident was found unresponsive, she would look at the resident electronic medical record for any advanced directives. Staff B, LPN said there was not a second verification process for finding a resident's advance directive status. Staff B, LPN said Resident #2 was a DNR and would not start CPR. An interview was conducted on [DATE] at 12:20 P.M. with the Director of Nursing (DON). The DON said the expectation was for nurses to verify code status by looking at the resident's paper medical chart and not the electronic medical record. An interview was conducted on [DATE] at 1:20 P.M. with the Social Services Director (SSD). The SSD said Resident #2 was a DNR. The SSD said she had not spoken to Resident #2 about their wishes. The SSD said all the DNRs are uploaded into PCC so that nurses can check for the goldenrod [state approved] DNR. A review of Resident #2's paper medical chart on [DATE] at 9:00 A.M. revealed a goldenrod signed by Resident #2. The goldenrod was not dated and not signed by a medical provider. An interview was conducted on [DATE] at 2:15 P.M. with the Nursing Home Administrator (NHA). The NHA said the DNR order was entered in the electronic medical record on [DATE]. The NHA said two nurses signed the goldenrod/DNR order and did not date it. The NHA said the physician did not sign the goldenrod/DNR until [DATE]. A review of a policy effective [DATE], titled, Advanced Medical Directives revealed .Social Services will place the Advanced Medical Directives in the resident's medical record and ensure that the presence, or absence, of Advanced Medical Directives is documented in the resident record. The procedure was 5: Document the Advanced Medical Directives that are current and in place on the medical record. 7: Update medical record with new or revised Advanced Medical Directives as indicated. 8: When a resident rescinds or changes his/her Advanced Medical Directives.removed the old document from the record and return it to medical records for filing in closed chart. Place updated document in the record and document in the medical record.

Based on record review and interviews, the facility failed to obtain the required Level II Pre admission Screening and Resident Review (PASRR) determination prior to admission for one resident (Resident #79) of nine reviewed, resulting in the resident being admitted without confirmation that the nursing facility was an appropriate placement. Findings include: Record review showed Resident #79 was admitted on [DATE] with multiple diagnoses including dementia in other diseases classified elsewhere with behavioral disturbance, mood disorder due to a physiological condition with mixed features, moderate recurrent major depressive disorder, unspecified anxiety disorder, and on 7/20/26 an added diagnosis of unspecified psychosis not due to a substance or known physiological condition. Review of Resident #79's Level I PASRR dated 5/15/26, completed by an acute care hospital, showed the form indicated the individual may not be admitted to a nursing facility and required a Level II PASRR evaluation due to a diagnosis of, or suspicion of, Serious Mental Illness. The PASRR documentation instructed the facility to request a Level II evaluation. Review of Resident #79's medical record showed no Level II PASRR results. The admission Checklist dated 6/9/26 documented that the admitting nurse verified all PASRR pages were present, checked the accuracy, and verified whether the resident had triggered a Level II. The 3008 form [a medical certification document used to establish medical eligibility for Medicaid long-term care services, such as nursing facility care or home- and community-based waiver programs] completed prior to admission showed the resident required a surrogate and listed the primary diagnosis as dementia with agitation. The History and Physical dated 5/14/26, completed at an acute care facility prior to admission, documented that the resident had been returned from another facility due to episodes of agitation with aggression and that the prior facility would not take the resident back. During an interview with the admission Coordinator (AC) on 7/21/26 at 11:11 a.m., the AC stated hospitals upload PASRR documents and the AC prints and provides them to the floor nurse, who then uploads them into the resident record. The AC stated hospitals complete Level I PASRRs nine out of ten times and often do not provide Level II determinations. During an interview on 7/21/26 at 11:20 a.m., the Social Services Director (SSD) stated being the one who determined if a Level I was updated. The hospital was definitely supposed to send the Level II if it was required. The SSD reported being unsure whether Resident #79 had a Level II PASRR because they were an interim SSD and had only been at the facility for three weeks. The SSD reviewed page two of the Level I PASRR and confirmed it was missing diagnoses. The SSD also verified there were no Level II PASRR results uploaded in the resident's chart. During a follow up interview at 11:35 a.m., the SSD added that the resident came from a named acute care facility. During an interview on 7/21/26 at 2:07 p.m., the SSD stated that Resident #79's behaviors had been stable and that the state contracted PASRR vendor had ruled out the need for a Level II. The SSD provided the vendor's decision and reported that it was received that day. The SSD stated that if the Level I indicated a Level II was required, the facility should have obtained the determination prior to admitting the resident. Review of the facility's policy titled PASRR Requirements for Completion, effective August 2025, showed the PASRR process is required prior to admission per 42 CFR 483.100 and applies to all individuals entering a Medicaid certified nursing facility regardless of payer source. The procedure stated that admissions must confirm a Level I PASRR is completed prior to transfer and determine whether a serious mental illness or intellectual disability exists that triggers a Level II. The policy further stated that if a Level II evaluation is required, all documents must be submitted timely so the Level II can be completed within required timeframes.

Based on observations, record reviews, and interviews, the facility failed to ensure that one (Resident #94) of two residents sampled for limited range of motion (ROM) received necessary treatment and screening to maintain mobility and prevent decline. This failure resulted in the resident demonstrating a closed right fist with pain behaviors, lack of an ordered orthotic device, and no evidence of quarterly therapy screenings following hospital discharge.Findings included: On 7/20/26 at 9:53 a.m., Resident #94 was observed lying in bed holding the right arm over the chest at a greater than 45 degree angle, with the right hand clenched and the thumb positioned inside the palm. The resident grimaced, opened the mouth, and reached with the left hand toward the right fist. Staff B (LPN) stated the resident did not have any device for the clenched hand and the nurse did not know whether the resident could open the hand. Staff B also indicated the resident's actions suggested pain and that the staff member was unsure which language the resident spoke. Review of Resident #94's admission Record showed admissions on 11/14/25 and 1/20/26. Diagnoses included dysphasia following non traumatic intracranial hemorrhage, expressive language disorder, need for assistance with personal care, and abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident did not complete a Brief Interview of Mental Status due to severe cognitive impairment, had range of motion impairment in both upper and lower extremities, and had no functional speech, with the resident rarely or never understood. Review of the resident's care plan showed an Activities of Daily Living (ADL) self care performance deficit related to cerebrovascular accident (CVA) with right side hemiplegia, cerebral ischemia, physical weakness, and deconditioning. The resident was aphasic and unable to make needs known. Interventions included a right enabler for bed mobility, notation that the resident was totally dependent for ADLs (11/21/25), and AM/HS routine care encouraging performance at the highest functional level.A separate care plan for pain instructed staff to observe and report changes in routine, sleep, functional abilities, range of motion, withdrawal, or resistance to care.The care plan did not include implementation of a right upper extremity orthotic device. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment dated 11/17/25 showed Resident #94 required total assistance for upper and lower body dressing and toileting tasks. Resident #94's right upper and lower extremities were flaccid following CVA, with zero (0/5) strength, and no palpable muscle tension. Risk factors noted the Resident #94 at risk for falls and functional decline due to impairments. Review of Resident #94's OT Discharge summary dated [DATE] showed Resident #94's abilities remained impaired, with maximum assist for dressing and total assist for toileting at discharge. The discharge occurred due to hospital transfer. An interview was conducted on 7/20/26 at 10:08 a.m. with Staff I, Certified Nursing Assistant (CNA). Staff I stated Resident #94 could open the hand, but did not want to, and staff had to perform the movement. Staff I stated the resident did not have an orthotic device, but needed one. An interview was conducted on 7/21/26 at 5:25 p.m. Staff K, CNA, reported Resident #94 could help open (right) hand. An interview was conducted on 7/22/26 at 9:41 a.m. with the Director of Rehabilitation (DOR). The DOR stated Resident #94 was not currently receiving therapy and had ended physical, occupational, and speech therapy on 1/10/26 when discharged to the hospital. The DOR stated when therapy discharged the resident on 1/10/26 the resident did not have contractures. The DOR stated the Minimum Data Set (MDS) staff and unit managers do weekly rounds for residents' who are due for quarterly (assessments). The DOR stated the rounds are not documented electronically but on paper. Review of the January, February, and March 2026 screening list did not include Resident #94. The DOR stated the resident may not have been put on the list and would need to go through the documentation to see if the resident had been screened. A request was made for documentation showing Resident #94 had been screened since returning from the hospital in January. The DOR described a contracture as being a shortening of tendon or muscle after being flaccid which could cause pain. The DOR stated therapy should be notified if a resident developed a contracture or positioning was incorrect, therapy would assess the shortening and start passive range of motion if tolerated then present either a passive or functional brace or a palm guard. The DOR observed Resident #94 holding right hand in closed fist lying on left chest. The resident was grimacing and rubbing right hand. The DOR stated the resident was not like this last time she had seen the resident. The DOR attempted to move elbow and stated the resident was resisting. The resident continued to grimace, not allowing the DOR to attempt opening of the right hand. The DOR stated therapy should have been notified of the change in positioning of arm and hand for treatment. The DOR stated she would review the quarterly screenings to find out when Resident #94 was last seen. Review of the January, February, and March 2026 Screening List did not show Resident #94. The DOR stated the resident may not have been put on the list and would need to go through the documentation to see if Resident #94 had been screened. A request was made for documentation showing Resident #94 had been screened since returning from the hospital in January. No documentation was provided prior to survey exit. During the observation of Resident #94 with the DOR on 7/22/26 at 9:41 a.m., Staff J, CNA stated Resident #94 did not open the right hand and had been this way since being moved to a different hall. An interview was conducted on 7/22/26 at 2:54 p.m. Staff J, CNA, stated the resident used to be on a different hall but the right hand has not changed in the past six months and would benefit from something in the hand. Review of the policy - Therapy Evaluation, undated revealed evealed requirements for initial evaluation and documentation of medical and functional status prior to treatment. The policy states residents screened or referred for therapy must receive evaluation after physician order, and therapy recommendations must be documented, submitted to the physician, and placed in the chart.The policy did not demonstrate that the facility followed these procedures for Resident #94 after returning from the hospital.

Based on observations, interviews, and record review, the facility did not ensure that the environment for one (Resident #10) of three residents reviewed, remained as free of accident hazards as possible. The facility failed to ensure that oversized fall mats and hanging electrical wires did not create gaps, obstructions, or entrapment risks in the resident's immediate environment. This deficient practice had the potential to result in accidents or injury. Findings include: On 7/19/2026 at 9:40 a.m., an observation was made in Resident #10's room. Resident #10 had two oversized dark blue fall mats placed on each side of her bed. Each mat was approximately twelve inches high. The resident's bed was positioned with both the head and foot sections elevated to approximately 30 degrees. Resident #10 was lying in bed with a blanket covering her face and appeared to be sleeping. Review of Resident #10's admission record showed she was admitted on [DATE] and readmitted on [DATE]. Diagnoses included moderate protein calorie malnutrition, unspecified dementia without behavioral disturbances, muscle wasting and atrophy of multiple sites, and cognitive communication deficit. A review of Resident #10's Minimum Data Set (MDS) dated [DATE] showed Resident #10 required substantial/maximal assistance for rolling left and right. Substantial/maximal assistance is defined as requiring a helper to complete more than half (over 50%) of the effort needed for the activity. On 7/21/2026 at 8:39 a.m., an observation was made during breakfast tray delivery to Resident #10's room. The resident's assigned Certified Nursing Assistant (CNA) and another CNA repositioned the resident and prepared her breakfast tray. The assigned CNA lifted the oversized fall mat on the left side, folding it upward into a block like shape. The second CNA moved along the limited floor space against the wall to position herself at the bedside. On 7/21/2026 at 10:20 a.m., an interview was conducted with the facility's Program Manager for Therapy. Resident #10 had therapy for both occupational and physical therapy with a start date of 3/23/2026 and a discharge date of 6/09/2026 and 6/10/2026. The Program Manager for Therapy stated Resident #10 had a decline with her upper body from minimal assist to substantial/moderate assist and a slight improvement for her lower body from total assistance to max 2 assist. The Program Manager for Therapy stated she recalled the resident had a fall in February with the Interdisciplinary Team (IDT) decision to place one fall mat as a plan of correction. On 7/21/2026 at 8:50 a.m., an observation was made of Resident #10 lying in bed with both the head and foot sections elevated to approximately 45 degrees. A gap was observed between the head of bed mattress and the bed frame. The oversized dark blue fall mat met the bed frame and created a triangular shaped gap measuring approximately twelve inches at the top and tapering to approximately two inches along the frame. A similar triangular gap was observed on the opposite side of the bed. The left fall mat touched the wall at its upper portion, leaving a gap of approximately four to five inches toward the bottom. Electrical wires were observed hanging downward from the television area and resting on the floor. Additional triangular gaps were observed at the foot of the bed, including a five to six inch gap between the end of the mattress and the footboard frame. On 7/21/2026 at 1:10 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that following Resident #10's fall in February, an intervention was added to her care plan for the floor mats. The DON stated that although the resident did not move much, she was considered a fall risk and still required fall mats. The DON stated the mats were sturdy and would not give. On 7/21/2026 at 1:27 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated the floor mats were implemented following the resident's February fall. She stated the resident was considered a fall risk and that the mats were intended to eliminate level changes by aligning the mats as closely as possible to the bed surface. The NHA stated she wanted to visually assess the mats in relation to the resident's bed.On 7/21/2026 at 2:00 p.m., an observation was made with the NHA and the Chief Clinical Officer in Resident #10's room. Resident #10 was lying in a similar position as earlier in the day, except both legs were hanging off the right side of the bed from the shin area downward. Both the NHA and Chief Clinical Officer acknowledged the triangular gaps along both sides of the bed and the gap between the mattress and the footboard frame. A review of the facility's policy titled Free of Accident Hazards/Supervision/Devices, effective August 2025, showed the policy required the facility to identify and provide needed care and services in accordance with resident preferences, goals, and professional standards. The policy required that the resident environment remain as free of accident hazards as possible and that each resident receive adequate supervision and assistive devices to prevent accidents. [Photographic evidence obtained]

Based on interviews and record review the facility failed to ensure its facility-wide assessment was updated and included staff competencies and training needed to care for residents with different acuity levels including those with behavioral needs, specific staffing needs for each shift, recruitment and retention strategies, or input from direct care staff for one of one facility assessment. The incomplete assessment limited the facility's ability to identify the resources needed to provide care safely and respond effectively to care needs.Findings Included: Review of the facility assessment dated [DATE] revealed the facility did not include an emergency plan, a hazard vulnerability assessment, or recruitment and retention strategies. The assessment also lacked staff competency requirements for residents with varying acuity levels, training needs for residents with behavioral needs, and specific staffing requirements for each shift. In addition, the assessment did not contain input from direct care staff. During an interview on 07/22/2026 at 3:55 p.m., the Staffing Coordinator stated she staffed the facility daily based on the per patient day (PPD) number. She stated she did not know what the facility assessment was and did not use the assessment to determine staffing patterns. During an Interview on 07/22/2026 at 4:04 p.m., the Nursing Home Administrator (NHA) stated she updated the facility assessment in July 2026. She stated the assessment included the emergency plan and staff education. She also stated the assessment did not include staffing needs based on resident acuity and that the facility typically staffed based on census. The Administrator stated the facility held hiring events to obtain additional staff and that regional consultants rotated through the building to assist. The facility did not provide a policy related to the facility assessment.

Based on observations, record reviews, and interviews the facility failed to reconcile medication ensuring an accurate inventory of the controlled drugs administered to one (Resident #79) of two residents.Findings included:On 7/19/26 at 11:06 a.m., Resident #79 was observed lying in bed with eyes closed, the room was dark and without any music and/or television playing.On 7/21/26 at 9:18 a.m. Resident was observed lying in bed with eyes closed, the room did not have any music and/or television playing.On 7/21/26 at 3:41 p.m. Resident #79 was observed lying in bed with eyes closed, all lights in the room were off and no music or television was playing.Review of Resident #79's admission Record showed the resident was admitted from an acute care hospital on 6/9/26. The record included diagnoses not limited to anxiety disorder, dementia with other behavioral disturbance, psychosis not due to a substance or known physiological condition, mood disorder due to known physiological condition with mixed features, and moderate recurrent major depressive disorder.Review of Resident #79's Medication Administration Record (MAR) showed an order, dated 7/14/26 for Ativan 0.5 milligram (mg)/Benadryl 12.5 mg/Haldol 0.5 mg (ABH) gel - apply to alternating sites topically every 12 hours as needed for anxiety with agitation for 15 days. The MAR showed the resident had received 4 doses: once on 7/17, 7/18, 7/19, and 7/20/26.Review of Resident #79's Controlled Drug Record for ABH gel showed the resident had received seven doses: once on 7/16, 7/17, 7/18, 7/19, 7/21/26, and twice on 7/20/26. During an interview on 7/21/26 at 10:30 a.m. Staff B, Licensed Practical Nurse (LPN) reported giving a dose of ABH gel to Resident #79 as the aide had reported the resident was beginning to escalate. Review of the available doses of ABH gel showed a total of 23 syringes out of 30 delivered from pharmacy, confirming 7 doses had been administered.An interview was conducted with the Director of Nursing (DON) on 7/21/26 at 1:44 p.m. The DON said staff were to document administration of narcotics in the electronic record then on the narcotic record upon administration.An interview was conducted with the Consultant Pharmacist on 7/21/26 at 12:55 p.m. The consultant explained that a quarterly review of the nursing station is completed, including checking MARs for medication administrations and verifying that all signatures correspond with the narcotic records. Staff are expected to sign out narcotics at the time of administration. For medications given as needed (PRN), staff should document immediately, as the computer is readily accessible. The consultant stated this is the standard practice and, from a pharmacist's perspective, signing at the time of administration is expected because it is easy to forget later.During an interview on 7/22/26 at 1:50 p.m. the Director of Nursing (DON) reviewed Resident #79's MAR and saw the order for ABH gel and didn't see any doses were administered yesterday (7/21/26). Reviewed a copy of the resident's ABH controlled drug record with the DON, who stated staff should be documenting the narcotic count and the administration record. Review of the policy - Controlled Substances; Section 7.4, dated 01/26, revealed Controlled medications are substances that Have an accepted medical use (medications which fall under U. S. Drug Enforcement Agency (DEA) schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations.2. The director of nursing and the consultant pharmacist to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable inaccurate reconciliation, and determine that drug records are in order and then an account of all controlled drugs is maintained and periodically reconciled.4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: (Note: refer to state regulations for particulars regarding scheduled classes in proper storage.)a. Date and time of administrationb. Amount administeredc. Signature of the nurse administering the dose5. Administer the controlled medication and document dose administration on the MAR.

Based on observations, interviews and record review the facility did not ensure infection control practices were demonstrated according to professional standards related to the use of personal protective equipment for one (room [ROOM NUMBER]) of two rooms sampled.Findings included:An observation on 7/19/2026 at 9:35 A.M. of room [ROOM NUMBER]B, 108A, and 108B was conducted. The rooms contained a contact precaution sign on the entryway to the door.An observation on 7/19/2026 at 12:52 P.M. of room [ROOM NUMBER]B revealed Staff G, Certified Nursing Assistant (CNA) entering room [ROOM NUMBER]B without personal protective equipment (PPE). Staff G, CNA was providing room [ROOM NUMBER]B with ice water. Staff G, CNA was touching room [ROOM NUMBER]B's bed and bedside table. Staff G, CNA exited room [ROOM NUMBER]B without performing hand hygiene and proceeded to prepare ice water in white foam cups.An interview on 7/19/2026 at 12:54 P.M. with Staff G, CNA, was conducted. Staff G, CNA said all residents with a urinary catheter were required to be on contact precautions. Staff G, CNA said when a resident was on contact precautions, she would only wear PPE when providing care to the urinary catheter, not just providing water.An interview on 7/19/2026 at 12:56 P.M. with Staff F, CNA, was conducted. Staff F, CNA said if a resident was on enhanced barrier precautions (EBP), the staff were required to wear PPE before entering the resident's room. Staff F, CNA said if a resident was on contact precautions, the staff are not required to wear PPE. Staff F, CNA said the staff would only wear PPE with a contact precaution resident when providing high contact care.An observation on 7/20/2026 at 1:22 P.M. of Staff E, CNA, was conducted. Staff E, CNA walked into room [ROOM NUMBER] without performing hand hygiene or donning PPE. Staff E, CNA was conversing with the resident in 102B, touching the resident's curtain, and standing next to the resident's left side of the bed. Staff E, CNA walked out of 102B and proceeded to walk down the hallway.An interview on 7/20/2026 at 1:25 P.M. with Staff E, CNA, was conducted. Staff E, CNA said she was not providing care to the resident in 102B and therefore would not need to wear PPE.An interview on 7/22/2026 at 12:10 P.M. with the Director of Nursing (DON) was conducted. The DON said her expectation was for all staff to don PPE prior to entering a contact precaution room. The DON said when a resident was placed on enhanced barrier precautions, then her expectation would be for staff to don PPE when providing direct care.An interview on 7/22/2026 at 1:00 P.M. with Staff D, Licensed Practical Nurse (LPN) was conducted. Staff D, LPN said when a resident was on contact precautions, she would not need to wear a gown or gloves unless she was providing direct care to the resident. Staff D, LPN said if she was passing medications to a resident on contact precautions, she would not wear PPE. Staff D, LPN said if a resident was on enhanced barrier precautions, she would not wear a gown or gloves. Staff D, LPN said enhanced barrier precautions means washing your hands after providing care to the resident.A review of a policy effective in October 2021, titled, Infection Prevention and Control Program revealed the infection prevention, and control program is comprehensive program that address detection, prevention and control of infections and communicable diseases among residents, visitors, volunteers, those individuals providing services under contractual agreement and personnel. One of the goals of the program was, D: Identify and correct problems relating to infection control and prevention practices. The major activities of the program was, C: Prevention of spread of infections is accomplished by the use of Standard Precautions, orgamism specific precautions, and other barriers.

Based on observations, interviews, record reviews, the facility failed to implement and maintain an infection prevention and control program to mitigate and prevent the spread of infection related to: 1) not ensuring staff were donning appropriate Personal Protective Equipment (PPE) when entering a resident room under transmission based precautions, 2) not ensure residents were offered handy hygiene prior to meal service for one of four halls observed and 3) did not ensure the laundry area was kept in a manner to prevent the spread of infection.Findings included: An observation was made on 2/2/26 at 12:52 p.m. of staff delivering meal trays to residents on the 400-hall. The observations showed: At 1:02 p.m. Staff E, Licensed Practical Nurse (LPN) was observed delivering tray to room [ROOM NUMBER], A-bed. The staff member did not offer hand hygiene to the resident. At 1:03 p.m. Staff E delivered tray to room [ROOM NUMBER], A-bed. The staff member did not offer hand hygiene to the resident. At 1:05 p.m. Staff M, Risk Manager brought tray to room [ROOM NUMBER] B-bed and did not offer the resident hand hygiene. At 1:09 p.m. Staff E delivered tray to room [ROOM NUMBER] an did offer hand hygiene to the resident. At 1:11 p.m. Staff J, Traveling Social Service Director, brought Resident #9 to room and Staff M, Risk Manager brought tray to resident. The staff members did not offer the resident hand hygiene. At 1:16 p.m. Staff N, Registered Nurse (RN) delivered another tray to room [ROOM NUMBER] A-bed, offering to cut potato and meat. The staff member did not offer hand hygiene to the resident. An interview was conducted on 2/4/26 at 9:39 a.m. with Staff C, LPN/Clinical Reimbursement Specialist (CRS). Staff C, LPN/CRS stated passing meal trays at breakfast and lunch. Staff C stated hand sanitizer is provided in multiple locations. The staff member reported offering hand hygiene to residents. An interview was conducted on 2/4/26 at 9:51 a.m. with Staff O, Certified Nursing Assistant (CNA). Staff O, CNA said I sometimes offers hand hygiene in the dining room. An interview was conducted on 2/4/26 at 10:37 a.m. with Staff P, CNA. Staff P, CNA said hand hygiene is offered when passing meal trays. Staff P said before meals I get the hand sanitizer from the wall (waving hand toward wall dispenser in hallway). An interview was conducted on 2/4/26 at 10:40 a.m. with Staff H, LPN. Staff H, LPN said residents do not have hand sanitizer wall dispensers in room, some have individual bottles. Interviews were conducted with a five random residents on the 100, 300, and 400 hallways. The residents reported eating in their rooms. The residents stated hand hygiene is not offered before meals. An observation and interview was conducted on 2/4/26 at 8:25 a.m. of the laundry area with the Nursing Home Administrator (NHA), Account Manager (AM), and Staff Q, laundry aide (LA). Staff Q, LA moved through a narrow walkway with a wooden frame table on one wall and carts on the opposite wall. Above the table was a rack with personal items, hanging barely above top of the table. The table was holding stacks of folded bed linens and gowns with a small area for folding. The laminate top of the folding table was separating from the wood underneath, making an uncleanable surface. Mechanical equipment was observed with exposed wires near ceiling. The wires were smothered with dust. Staff Q, LA stated not cleaning the wires. Staff Q, LA stated only cleaning the laundry every other day. An observation was conducted on 2/4/26 at 10:50 a.m. revealed Staff Q, LA pulling laundry from the washer. The rim of the washer, behind the door was missing a portion of a black-colored gasket and the area had a tan and white colored flaking material, the linens were in contact with this flaking material. The NHA stated she was aware there were issues with the area. An interview was conducted on 2/4/26 at 10:50 a.m. with the NHA. The NHA reported the housekeeping supervisor was responsible for the upkeep and auditing of the laundry area. Photographic evidence was obtained. An observation on 2/4/26 at 11:11 a.m., the Director of Nursing (DON) entered room [ROOM NUMBER] without personal protective equipment (PPE) or performing hand hygiene. room [ROOM NUMBER] had an infection control caddy and a sign on the entrance displaying droplet precautions. The DON exited the room without performing hand hygiene. The DON re-entered the room without gloves or gown and touched the privacy curtain; donned the gown that she was holding while inside the room; and grabbed a clear bag displaying disposable vital sign equipment. The vital sign equipment had not been opened. The DON removed the PPE and exited the room without performing hand hygiene. An interview on 2/4/26 at 11:20 a.m. with the DON was conducted. The DON said her expectation for staff entering a room on droplet precautions are staff need to don a gown, mask, gloves, and face shield. A review of a facility provided policy effective October 2021 titled, Infection Prevention and Control Program revealed: The infection prevention and control program (IPCP) is a comprehensive program that addresses detection, prevention, and control of infections and communicable diseases among residents, visitors, volunteers, those individuals providing services under contractual agreement, and personnel. The goals for the IPCP are to: a. Provision of a safe, sanitary, and comfortable environment; b. Decrease the risk of infection and communicable diseases development and transmission to the residents, volunteers, visitors, individuals providing services under a contractual agreement, and personnel. Procedure: The major activities of the program are: . c. Implementation of infection control and prevention measures Prevention of the spread of infection is accomplished by use of standard precautions, organism specific precautions, and other barriers, appropriate treatment and follow-up, and employee work restrictions for illness; d. Prevention of infection and communicable diseases Staff, volunteers, visitors, those individuals providing services under contractual bases and resident education is done to focus on the risk of infection and practices to decrease risk.

Based on interview and record review, the facility failed to maintain an ongoing antibiotic stewardship program for 11 of 12 months reviewed.Findings include: An interview was conducted with Staff A, Infection Preventionist (IP) and the Director of Nursing (DON) on 2/4/26 at 10:37 a.m. Staff A, IP said she did not have the infection control logs prior to December 2025. The DON said she had not been able to locate the logs. Staff A, IP said the facility had one resident that was positive for influenza and that resident was being treated with an antibiotic. The DON stated, an antibiotic is not appropriate for a viral infection but that is what the resident was admitted with. The DON said the resident should have been treated with an antiviral medication. Staff A, IP said she does not know if the pharmacist reviews the medications to ensure appropriateness of medications. Staff A, IP said she follows McGeer's Criteria {a standardized surveillance used in long-term care facilities to identify and track infections to prevent the overuse of medications}. Staff A, IP said she had not been completing the McGeer's criteria form and does not know if the facility wants her to complete the form. Staff A, IP said she had not completed hand hygiene audits and review of the hand hygiene audit book revealed the last audit had been completed on 4/22/25. The DON said the facility reviews the infection control prevalence rates each month in the quality assurance meeting; the DON was unable to provide prevalence rates at the time of the interview. The DON was not able explain how tracking was being completed or audited. No documentation was provided for review for antibiotic use, handwashing, or infection tracking including signs and symptoms, prior 12 months was requested. A review of a facility policy effective March 2017 titled, Antibiotic Stewardship revealed, The Centers for Disease Control and Prevention (CDC) recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Per CDC, 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harm for the fail and older adult can include the risk for diarrheal infections, increased adverse drug events and drug interactions, colonization and/or infection with antibiotic-resistant organisms. Actions taken to improve antibiotic use will reduce adverse events, prevent emergence of resistance, and lead to better outcome for residents. The procedure is as follows: . 3: The Director of Nursing and the Infection Preventionist will monitor for compliance with the Antibiotic Stewardship policies. 4: Antibiotic use and resistance data will be reviewed at the quality assurance and performance improvement meeting and as needed. A review of a facility policy effective April 2017 titled, Antibiotic Stewardship Tracking: Monitoring Antibiotic Prescribing, Use, and Resistance revealed: . measurements of antibiotic use: . monthly prevalence studies regarding antibiotic usage will be presented to quality assurance and performance improvement committee (QAPI). This information can also be located in the infection prevention and control monthly summary manuals. Information provided during the QAPI meeting regarding measurements of antibiotic use will include: 1: days of antibiotic therapy . 2: antibiotic prevalence rate . A review of a facility policy effective April 2017 titled, Antibiotic Stewardship: Actions to Improve Antibiotic Prescribing and Use revealed: . Consultant Pharmacist Support: The facility pharmacy will review antibiotic courses for appropriateness of administration and/or infection. The facility pharmacy will notify staff for clinical/laboratory monitoring to prevent adverse drug events from antibiotic use.

Based on observations, record reviews, and interviews, the facility failed to ensure an assessment of self-administration of medications for one resident (#16) of one resident reviewed.Findings included: During an observation on 02/02/2026 at 10:10 a.m., Resident #16 was observed sitting in a wheelchair near the side of a bed, holding a clear mask with white fog coming from the mask from the nebulizer treatment. The resident stated the nurse brings in the medication for me, and I turn the machine off once I am done. Review of Resident #16's admission record revealed an admission date of 08/04/2025. Resident #16 was admitted to the facility with diagnosis to include chronic obstructive pulmonary disease with (acute) exacerbation, other asthma, respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia, and other pulmonary embolism without acute cor pulmonale. Review of Resident #16's Minimum Data Set (MDS), section C. Cognitive Patterns revealed a brief mental status (BIMS) of 15 out of 15 showing intact cognition. Review of Resident #16's care plan dated 08/05/2025 revealed there was no care plan for self-administration of medications. During an interview on 2/03/2026 at 2:20 p.m., Staff I, Licensed Practical Nurse (LPN)/Unit Manager (UM), stated when giving a nebulizer treatment the nurse should stay in the room until the treatment is complete. It is best practice to keep the resident in eyesight. During an interview on 02/03/2026 at 2:24 p.m., the Director of Nursing (DON stated when a resident is doing a nebulizer treatment, the nurse should go back in 15 mins to check on the resident. the DON stated the nurse does not need to stay in the room until the treatment has finished. Review of the facility policy titled, Medication Administration, Nebulizer (updraft), dated 01/23 revealed: Policy: to allow for safe, accurate, and effective administration of medication using a small volume nebulizer.Procedures.13. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer.

Based on observations, record reviews, and interviews the facility failed to obtain a blood test to monitor the therapeutic level of a medication used as a psychotropic, for one (#118) of five residents sampled for unnecessary medications. Findings included: On 2/2/26 at 10:25 a.m. Resident #118 was observed lying curled up in bed, covered with a blanket. During random tours of the facility on 2/2 through 2/4/26 the resident was seen sitting in wheelchair in hallway and on covered porch leading to smoking area. Review of Resident #118's admission Record showed the resident was admitted on [DATE] with diagnoses not limited to generalized anxiety disorder (GAD), unspecified recurrent major depressive disorder (MDD), unspecified mood (affective) disorder, and unspecified anxiety disorder. Review of Resident #118's active physician orders included but not limited to the following physician orders: Depakote Oral Tablet Delayed Release 125 milligram (mg) (Divalproex Sodium) - Give 3 tablet(s) by mouth two times a day for mood disorder, ordered 10/13/25. Depakote Valproic Acid levels quarterly every night shift every 90 days, ordered 8/14/25. Review of Resident #118's laboratory testing results from September 2025 to current revealed one Valproic Acid (Depakote) level had been obtained 9/17/25. The result showed a subtherapeutic level of 31 for the medication (reference range 50 - 100). The laboratory results did not show any other Depakote level had been obtained. Review of Resident #118's November 2025 Treatment Administration Record (TAR) showed a Depakote Valproic Acid level was to be obtained on 11/12/25. The TAR did not reveal the sample had been completed (administered), the box allowing for nursing documentation was blank. Review of Resident #118's progress notes from 11/9 - 11/16/25 did not include any documentation from staff revealing the resident had refused the blood draw to be completed or the physician had been notified the lab test had not been obtained on 11/12/25.Review of the policy - Lab/Radiology Process Guidelines, undated, showed staff were to obtain the order for labs/radiology test from the physician, complete the lab/radiology log sheet in the lab/radiology book behind the date of ordered labs/test, and complete and print the electronic requisition sheet and labels then place form behind lab/radiology log sheet under the day the lab/test should be done. The staff, upon receiving the results, notify the physician and resident/resident representative of the results and file the results in the medical record under Labs/Radiology tab, document in a progress note the labs/radiology tests received and who the results were reported to including any additional follow up or new physician orders received, and if a resident refuses the lab/radiology test document the physician was notified along with any guidance and the notification of the resident/resident representative. Review of Resident #118's psychiatry progress note, dated 11/4/25, revealed tapering of the resident's medication would not achieve the desired therapeutic effects therefore a gradual dose reduction was contraindicated. The review of systems showed the resident had a depressed mood, loss of energy, irritability, not able to control worry with aggravating factors of being in the facility, ongoing medical problems, and life stressors. Review of Resident #118's psychology note, dated 1/21/26, revealed the resident was socially isolated and had discussed issues with anxiety and depressed mood. The resident had discussed the difficulty of dealing with loss and dealing with grief, sadness of health conditions, and talked about missing things. The resident had appeared sad, wary, irritable, attentive, communicative, normal weight, casually groomed, and unhappy. The resident was tearful, thought content was depressed, and body posture and attitude conveyed an underlying depressed mood. An interview and online lab review was conducted on 2/3/26 at 4:04 p.m. Staff H, Licensed Practical Nurse (LPN). The staff member was unable to locate any Depakote lab results other than the one on 9/16/25. An interview was conducted on 2/4/26 at 10:28 a.m. with the Director of Nursing (DON). The DON stated in the future staff are to ensure labs are done and if not to let the physician know and ask if they want to order them stat. The DON stated she was unable to locate the Depakote results (ordered for 11/12/25).

Based on interview and record review, the facility failed to ensure residents with a serious mental disorder(s)/diagnoses were referred to the State's Mental Health authority for a Level II Preadmission Screening and Resident Review (PASRR) review for two residents (#9 and #10) out of five residents sampled. Findings included: 1. Review of Resident #10's admission record showed the resident was admitted on [DATE]. The record included diagnoses not limited to unspecified schizophrenia, unspecified depression, unspecified anxiety disorder, and chronic post-traumatic stress disorder. Review of Resident #10's Minimum Data Set (MDS) dated [DATE], Section N- Medications revealed antipsychotic, antianxiety, and antidepressant usage.Review of Resident #10s Pre-admission Screening and Resident Review (PASRR) dated 1/28/26 revealed anxiety disorder, depressive disorder, schizophrenia, chronic post-traumatic stress disorder, and unspecified insomnia marked in Section A. These findings were based on documented history, individual, legal representative or family report, and medications. The screening showed the resident had no functional limitations in major life activities, no interpersonal functioning, no concentration, persistence, and pace; no difficulty with adaptation to change, and no recent treatment for mental illness requiring psychiatric treatment more intensive than outpatient care or significant disruption to normal living. A review of Resident #10's psychiatric note dated 1/21/26 showed the resident has continued anxiety symptoms, feelings of depersonalization, persistent worry, depression related symptoms, and feelings of grief. Review of Resident #10's care plan revealed a focus- Psychotropic medication, the resident uses psychotropic medications related to antidepressant to manage depression, antianxiety to manage anxiety, and anti-psychotic to manage schizophrenia with delusions.On 2/3/26 at 4:33 p.m., an interview was conducted with the Director of Nursing (DON). She reviewed Resident #10's PASRR and stated a Level II may not be necessary if the Resident is not currently affected by the mental illness. On 2/4/26 at 10:15 a.m., an interview was conducted with Staff J, Travelling Social Services Director (SSD). Staff J stated a Level II PASRR is not automatically submitted solely based off the resident having a diagnosis of schizophrenia. Staff J stated if the symptoms are managed through medication and the resident is not exhibiting disruptive behaviors, the resident does not need a Level II. 2. Review of Resident #9's admission Record showed the resident was admitted on [DATE] and 2/18/22. The record included diagnoses not limited to bipolar type schizoaffective disorder (2/18/22), cognitive communication deficit (6/28/20), unspecified schizophrenia (2/18/22), adjustment disorder with mixed disturbance of emotions and conduct (1/24/18), and unspecified recurrent major depressive disorder (12/12/17).Review of Resident #9's record on 2/2/26 at 2:21 p.m. revealed a Pre-admission Screening and Resident Review (PASRR) dated 12/13/23 and completed at the facility. The screening revealed diagnoses of anxiety disorder, bipolar disorder, depressive disorder, schizoaffective disorder, schizophrenia, cognitive communication disorder, adjustment disorder, and psychosis. Review of Resident #9's psychiatry note, dated 1/23/26, showed the resident denied changes in mood or concerning exacerbations with regards to psychotic features relevant to past psychiatric history. The plan was to continue with Depakote and Risperdal related to unspecified schizophrenia, unspecified recurrent major depressive disorder, and bipolar type schizoaffective disorder. The note revealed the patients chart was reviewed on 10/21/25 for confirmation of the diagnosis and report from a behavioral health facility confirmed the diagnosis with alteration in mood, hallucinations, and delusions of God (12/5/17). Review of Resident #9's PASRR dated 2/3/26 included diagnoses of depressive disorder, schizoaffective disorder, schizophrenia, adjustment disorder with mixed disturbance of emotions and conduct, bipolar type schizoaffective disorder, and cognitive communication deficit based on documented history, individual, legal representative or family report, and medications. The review showed the resident did not have a disorder resulting in functional limitations in major life activities, did not have or may have had serious difficulty with interpersonal functioning, concentration, persistence, and pace, and/or adaptation to change. The screening showed the resident did not have a diagnosis of dementia or related neurocognitive disorder, and a Level II evaluation was not required due to the resident not having a diagnosis or suspicion of a serious mental illness or intellectual disability. An interview was conducted on 2/3/26 at 4:28 p.m. with the Director of Nursing (DON). The DON reviewed the resident's PASRR and stated if it was not affecting them at the moment they may not need a Level II. An interview was conducted on 2/4/26 at 9:56 a.m. with Staff J and Staff L, facility Social Service Director (SSD). Staff J reported doing the PASRR's and had completed online tutorial training with contracted PASRR provider and other staff. Staff J described the process of putting resident's diagnoses based on history, behaviors, and medications and the system triggers a Level II. The staff member stated a PASRR should be completed at time of admission and are reviewed by self and other clinical staff at time of admission during clinical meetings and if the resident was having changes or conditions. If the resident doesn't have a PASRR at admission the SS will do it or ask transferring facility to provide so it will be completed same day as the admission. The staff member reviewed Resident #9s PASRR and stated if they are being managed by medications, seeing psych, and not displaying any behaviors they are stable, and they are controlled. Staff J stated schizophrenia was not an automatic (Level II) if the resident was not exhibiting behaviors. Staff J said, Schizophrenia is a mental illness, I don't determine if it is a serious mental illness, (State Approved Vendor) does. Review of the policy, PASRR – Requirements for Completion, effective August 2025 showed Preadmission screening will be conducted prior to admission as the PASRR process is federally mandated pre-admission screening program (see 42 CFR 483.100) required to be performed on all individuals prior to admission to a nursing home. The Screening is reviewed by admissions for suspicion of serious mental illness and intellectual disability to ensure appropriate placement in the least restrictive environment and to identify the need to provide applicants with needed specialized services. ASR screening applies to all new admissions into a Medicaid certified nursing facility and includes private pay, Medicare, and Medicaid admissions regardless of payer source. The procedure revealed:1. During the admissions process, admissions will communicate with the facility regarding prospective admissions. A level 1 PASR will be provided prior to admission to the skilled nursing facility. The facility administration will confirm that a level 1 review has been completed prior to the transfer to the SNF setting.2. Determine if a serious mental illness and/ or intellectual disability or a related condition exists while reviewing the PSR form completed by the acute care facility. (Trigger for Level II Completion)3. If serious mental in illness or ID is indicated, determine if the resident will be admitted from a hospital for an acute care stay and the attending physician has certified that the individual is likely to require less than 30 days of nursing facility services. Assure that the certification is signed and dated.4. If the physician indicates the state will likely be less than 30 days SNF services, the resident can be admitted to an SNF. If the anticipated stay becomes longer than 30 days a level II must be completed prior to day 40.The Florida specific guidelines of the policy revealed staff were to ensure that sections 1 - 5 are completed prior to admission. If the pre admission screening requires a level 2 evaluation submit all required documents to [State Approved Vendor] timely, so a level II can be completed within the required time frames.

Based on observations, record reviews, and interviews the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) screenings were completed accurately at the time of admission for two (#42 and #118) of six residents sampled for the accuracy of PASRRs.Findings included: Review of Resident #42's admission Record showed the resident was admitted on [DATE] with diagnoses not limited to cognitive communication deficit, dementia in other diseases classified elsewhere unspecified severity with anxiety, moderate recurrent major depressive disorder, generalized anxiety disorder, and unspecified Alzheimer's disease. Review of Resident #42's PASRR level I located in the paper chart, on 2/2/26 at 3:05 p.m. revealed a screening dated 11/11/25 showing the resident did not have any mental illness, suspected mental illness, and/or intellectual disability based on documented history. The screening showed the resident had no indication of a disorder resulting in functional limitations in major life activities did not have difficulty with interpersonal functioning, concentration, persistence, and pace, or adaptation to change. The screening showed the individual had not exhibited actions or behaviors that may make them a danger to themselves or others, did not have a primary diagnosis of dementia or related neurocognitive disorder, and did not have a secondary diagnosis of dementia, related neurocognitive disorder and the primary diagnosis was a serious mental illness or intellectual disability. The screening showed a Level II evaluation was not required. Review of Resident #42's care plan showed the resident was noted with the following behaviors: Attempted to get out of bed without assistance, resident becomes agitated easily, resident noted with preference of being on floor at times, resident has verbal and physical behaviors directed at others at times. The focus was initiated on 11/14/25 and revised on 1/31/25. Review of Resident #42's psychiatry note dated 1/20/26 revealed the review of systems shown a loss of energy related to depression, obsessions/compulsions related to anxiety and an impairment of complex attention, learning and memory and perceptual motor related to dementia. The aggravating factors were being in the facility, ongoing medical problems, and life stressors. The resident was lethargic and non-responsive, lethargic and detached with a limited fund of knowledge, poor judgement and poor attention and concentration. Review of a facility provided Level I PASRR, dated 2/2/26 showed diagnoses of anxiety disorder, depressive disorder, dementia in other diseases classified elsewhere unspecified severity with anxiety, and unspecified Alzheimer's disease. The screening showed the resident had no indication of a disorder resulting in functional limitations in major life activities did not have difficulty with interpersonal functioning, concentration, persistence, and pace, or adaptation to change. The screening showed the individual had not exhibited actions or behaviors that may make them a danger to themselves or others, did not have a primary diagnosis of dementia or related neurocognitive disorder, and did not have a secondary diagnosis of dementia, related neurocognitive disorder and the primary diagnosis was a serious mental illness or intellectual disability. The screening showed a Level II evaluation was not required. During an interview on 2/3/26 at 4:27 p.m. the Director of Nursing (DON) reviewed the Level I PASRR completed on 11/11/25 and stated the PASRR should have been redone to include all diagnoses. During an interview on 2/4/26 at 10:07 a.m. Staff J reviewed the PASRR completed on 11/11/25 and stated they did an audit this week and it had been redone on 2/2/26. 2. Review of Resident #118's admission Record showed the resident was admitted on [DATE] and 8/14/25. The record included diagnoses not limited to generalized anxiety disorder (10/13/24), unspecified recurrent major depressive disorder (10/13/24), unspecified insomnia (12/10/25), uncomplicated unspecified cannabis use (10/12/24), unspecified mood (affective) disorder (10/12/24), and unspecified anxiety disorder (10/12/24). Review of Resident #118's record on 2/2/26 at 2:33 p.m. did not show a PASRR had been uploaded into the electronic record. The PASRR in the resident's paper chart reviewed on 2/2/26, was dated 9/19/24 and completed at an acute care facility did not show the resident had any mental illnesses, suspected mental illness, and/or intellectual disability. Review of Resident #118's PASRR, which the facility provided on 2/3/26, was dated 2/3/26 and included Resident #118s diagnoses of anxiety disorder, depressive disorder, substance abuse, unspecified insomnia, and unspecified mood (affective) disorder. The screening showed the resident had no functional limitations in major life activities, no interpersonal functioning difficulty, no concentration, persistence and/or pace difficulties, no adaption to change difficulty, or and a recent treatment requiring more intensive than outpatient or a significant disruption to the normal living situation. Review of Resident #118's psychology note dated 1/21/26 showed continued stress-related symptoms had been reported by the resident, was having anxiety symptoms, having episodes of crying, feelings of bitterness and irritability had occurred, and had been preoccupied with feelings of loss and sadness. The resident had discussed a depressed mood, issues with anxiety, difficulty of dealing with loss and grief during the session. An interview was conducted on 2/3/26 at 4:25 p.m. with the Director of Nursing (DON). The DON reviewed Resident #118's PASRR and stated it should have been redone prior. During an interview on 2/4/26 at 10:09 a.m. Staff J (Traveling Social Service Director) confirmed the PASRR had missing diagnoses and reported redoing the PASRR on 2/3/26 as the facility had done an audit and it was time to do it. Review of the policy, PASRR - Requirements for Completion, effective August 2025 showed Preadmission screening will be conducted prior to admission as the PASRR process is federally mandated pre-admission screening program (see 42 CFR 483.100) required to be performed on all individuals prior to admission to a nursing home. The Screening is reviewed by admissions for suspicion of serious mental illness and intellectual disability to ensure appropriate placement in the least restrictive environment and to identify the need to provide applicants with needed specialized services. ASR screening applies to all new admissions into a Medicaid certified nursing facility and includes private pay, Medicare, and Medicaid admissions regardless of payer source. The procedure revealed:1. During the admissions process, admissions will communicate with the facility regarding prospective admissions. A level 1 PASR will be provided prior to admission to the skilled nursing facility. The facility administration will confirm that a level 1 review has been completed prior to the transfer to the SNF setting.2. Determine if a serious mental illness and/ or intellectual disability or a related condition exists while reviewing the PSR form completed by the acute care facility. (Trigger for Level II Completion)3. If serious mental in illness or ID is indicated, determine if the resident will be admitted from a hospital for an acute care stay and the attending physician has certified that the individual is likely to require less than 30 days of nursing facility services. Assure that the certification is signed and dated.4. If the physician indicates the state will likely be less than 30 days SNF services, the resident can be admitted to an SNF. If the anticipated stay becomes longer than 30 days a level II must be completed prior to day 40.The Florida specific guidelines of the policy revealed staff were to ensure that sections 1 - 5 are completed prior to admission. If the pre admission screening requires a level 2 evaluation submit all required documents to CARES timely, so a level II can be completed within the required time frames.

Based on observations, record review, and interviews, the facility failed to update and revise the person-centered comprehensive care plan for one resident (#50) of six residents sampled.Findings included: A review of the admission record for Resident #50 showed she was admitted to the facility on [DATE] with diagnoses including but not limited to needing assistance with personal care and type 2 diabetes mellitus with foot ulcer. A review of Resident #50's Minimum Data Set (MDS), Section C, dated 1/05/2026 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact. A review of Resident #50's evaluations revealed skin checks completed within the last two months revealed no skin impairments. A review of Resident #50's care plan revealed she is care planned for an actual wound on her left heel. The goal was to minimize additional wound from developing. The interventions included treatment as ordered; and observe that dressing is covered and adhering. An interview on 2/4/2026 at 9:29 A.M. with Staff B, Registered Nurse. She said Resident #50 does not have any wounds or redden areas on her bottom or feet. An observation on 2/4/2026 at 9:58 A.M. of Resident #50's skin revealed resident does not have a wound on the left heel or on her bottom. The observation was conducted with Staff C, Licensed Practical Nurse, (LPN) present. An interview was conducted at that time with Staff C, LPN. She said she is responsible for updating Resident #50's care plan. She said she does not know why Resident #50's care plan reveals that she had a wound; she said she does not remember her ever having a wound. An interview on 2/4/2026 at 10:02 A.M. with the Director of Nursing (DON) was conducted. She said Resident #50 does not have a wound on her bottom or her feet. She said she does not know why Resident #50 was care planned for an actual wound on her left heel. A review of a facility provided policy effective October 2021, titled, Wound Prevention and Treatment Overview revealed, 5: Review and revise plan of care as need. A review of a facility provided policy effective February 2024, titled, Care Plan - Interdisciplinary Plan of Care from Intern to Meeting was reviewed. The policy is as follows: The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. The procedure is 2: update to care plans, a: ongoing updates to care plans are added by a member of the interdisciplinary team, as needed. 3: Dates and documentation of the plan of care, a: new, revised, or discontinued problems, goals, or interventions are dated for the date the documentation was made.

Based on observations, record reviews, and interviews the facility failed to provide one resident (#42) of two residents an environment that was free from avoidable accidents and hazards related to implementation of adequate non-slip material under moveable floor mats.Findings included: An observation was made on 2/2/26 at 10:55 a.m. of Resident #42 lying on floor in between a low bed (pushed against wall) and an oversized floor mat (approximately same height as bed). The air mattress on bed was uneven full of distinct lumps, bumps and irregular surface. The resident was fidgeting on the floor and appeared to be trying to raise up. The resident grasped back of head and said ouch. Staff J, Traveling Social Service Director (SSD) was walking by room and notified of the resident being on the floor. Review of Resident #42's Situation, Background, Appearance, and Recommendation (SBAR) dated 2/2/26 at 11:15 a.m. showed the nurse was notified that the resident had rolled from the mattress onto the floor. The resident was immediately removed from the floor using a Hoyer lift. Resident was assessed and vital signs were within normal limits. MD (Medical Doctor) and family notified. Resident will be transferred for CAT (Computed Tomography) scan of head. Review of Resident #42's care plan showed the resident was at risk for falls or fall related injury because of deconditioning (and) gait/balance problems. The interventions included but not limited to : (name brand - non slip material) between floor and fall mat to prevent movement Floor mats bilateral to sides of bed while in bed.An observation was conducted on 2/3/26 at 1:14 p.m. with Staff K, Certified Nursing Assistant (CNA) of the floor under Resident #42's floor mat. The observation revealed the floor mat was folded in half widthwise with no non-slip material visible. The staff member moved the floor mat without difficulty and revealed 2 pieces of non-slip material, one approximately 4-inch x 6 inch and the other approximately 6-inch x 8 inch. Staff K stated those (pieces of non-slip material) were not going to stop the floor mat from moving. The floor mat was approximately 3-foot-wide x length of bed x 6-8 inches tall. An observation was attempted on 2/3/26 at 1:36 p.m. of the pieces of non-slip material with the Director of Nursing (DON). Staff K was assisting Resident #42 with eating. Photographic evidence was shown to the DON who stated she did not feel that there would be enough non-slip material to keep it (floor mat) sticking to the ground.Review of the policy - Fall and Injury Reduction Policy, effective March 2023, revealed The facility has designated and implemented processes, which strive to reduce the risk for falls and injuries. This policy guides the identification, implementation of appropriate interventions, and management. It is expected this policy will assist the facility with reducing the likelihood of a fall or injury while maintaining or maximizing dignity and independence through education of staff and residents, early identification of risk factors by collecting data, identifying resident behavior which may increase the likelihood of such occurrence. The guidelines included:1. Evaluate and review to identify risk factors for falls and injuries. a. Review the completed admission/ readmission data collection and baseline care plan, as a recent fall pre admission places the resident at risk, interventions to be implemented based on why the resident fell previously and current risk factors.2. Review/ evaluate other interdisciplinary data collection tools such as Brief Interview of mental status (BIMS) score or other cognition assessment, mobility etc.3. Discuss goals and interventions with resident/ resident representative/ family for inclusion in the plan of care.4. Implement a plan of care based on individual resident needs.5. Communicate interventions during shift report, daily clinical rounds and/ or entry on electronic care communication tool to the caregiving team.7. Review and revise the plan of care as needed to reflect resident current needs. Photographic evidence was obtained.

Based on interviews, and record review, the facility failed to provide necessary care and services to prevent Urinary Tract Infections (UTIs) from developing or worsening by 1.) Failing to follow physician's orders for a silver coated foley catheter, failed to order labs, and change the foley catheter per orders for one resident (#2) out of four residents reviewed, resulting in Resident #2 developing a urinary tract infection that progressed to Fournier's gangrene and sepsis. 2.) Failed to give antibiotics for UTI as ordered for one resident (#13) out of four residents reviewed with catheters. This failure placed Resident #13 at risk for worsening infection or delayed recovery.Findings included: 1.) Review of the admission records showed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but are not limited to type 2 diabetes mellitus without complications, muscle wasting and atrophy, need for assistance with personal care, sepsis, unspecified organism, obstructive and reflux uropathy, unspecified. Review of Resident #2's May 2025 Medical Administration Record (MAR)/Treatment Administration Record (TAR) revealed the resident had an appointment with a urologist on 5/13/25. The appointment was checked off on 5/12/25. There were no notes regarding this appointment in the electronic medical record or the chart. Review of Resident #2's May 2025 orders showed the resident's primary care provider (PCP) ordered the facility to use a #16 French silver coated foley catheter and change the catheter every 3-4 weeks during night shift, starting on 5/19/25. The order was to start doing this every month for neurogenic bladder and recurring Urinary Tract Infections (UTIs). He placed the order again on 5/22/25 with an order summary of using the #16 French silver coated foley catheter and change on a every 3-4 weeks schedule once foley is received. There were no records of the resident ever receiving the silver coated foley catheter after these orders were placed. Review of Resident #2's June 2025 MAR/TAR revealed the resident was last treated for UTI, with Rocephin 1 GM, on 6/10/25 at 8:29 p.m. The resident had an order for a urinalysis, with a urine culture and sensitivity test on 6/9/25. The resident had an order for additional labs on 6/10/25. The testing results of the urine polymerase chain reaction (PCR) panel were positive for pathogens. The resident had an order for enhanced barrier precautions related to foley catheter care every shift for infection prevention and control. Review of Resident #2's June 2025 MAR/TAR showed the resident had a pain level of 7 out of 10 on 6/9/25 and a pain level of 8 out of 10 on 6/10/25, during the evening when the resident was diagnosed with the previous UTI. (The pain scale is a tool used to measure and assess the intensity of pain on a scale of 0-10 where 0 represents no pain and 10 represents the worst possible pain). Review of Resident #2's progress notes completed on 7/2/25 at 10:51 a.m., by Staff D, Licensed Practical Nurse (LPN), revealed the resident had complaints of severe pain in pelvic area, hard and swollen pelvic area, and the area was tender to touch. Staff D contacted the providers answering service and spoke with the primary care providers Advanced Registered Nurse Practitioner (ARNP). The ARNP instructed Staff D to order a kidney, ureter, bladder (KUB) and pelvic ultrasound. Review of Resident #2's July 2025 MAR/TAR, revealed a KUB and pelvic ultrasound were ordered for lower pelvic pain. The documentation showed the order was, discontinued due to clarification. On 7/3/25, another order for the pelvic ultrasound was discontinued due to, No directions specified for order. Review of Resident #2's July 2025 MAR/TAR showed a completed order for KUB and pelvic ultrasound on 7/2/25 at 3:40 p.m. and an abdominal x-ray was taken at 4:00 p.m. Review of Resident #2's ultrasound results, dated 7/2/25 showed the reproductive organs were not visualized, the urinary bladder was empty, and it was a nondiagnostic study. Review of Resident #2's x-ray results, dated 7/2/25 showed there was no evidence of pneumoperitoneum or abnormal calcifications. Resident #2's record did not show any orders for labs to establish if there was an infection during July 2025. The last labs order for the resident were the labs on 6/10/25. Review of Resident #2's July 2025 MAR showed a documented pain level of 8 out of 10 on the day shift of 7/2/25, and the pain level was documented at 10 out of 10 during the evening shift of 7/2/25. On 7/3/25, the resident's pain levels were listed as N/A (not applicable) for day and evening shifts. The pain level was documented as 7 out of 10 during the evening shift on 7/4/25. The pain level was documented as 0 out of 10 during the day shift and N/A during the evening shifts for 7/5/25 to 7/6/25. All the pain levels for the night shifts were documented as 0 out of 10 for 7/1/25 through 7/6/25. Review of Resident #2's progress notes showed documentation of her pain level being 10 out of 10 on 7/7/25. The notes showed the resident's temperature was last checked on 6/27/25. Review of Resident #2's May, June, and July 2025 MAR/TAR's revealed the resident's catheter was changed on 5/25/25 but was not changed again until the resident complained of pain on 7/2/25. The weekly skin checks in the electronic medical record, from 5/14/25 to 7/2/25 revealed, No new area of skin impairment. Review of Resident #2's progress notes completed on 7/4/25 at 11:39 a.m., by the Assistant Director of Nursing (ADON) at that time, revealed a skin assessment was completed. She noted Resident #2 had skin redness in the coccyx/buttock area. No open areas were observed, with only scant, pinpoint dot-like size amount of sanguineous drainage seen on brief from hemorrhoids irritation. She noted a small nickel-sized reddened area observed directly above the excoriated area on the coccyx. She noted that peri-care and foley care had been provided. No documentation was completed about wounds in the perineal area. The ADON documented the resident complained of high pain sensitivity to the wound area on palpation and movement. The ADON repositioned the resident and noted that she would continue to monitor and follow the plan of care. Review of Resident #2's care plans showed a focus area of indwelling catheter. Interventions included observing for signs of discomfort, observe and document for pain or discomfort due to the catheter, and to document and report any signs and symptoms of UTI. There was an additional focus area of Wound Risk. Interventions included obtaining vital signs per order. Documented under the focus area of pain, interventions included administering pain medication as ordered and observe for effectiveness, and to observe and anticipate the residents need for pain relief. There was an additional focus area of skin integrity risk. Interventions included monitoring and documenting location, size, and treatment of skin. Report abnormalities, failure to heal and signs and symptoms of infection. Review of Resident #2's Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Section H, Bladder and Bowel, revealed the resident had an indwelling catheter and no toileting program had been attempted at that time. Section M, skin conditions, noted the resident was at risk of developing pressure ulcers or injuries. The MDS information provided did not contain any documented pressure injuries. Review of Resident #2's hospital record, dated 7/7/25 showed: Resident #2 reported for the past few weeks they have been asking the facility to send them to the emergency room for not feeling well. Upon examination, the resident had purulent drainage from their peritoneal area with foul smelling odor. They also had a large necrotic area appearing in their genital region. The foley catheter was in place with purulent drainage. The resident reported to the hospital that they had been smelling this foul odor for the past few weeks. Review of Resident #2's hospital lab records, dated 7/7/25 at 2:34 p.m. showed elevated white blood cell (WBC) results: WBC 30.85 (units 10*3/uL) [Microliter]. Review of Resident #2's hospital general surgery plan, dated 7/7/25 showed: Fournier's gangrene with a necrotizing soft tissue infection of the lower abdominal wall as well as peritoneum with purulence draining from indwelling catheter. Patient is in septic shock at this time and is being actively resuscitated with volume. Patient will need emergent debridement for source control, and I have discussed this with the patient. I discussed the procedure in detail including significant disfigurement from the removal of the necrotic tissue and that further operations we will need to be undertaken for either reconstruction or further debridement of necrotic tissue. We also discussed possible need for an ostomy in the future. On 10/27/25 at 3:50 p.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She stated if there were signs of infection in residents with catheters, she would let the nurse know immediately. She would document what was observed in the electronic medical record, under catheter care tasks. Staff B said the last training she received was an in-service in July 2025 where they discussed catheter procedures. On 10/27/25 at 3:57 p.m., an interview was conducted with Staff E, Registered Nurse (RN). Staff E stated the care provided depended on the type of catheter a resident had. She noted nurses flushed and cleaned foley catheters and CNAs emptied the catheter bags throughout the day. Staff E stated the care was provided every shift, but it also depended on the resident's condition at that time. If signs of infection were observed, she would check vitals, notify the provider to get orders for a urinalysis and culture, and call the resident's representative. Staff E said a change of condition evaluation would have been completed as well. She stated she had not received training on resident's change of condition but did receive education on documenting last week. On 10/27/25 at 4:05 p.m., an interview was conducted with Staff A, LPN. He stated the CNAs and nurses cleaned the catheters. Staff A said the nurses and CNAs must assess if the catheter was intact and draining and observe for urine color. Staff A said, If the line is cloudy, the nurses change it. He stated if he suspected an infection, he would call the doctor to ask for a culture. Staff A stated there was a section in the chart for change of condition and progress notes. he stated any change of condition should be documented in those sections of the record and should also be shared in shift-to-shift report. Staff A stated the staff had been trained in catheter care and change in condition, upon hire and continued with occasional in-service trainings. He stated the training instructed, If an infection is discovered, then the clinical nursing staff would go and review all the foleys in the facility. As part of this review, leadership would provide training with demonstration and education. On 10/28/25 at 11:45 p.m., an interview was conducted with Staff D, LPN. She stated Resident #2 had pelvic pain on 7/2/25, and she was told to give the resident medication. On 7/2/25, Staff D changed the resident's catheter. Staff D thought she changed the catheter after resident reported the pain, but she was not sure. She stated she could not remember anything else ordered for the resident. She was not sure; it was a long time ago. Staff D said she did not remember if there were any signs of infection. She stated one of the CNAs saw discharge coming out of the adult brief on 7/7/25. Staff D noted the CNA called someone to have the resident sent out to the emergency room (ER). On 10/28/25 at 12:49 p.m., a telephone interview was conducted with Staff C, LPN. Staff C said 7/7/25 was the first time she had worked with Resident #2. The resident presented with a large amount of perineal discharge, and Staff C notified the provider. She stated the resident was then sent to the ER. Staff C said she believed that during discussions they mentioned the resident having pain. Staff C stated she believed the resident had an ultrasound and followed with urology. Staff C said she was not sure because she only found out about Resident #2's treatment through conversations with other staff. Staff C stated she was told the staff had noticed a foul odor. Staff C said a CNA notified her about the discharge and asked her to assess. Staff C stated the event was a long time ago and she was not exactly sure who the CNA was that day, on 7/7/25. On 10/28/25 at 12:54 p.m. a telephone interview was conducted with Staff G, RN. She did not remember much about the resident. She stated, If there were labs ordered, then they would be placed in the system. On 10/29/25 at 2:09 p.m., an interview was conducted with the Director of Nursing (DON). She stated it was common to call physicians for new orders. She confirmed she knew there had been discrepancies with provider notifications for labs or changes in conditions. The DON said, If the resident is presenting with signs of infection, then the CNA should report it to the nurse. The nurse will assess and perform interventions if the resident has orders. They will check for recent antibiotics use due to UTIs. They will call the provider if it is a new onset of infection. She stated the staff have had in-service training for catheter care since she began working at the facility. The DON stated they had not implemented a demonstration training, but they were going to soon. Review of a facility policy titled General Procedures and Treatment Modalities, pages 783-785 revealed the catheter care procedures. Review of page 785 shows to call the health care provider if there are signs of fever, or cloudy, bloody, odoriferous urine develops. 2.) Review of admission Records showed Resident #13 was admitted to the facility on [DATE] with diagnoses including but are not limited to chronic systolic (congestive) heart failure, type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, and obstructive and reflux uropathy, unspecified. Review of Resident #13's August 2025 and September 2025 MAR showed an order was placed for Ertapenem Sodium Injection Solution Reconstituted 1GM. One application was to be given every day at bedtime for Proteus Mirabillis in urine for five days starting on 8/29/25. Review of Resident #13's August 2025 and September 2025 MARs showed the doses administered to the resident were on 9/1/25, 9/2/25, and 9/3/25. The resident received three doses of the five ordered doses. Review of Resident #13's progress note did not show any documentation detailing why the doses were missed, or if the provider was notified that the resident did not receive all doses of the prescribed antibiotic for the UTI. Review of a facility policy titled Lab/Radiology Process Guidelines, undated, showed: 5. Upon receiving the results, notify the physician and resident/resident representative of the results, and file the results in the medical record under Labs/Radiology tab. 6. Document in a progress note the labs/radiology tests you received and who the results were reported to. Include any additional follow up or new physician orders received in the progress. 8. Stat and critical labs must be called to the physician as soon as they have resulted, with the nurse documenting the communication and follow-up in the electronic medical record. Review of a facility policy titled, Physician Notification, dated October 2021 revealed, The facility strives to ensure each resident's health is supervised by a qualified attending physician. The attending physician in the facility is ultimately responsible for supervision and management of the care of the resident/patient. Review of a facility policy titled Abuse Prevention Program, reviewed September 2025, showed: Policy: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff bum out, or resident behavior which may increase the likelihood of such events. Definitions: Neglect -Failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on interviews, and record review, the facility failed to ensure 1.) necessary care and services were to prevent Urinary Tract Infections (UTIs) from developing or worsening by, failing to follow physician's orders for a silver coated foley catheter, failed to order labs, and change the foley catheter per orders for one resident (#2) out of four residents reviewed, resulting in Resident #2 developing a urinary tract infection that progressed to Fournier's gangrene and sepsis. Failed to give antibiotics for UTI as ordered for one resident (#13) out of four residents reviewed with catheters. This failure placed Resident #13 at risk for worsening infection or delayed recovery. 2.) The facility did not ensure providers were notified of abnormal lab results for two residents (#1 and #4) out of three residents reviewed for labs and 3.) failed to ensure pain was managed for one resident (#12) out of three residents sampled.Findings included: 1.) Review of the admission records showed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but are not limited to type 2 diabetes mellitus without complications, muscle wasting and atrophy, need for assistance with personal care, sepsis, unspecified organism, obstructive and reflux uropathy, unspecified. Review of Resident #2's May 2025 Medical Administration Record (MAR)/Treatment Administration Record (TAR) revealed the resident had an appointment with a urologist on 5/13/25. The appointment was checked off on 5/12/25. There were no notes regarding this appointment in the electronic medical record or the chart. Review of Resident #2's May 2025 orders showed the resident's primary care provider (PCP) ordered the facility to use a #16 French silver coated foley catheter and change the catheter every 3-4 weeks during night shift, starting on 5/19/25. The order was to start doing this every month for neurogenic bladder and recurring Urinary Tract Infections (UTIs). He placed the order again on 5/22/25 with an order summary of using the #16 French silver coated foley catheter and change on a every 3-4 weeks schedule once foley is received. There were no records of the resident ever receiving the silver coated foley catheter after these orders were placed. Review of Resident #2's June 2025 MAR/TAR revealed the resident was last treated for UTI, with Rocephin 1 GM, on 6/10/25 at 8:29 p.m. The resident had an order for a urinalysis, with a urine culture and sensitivity test on 6/9/25. The resident had an order for additional labs on 6/10/25. The testing results of the urine polymerase chain reaction (PCR) panel were positive for pathogens. The resident had an order for enhanced barrier precautions related to foley catheter care every shift for infection prevention and control. Review of Resident #2's June 2025 MAR/TAR showed the resident had a pain level of 7 out of 10 on 6/9/25 and a pain level of 8 out of 10 on 6/10/25, during the evening when the resident was diagnosed with the previous UTI. (The pain scale is a tool used to measure and assess the intensity of pain on a scale of 0-10 where 0 represents no pain and 10 represents the worst possible pain). Review of Resident #2's progress notes completed on 7/2/25 at 10:51 a.m., by Staff D, Licensed Practical Nurse (LPN), revealed the resident had complaints of severe pain in pelvic area, hard and swollen pelvic area, and the area was tender to touch. Staff D contacted the providers answering service and spoke with the primary care providers Advanced Registered Nurse Practitioner (ARNP). The ARNP instructed Staff D to order a kidney, ureter, bladder (KUB) and pelvic ultrasound. Review of Resident #2's July 2025 MAR/TAR, revealed a KUB and pelvic ultrasound were ordered for lower pelvic pain. The documentation showed the order was, discontinued due to clarification. On 7/3/25, another order for the pelvic ultrasound was discontinued due to, No directions specified for order. Review of Resident #2's July 2025 MAR/TAR showed a completed order for KUB and pelvic ultrasound on 7/2/25 at 3:40 p.m. and an abdominal x-ray was taken at 4:00 p.m. Review of Resident #2's ultrasound results, dated 7/2/25 showed the reproductive organs were not visualized, the urinary bladder was empty, and it was a nondiagnostic study. Review of Resident #2's x-ray results, dated 7/2/25 showed there was no evidence of pneumoperitoneum or abnormal calcifications. Resident #2's record did not show any orders for labs to establish if there was an infection during July 2025. The last labs order for the resident were the labs on 6/10/25. Review of Resident #2's July 2025 MAR showed a documented pain level of 8 out of 10 on the day shift of 7/2/25, and the pain level was documented at 10 out of 10 during the evening shift of 7/2/25. On 7/3/25, the resident's pain levels were listed as N/A (not applicable) for day and evening shifts. The pain level was documented as 7 out of 10 during the evening shift on 7/4/25. The pain level was documented as 0 out of 10 during the day shift and N/A during the evening shifts for 7/5/25 to 7/6/25. All the pain levels for the night shifts were documented as 0 out of 10 for 7/1/25 through 7/6/25. Review of Resident #2's progress notes showed documentation of her pain level being 10 out of 10 on 7/7/25. The notes showed the resident's temperature was last checked on 6/27/25. Review of Resident #2's May, June, and July 2025 MAR/TAR's revealed the resident's catheter was changed on 5/25/25 but was not changed again until the resident complained of pain on 7/2/25. The weekly skin checks in the electronic medical record, from 5/14/25 to 7/2/25 revealed, No new area of skin impairment. Review of Resident #2's progress notes completed on 7/4/25 at 11:39 a.m., by the Assistant Director of Nursing (ADON) at that time, revealed a skin assessment was completed. She noted Resident #2 had skin redness in the coccyx/buttock area. No open areas were observed, with only scant, pinpoint dot-like size amount of sanguineous drainage seen on brief from hemorrhoids irritation. She noted a small nickel-sized reddened area observed directly above the excoriated area on the coccyx. She noted that peri-care and foley care had been provided. No documentation was completed about wounds in the perineal area. The ADON documented the resident complained of high pain sensitivity to the wound area on palpation and movement. The ADON repositioned the resident and noted that she would continue to monitor and follow the plan of care. Review of Resident #2's care plans showed a focus area of indwelling catheter. Interventions included observing for signs of discomfort, observe and document for pain or discomfort due to the catheter, and to document and report any signs and symptoms of UTI. There was an additional focus area of Wound Risk. Interventions included obtaining vital signs per order. Documented under the focus area of pain, interventions included administering pain medication as ordered and observe for effectiveness, and to observe and anticipate the residents need for pain relief. There was an additional focus area of skin integrity risk. Interventions included monitoring and documenting location, size, and treatment of skin. Report abnormalities, failure to heal and signs and symptoms of infection. Review of Resident #2's Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Section H, Bladder and Bowel, revealed the resident had an indwelling catheter and no toileting program had been attempted at that time. Section M, skin conditions, noted the resident was at risk of developing pressure ulcers or injuries. The MDS information provided did not contain any documented pressure injuries. Review of Resident #2's hospital record, dated 7/7/25 showed: Resident #2 reported for the past few weeks they have been asking the facility to send them to the emergency room for not feeling well. Upon examination, the resident had purulent drainage from their peritoneal area with foul smelling odor. They also had a large necrotic area appearing in their genital region. The foley catheter was in place with purulent drainage. The resident reported to the hospital that they had been smelling this foul odor for the past few weeks. Review of Resident #2's hospital lab records, dated 7/7/25 at 2:34 p.m. showed elevated white blood cell (WBC) results: WBC 30.85 (units 10*3/uL) [Microliter]. Review of Resident #2's hospital general surgery plan, dated 7/7/25 showed: Fournier's gangrene with a necrotizing soft tissue infection of the lower abdominal wall as well as peritoneum with purulence draining from indwelling catheter. Patient is in septic shock at this time and is being actively resuscitated with volume. Patient will need emergent debridement for source control, and I have discussed this with the patient. I discussed the procedure in detail including significant disfigurement from the removal of the necrotic tissue and that further operations we will need to be undertaken for either reconstruction or further debridement of necrotic tissue. We also discussed possible need for an ostomy in the future. On 10/27/25 at 3:50 p.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She stated if there were signs of infection in residents with catheters, she would let the nurse know immediately. She would document what was observed in the electronic medical record, under catheter care tasks. Staff B said the last training she received was an in-service in July 2025 where they discussed catheter procedures. On 10/27/25 at 3:57 p.m., an interview was conducted with Staff E, Registered Nurse (RN). Staff E stated the care provided depended on the type of catheter a resident had. She noted nurses flushed and cleaned foley catheters and CNAs emptied the catheter bags throughout the day. Staff E stated the care was provided every shift, but it also depended on the resident's condition at that time. If signs of infection were observed, she would check vitals, notify the provider to get orders for a urinalysis and culture, and call the resident's representative. Staff E said a change of condition evaluation would have been completed as well. She stated she had not received training on resident's change of condition but did receive education on documenting last week. On 10/27/25 at 4:05 p.m., an interview was conducted with Staff A, LPN. He stated the CNAs and nurses cleaned the catheters. Staff A said the nurses and CNAs must assess if the catheter was intact and draining and observe for urine color. Staff A said, If the line is cloudy, the nurses change it. He stated if he suspected an infection, he would call the doctor to ask for a culture. Staff A stated there was a section in the chart for change of condition and progress notes. he stated any change of condition should be documented in those sections of the record and should also be shared in shift-to-shift report. Staff A stated the staff had been trained in catheter care and change in condition, upon hire and continued with occasional in-service trainings. He stated the training instructed, If an infection is discovered, then the clinical nursing staff would go and review all the foleys in the facility. As part of this review, leadership would provide training with demonstration and education. On 10/28/25 at 11:45 p.m., an interview was conducted with Staff D, LPN. She stated Resident #2 had pelvic pain on 7/2/25, and she was told to give the resident medication. On 7/2/25, Staff D changed the resident's catheter. Staff D thought she changed the catheter after resident reported the pain, but she was not sure. She stated she could not remember anything else ordered for the resident. She was not sure; it was a long time ago. Staff D said she did not remember if there were any signs of infection. She stated one of the CNAs saw discharge coming out of the adult brief on 7/7/25. Staff D noted the CNA called someone to have the resident sent out to the emergency room (ER). On 10/28/25 at 12:49 p.m., a telephone interview was conducted with Staff C, LPN. Staff C said 7/7/25 was the first time she had worked with Resident #2. The resident presented with a large amount of perineal discharge, and Staff C notified the provider. She stated the resident was then sent to the ER. Staff C said she believed that during discussions they mentioned the resident having pain. Staff C stated she believed the resident had an ultrasound and followed with urology. Staff C said she was not sure because she only found out about Resident #2's treatment through conversations with other staff. Staff C stated she was told the staff had noticed a foul odor. Staff C said a CNA notified her about the discharge and asked her to assess. Staff C stated the event was a long time ago and she was not exactly sure who the CNA was that day, on 7/7/25. On 10/28/25 at 12:54 p.m. a telephone interview was conducted with Staff G, RN. She did not remember much about the resident. She stated, If there were labs ordered, then they would be placed in the system. On 10/29/25 at 2:09 p.m., an interview was conducted with the Director of Nursing (DON). She stated it was common to call physicians for new orders. She confirmed she knew there had been discrepancies with provider notifications for labs or changes in conditions. The DON said, If the resident is presenting with signs of infection, then the CNA should report it to the nurse. The nurse will assess and perform interventions if the resident has orders. They will check for recent antibiotics use due to UTIs. They will call the provider if it is a new onset of infection. She stated the staff have had in-service training for catheter care since she began working at the facility. The DON stated they had not implemented a demonstration training, but they were going to soon. Review of a facility policy titled General Procedures and Treatment Modalities, pages 783-785 revealed the catheter care procedures. Review of page 785 shows to call the health care provider if there are signs of fever, or cloudy, bloody, odoriferous urine develops. 2.) Review of admission Records showed Resident #13 was admitted to the facility on [DATE] with diagnoses including but are not limited to chronic systolic (congestive) heart failure, type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, and obstructive and reflux uropathy, unspecified. Review of Resident #13's August 2025 and September 2025 MAR showed an order was placed for Ertapenem Sodium Injection Solution Reconstituted 1GM. One application was to be given every day at bedtime for Proteus Mirabillis in urine for five days starting on 8/29/25. Review of Resident #13's August 2025 and September 2025 MARs showed the doses administered to the resident were on 9/1/25, 9/2/25, and 9/3/25. The resident received three doses of the five ordered doses. Review of Resident #13's progress note did not show any documentation detailing why the doses were missed, or if the provider was notified that the resident did not receive all doses of the prescribed antibiotic for the UTI. Review of a facility policy titled Lab/Radiology Process Guidelines, undated, showed: 5. Upon receiving the results, notify the physician and resident/resident representative of the results, and file the results in the medical record under Labs/Radiology tab. 6. Document in a progress note the labs/radiology tests you received and who the results were reported to. Include any additional follow up or new physician orders received in the progress. 8. Stat and critical labs must be called to the physician as soon as they have resulted, with the nurse documenting the communication and follow-up in the electronic medical record. Review of a facility policy titled, Physician Notification, dated October 2021 revealed, The facility strives to ensure each resident's health is supervised by a qualified attending physician. The attending physician in the facility is ultimately responsible for supervision and management of the care of the resident/patient. Review of a facility policy titled Abuse Prevention Program, reviewed September 2025, showed: Policy: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff bum out, or resident behavior which may increase the likelihood of such events. Definitions: Neglect -Failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 2.) An interview was conducted on 10/28/25 at 10:10 a.m. with a Resident Representative (RR) for Resident #1. The RR said on 9/27/25 he was at the facility with Resident #1, and she was not herself. He said she was very lethargic, wanted to sleep and was in pain. I let the nurse and Certified Nursing Assistant (CNA) know my concern. He said at one point he nor the staff could find Resident #1's assigned nurse, Staff H, Licensed Practical Nurse (LPN) for over an hour. The RR said he was trying to find the nurse because the resident's medications were late, and she was in pain. He said a CNA he talked to didn't know where the nurse was nor did the other nurse working. He said at one point the staff called Staff H to find her. He said when Staff H finally returned to the unit, she was very short and asked what he wanted. The RR said he told Staff H his concerns about her medications, her pain, and the fact the resident had seizures the previous night. He said Staff H responded by saying so what's the problem. She's had seizures before, right? The RR said he felt like Resident #1 needed to go to the hospital because she was not her normal self and was not well. He said the resident had labs drawn early that morning, so he asked about the results of those as well. He said Staff H told him the results would be looked at on Monday when the doctor returned and that Resident #1 could not go to the hospital because the doctor was not on call on the weekend. Staff H, LPN was unable to be reached for an interview. Review of admission Records showed Resident #1 was admitted on [DATE] with diagnoses including elevated blood pressure without diagnoses of hypertension, systemic lupus erythematosus, end state renal disease and hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease. Review of Resident #1's Progress Notes from 9/26/25 showed a note at 10:12 p.m. stating The patient experienced two brief episodes of seizures earlier today. Vital signs were obtained and found to be within normal limits: blood pressure 127/73 mmHg, heart rate 86 bpm, temperature 97.7 °F, and blood sugar 107 mg/dL. At the time of evaluation, the patient was alert, oriented, and stable, with no signs of acute distress. Resident #1's Primary care physician was notified of the events and gave instructions to obtain laboratory tests in the morning. The patient remains in her room under observation, accompanied by her father. She continues to be stable and without new symptoms at this time. Monitoring will continue, and the clinical team remains vigilant for any significant changes in the patient's condition. Review of Resident #1's lab results showed results drawn on 9/27/25 at 8:17 a.m. and results printed at 1:53 p.m. The results showed the resident had low iron, unsaturated iron-binding capacity (UIBC), glucose, and chloride and had high blood urea nitrogen (BUN), creatinine, BUN/creatinine ratio, and potassium Review of Resident #1's progress notes did not show any documentation the physician was notified of abnormal lab values on 9/27/25. An interview was conducted on 10/29/25 at 1:05 p.m. with Resident #1's primary care provider (PCP). The PCP said he did speak with the nurse on 9/26/25 with Resident #1 had two seizures, but he did not speak to a nurse on 9/27/25 regarding the resident being in pain, having a change in condition, or abnormal lab values. He said Resident #1 was not normally in pain; that would have been new. He said he would have expected to be notified when a resident had pain that was not normal. The PCP reiterated that he did not hear from the nurse that day. Review of Resident #4's admission Records showed the resident was admitted on [DATE] with diagnoses including end stage renal disease, generalized epilepsy, thrombocytopenia (deficiency of platelets in the blood), history of transient ischemic attack, and dependence on renal dialysis. Review of Resident #4's orders showed an order for STAT (immediate) labs for a complete blood count (CBC) and comprehensive metabolic panel (CMP) on 9/28/25 related to tremors and feeling cold. Review of Resident #4's lab results showed the labs ordered were completed on 9/28/25 and results were printed on 9/28/25 at 7:10 p.m. The results showed Resident #4 had abnormal lab results including low red blood cells (RBC), hemoglobin, hematocrit, platelet count, lymphocytes, lymphocyte absolute and had high neutrophils. Review of Resident #4's progress notes did not show any documentation a provider was notified of the abnormal Stat lab results on 9/28/25. An interview was conducted on 10/28/25 at 2:41 p.m. with Resident #4's PCP's assistant. The assistant stated she was returning the phone call on behalf of the PCP. She said the provider would expect to be notified of any abnormal lab results. She said she and the provider did not recall if they were notified on 9/29/25, but the facility would be expected to document that information. She said the PCP did not document every time he received a phone call. An interview was conducted on 10/29/25 at 2:09 p.m. with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC). They said abnormal lab results were faxed to the facility and the nurse called the provider and let them know the results. They stated they expect this to happen within a couple of hours or receiving notification of abnormal lab results, and documentation of the contact should be in the progress notes or on the lab results sheet. They said if there were no new orders from the provider it should have been documented as well. They stated being aware of discrepancies with physician notifications. The RNC and DON reviewed Resident #1's medical record and confirmed there was no documentation prior to her discharge that a provider was notified of abnormal labs. They also reviewed Resident #4's medical record and confirmed there was no documentation a provider was notified of the abnormal Stat lab results. Review of a facility policy titled Lab/Radiology Process Guidelines, undated, showed: 5. Upon receiving the results, notify the physician and resident/resident representative of the results, and file the results in the medical record under Labs/Radiology tab. 6. Document in a progress note the labs/radiology tests you received and who the results were reported to. Include any additional follow up or new physician orders received in the progress. 8. Stat and critical labs must be called to the physician as soon as they have resulted, with the nurse documenting the communication and follow-up in the electronic medical record. 3.) On 10/28/2025 at 10:22 a.m., an interview was conducted with Resident #12. Resident #12 stated it took a couple days to get pain medication upon admission to the facility. The resident stated the staff was not ordering the medication. On 10/28/2025 at 2:51 p.m., a follow-up interview was conducted with Resident #12. The resident explained being upset about the pain and stated there was no reason she had to wait was so long to get pain medication. The resident stated the pain increased during the time she was without pain medication. Resident #12 stated when the colostomy bag breaks, the skin becomes very raw like a diaper rash. Resident #12 stated because she sat for long periods, her skin was bad. Resident #12 stated not wanting to sit on feces when left unchanged as it breaks her skin. The resident said it was upsetting and stated it felt like the skin was being torn off, kind of like a hot poker. The resident stated to get the feces off, the nurses had to rub the skin really hard, which was excruciating. Review of Resident #12's admission record revealed the resident was admitted to the facility on [DATE], with diagnoses including: Crohn's disease of large intestines with fistula, other intraoperative complications of the digestive system, acquired absence of other specified parts of the digestive tract, and gastro-esophageal reflux disease without esophagitis. Review of an evaluation titled BIMS (Brief Interview for Mental Status) Evaluation V 2.0, and dated 10/23/2025, revealed Resident #12 had a BIMS, score of 15, which indicated she was cognitively intact. Review of a care plan for Resident #12 dated 10/23/2025 revealed a focus - Resident #2 had an actual wound surgical to abdomen sacral wound, initiated on 10/23/2025. The goal was to promote wound healing and minimize additional wound from developing, initiated on 10/23/2025. Interventions included: observe for pain. Review of a physical therapy evaluation dated 10/23/2025, revealed the resident had pain when resting, with a frequency of constant, and when moving, all at a level of 6 out of 10 in the abdomen. Review of Resident #12's physician orders revealed: -Monitor pain every shift and record pain number on a scale of 0-10 scale, every shift for pain dated 10/21/2025. -Colostomy care every shift and as needed. Ordered 10/23/025. -Acetaminophen 325 milligram (mg), 2 tablets every six hours, as needed for pain. Ordered 10/23/2025. -Percocet oral tablet 10-325 mg, (oxycodone with acetaminophen), 1 tablet every 6 hours as needed for sub-acute pain. Ordered 10/24/2025. Review of Resident #12's Medication Administration Record (MAR), showed the resident had a documented pain level of 6 out of 10 on 10/23/2025. The MAR showed no documentation Acetaminophen nor Percocet being given on 10/23/2025 or 10/24/2025. Review of Resident #12's progress notes revealed no documentation as to why pain medication was not provided and no documentation a doctor was notified about the resident's pain levels from 10/23/2025 through 10/24/2025. On 10/28/2025 at 3:02 p.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). Staff D stated there was always a Tylenol order in place, and if the Tylenol did not work, then the doctor would need to be called. Staff D stated a pain level of three or higher warranted contacting the doctor. Staff D stated level 6 pain would be considered significant. Staff D reviewed Resident #12's medical record and confirmed the resident had level 6 pain on 10/23/2025, and pain medication was not provided on 10/23/2025. Staff D stated if the resident's primary physician could not be reached, then the Medical Director would need to be contacted. On 10/28/2025 at 3:19 p.m., an interview was conducted with Staff L, LPN. Staff L stated if there was no order for pain medication, the doctor would need to be contacted to provide instructions on what to do. On 10/29/2025 at 1:15 p.m., an interview was conducted with Staff C, LPN. Staff C stated when residents present with pain upon admission, orders would be followed. Staff C stated residents admitted from the hospital with pain and without orders for pain medication, had primary care providers, who would be contacted. If the primary care provider contact attempt was ineffective, then the Medical Director would be contacted. Staff C stated any level of pain, such as level 6 out of 10, warranted a call to the provider. Staff C reviewed Resident #12's medical record and confirmed the resident's pain level was documented at a six out of 10 on the pain scale and Acetaminophen was not administered. Resident #12 had no additional orders for pain medication on 10/23/2025. Staff C stated there was no reason not to provide the pain medication and stated, it's kind of cut and dry, right? On 10/28/2025 at 1:48 p.m., an interview was conducted with the Director of Rehab, (DOR). The DOR stated Resident #12 verbalized having constant aching pain in the abdomen at a level of 6 out of 10 with both movement and while at rest. On 10/29/2025 at 2:07 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated if a resident's primary care provider was contacted, it should have been documented in the resident's medical record. The DON stated if a resident's primary care provider was unreachable, the Medical Director should have been contacted, and if unreachable, the DON should have been contacted. The DON stated a resident's primary care provider should have been contacted for level 6 out of 10 pain. The DON stated pain medication should have been provided for Resident #12's colostomy care. The DON reviewed Resident #12's medical record and confirmed the resident had a pain level of 6 out of 10, on 10/23/2025 and no pain medication was provided until 10/25/2025. The DON confirmed acetaminophen was ordered on 10/23/2025 and was not provided on 10/23/205 and 10/24/2025. The DON confirmed Percocet was ordered on 10/24/2025 and it was not given until 10/25/2025. The DON stated her expectation was something would have been ordered by then. Review of a facility policy titled Clinical Programs Manual - Pain Management, dated 10/2021 revealed – Overview: The facility is committed to pain management through the following: Interdisciplinary data collection Interdisciplinary approach Resident/patient religious and cultural values Education of residents/patient and caregivers Residents/patients, families and caregivers will be educated on appropriate pain control. The inter disciplinary team will strive to reduce/eliminate the fears of addiction as it relates to pain medication and/or other issues the resident/patient and family may have. The team will encourage the resident/patient and family to report pain since the longer pain goes untreated, the harder it is to relieve. GUIDELINES 1. Collect data on the intensity of the resident/patient's pain. admission Data Collection Monthly, Return & PRN Data Collection 2. Identify the current analgesic regimen (i.e., analgesic usage covering a 24-hour period for several days as applicable.) 3. Analyze the reported pain severity on the current regimen. 4. Include the resident/patient and family in development of the Plan of Care. 6. Develop individualized comfort interventions using collaborative proactive, not reactive, interdisciplinary approach. Obtain physician's orders as needed. d. Identify the sources of pain. e. Maintain prescribed levels. 8. Obtain an order for around-the-cl

Based on interviews with residents, staff and administrative staff, and Medical Director, and review of the clinical record, incident log, and policy and procedure, it was determined the facility failed to protect residents' right to be free from physical, verbal, psychological, psychosocial and sexual abuse, and neglect by failing to implement a systematic process to carry out their abuse policy to ensure witnessed or reported abusive interactions, neglect and injuries were fully investigated and addressed for nine residents (#164, #6, #36, #90,#32, #100, #308, #106, #12) of 12 residents sampled. Incidents occurred between residents (#164, #6, #36) and staff members and between a resident (#90) and two other residents (#32, and #100). The facility failed to identify and prevent neglect by failing to ensure wound care orders were implemented for two residents (#308 and #106) and failed to investigate the cause of a fracture for one resident (#12) who stated they fell . These failures resulted in Immediate Jeopardy which began on 09/19/23 and was ongoing at the time of survey exit on 01/12/2024. Findings included: Cross reference F610, F726, and F867. A review of the facility's Abuse Prevention Program with an effective date of 2012 and a most recent change date of August 2022 revealed: POLICY: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burnout, or resident behavior which may increase the likelihood of such events. DEFINITIONS: Abuse - Includes Verbal, Physical, Sexual, and Mental/Emotional Abuse Abuse o Willful infliction of injury upon a resident by a staff member, another resident, a vendor, a visitor, or other individual. o Unreasonable confinement/Involuntary seclusion o Separation of a resident from other residents, or from their room or other area, against the resident's will or the will of the resident's representative. o Intimidation with resulting physical harm, or pain, or mental anguish. o Punishment with resulting physical harm, or pain, or mental anguish. o Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well being. o Corporal punishment and any physical or chemical restraint not required to treat the resident's symptoms. o Instances of abuse of residents, irrespective of any mental or physical condition, that causes physical harm, pain or mental anguish to include verbal, sexual, physical, & mental abuse. o Abuse that includes that which is facilitated or enabled using technology. o Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse o Oral, written, or gestured language that includes disparaging and derogatory terms to the residents or their families to describe the resident within their hearing distance, regardless of their age &/or ability to comprehend or disability. Physical Abuse o Includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc. o Also includes controlling behavior through corporal punishment or a restraint not required to treat the resident's symptoms. Sexual Abuse o Includes but is not limited to, humiliation, harassment, coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. Mental/Emotional Abuse o Includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. o During the delivery of personal care, staff must remove residents from public view & provide clothing or draping to prevent unnecessary exposure of body parts. o The taking of unauthorized photographs may constitute mental, physical, and/or sexual abuse. o Whether mental abuse has occurred is determined by a reasonable person standard and does not require a specific response from the resident. o Mental abuse related to photographs and/or audio/video recordings is prohibited; staff are prohibited from taking, keeping &/or distributing photographs that demean or humiliate residents. NOTE: If the facility has reason to believe that a resident representative is making decisions or taking actions that are not in the best interests of a resident, the facility shall report such concerns when indicated and, in the manner, required under state law. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, or other individuals. Neglect o Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Exploitation/Misappropriation of Resident/Patient Property o Deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident/patient's belongings or money without the resident's consent. o Taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion. Mistreatment o Inappropriate treatment or exploitation of a resident. Injury of Unknown Source o An injury that is suspicious for abuse, or neglect due to the severity of the injury, the site of the injury, the number of injuries at one time, or the number of injuries over time. o An injury should be classified as an injury of unknown source when all of the following criteria are met: o The source of the injury was not observed by any person; and o The source of the injury could not be explained by the resident; and o The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Serious Bodily Injury An injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization , or physical rehabilitation; or an injury resulting from criminal sexual abuse. Alleged Violation o A situation or occurrence that is observed or reported by staff, resident, relative, visitor of others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Suspected Crime (Elder Justice Act Reporting) o A report from a resident, representative or other relater that an event has occurred which is defined by law of the applicable political subdivision where the facility is located, involving individuals aged 60 or older. This may include, but may not be limited to, allegations of sexual assault, theft, and abuse. o Criminal sexual abuse: In the case of criminal sexual abuse which is defined in section 2011(l9)(B) of the Act (as added by section 6703(a)(l)(C) of the Affordable Care Act), serious bodily injury/harm shall be considered to have occurred if the conduct causing the injury is conduct described in section 2241 (relating to aggravated sexual abuse) or section 2242 (relating to sexual abuse) of Title 18, United States Code, or any similar offense under State law. In other words, serious bodily injury includes sexual intercourse with a resident by force or incapacitation or through threats of harm to the resident or others or any sexual act involving a child. Serious bodily injury also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act. Review of the facility's abuse log revealed a resident to resident incident occurred on 11/21/23 involving Resident #32 and Resident #90. Review of Resident # 32's progress note, dated 11/21/2023 at 9:04 p.m., signed by Staff L, Licensed Practical Nurse (LPN), revealed, Resident reported that another resident touched her inappropriately. States that while at the smoking area on Saturday [11/18/23], a male resident approached her and asked her if she would like to be sexually harassed, she agreed to it thinking it was a joke and he went ahead and touched her breast. Review of Resident #32's most recent Quarterly Minimum Data Set Assessment (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. During an interview on 01/10/24 at 3:05 p.m. Resident #32 said Resident #90 came up and asked if I wanted to be sexually harassed. I thought he was joking and then he groped my breast. When asked if she thought the touch on her breast could have been an accident, Resident #32 replied, I never told anyone it was an accident. Resident #32 continued to describe the events and said, Staff I, Certified Nursing Assistant (CNA) overheard me say to Resident #90, there will be no more of that, and asked what I was talking about. Resident #32 reported she told Staff I, CNA about Resident #90 touching her breast. Staff I then came to my room and helped me write a grievance. This was all reported to Staff I, CNA on the day it occurred, but I found out about four days after the incident, on 11/21/2023, that the grievance had been lost. I became hysterical and called the police. The police came and talked to me. This was on 11/21/2023, four days after the incident, and four days after Staff I, CNA helped me write the grievance. When I called the police, I heard Resident #90 was immediately placed on 1:1 (one to one) supervision, but I heard he got caught with someone else and was put on 1:1 again. During an interview on 01/10/24 at 3:15 p.m., Staff I, CNA reported she remembered Resident #32 reporting the allegation of sexual abuse. She said she reported the incident but was not sure who she had reported it to. Staff I was aware law enforcement was called but was not present at the facility when law enforcement came. Staff I said Resident #90 was placed on 1:1 supervision immediately after she reported it. Resident #90 was taken off of the 1:1 supervision (date unknown) but was placed back on 1:1, maybe less than two weeks later. A follow-up interview was conducted with Staff I, CNA on 01/11/24 at 1:17 p.m. She recalled reporting the event with Residents #32 and #90 on a Saturday (11/18/21) to the weekend nurse supervisor, Staff N, Registered Nurse (RN). Staff I, CNA did not know if Staff N, RN called the Director of Nursing (DON) or the Nursing Home Administrator (NHA) to report the event but remembered they wanted a statement. They had Resident #32 write the statement and Staff I, CNA signed under Resident #32's statement. The weekend supervisor (Staff N, RN) was sick the next day and I made a copy of the statement, but I can't find the copy. I slid the statement under the NHA's door on Sunday before I left the facility. On Monday, the NHA said the housekeeper must have swept up the statement because she did not see it. I came in that Tuesday, 11/21/2023 and went to the NHA's office. I attempted to give the NHA a copy of the statement, and the NHA didn't take it from me. The NHA said that she had it handled. An interview was conducted with the NHA on 01/11/2024 at 5:58 p.m. to discuss the incident between Resident #32 and #90 and the investigation of the incident. The NHA said she first learned of the incident when Resident #32 called law enforcement on 11/21/2023 and the evening unit manager, Staff L, LPN called her. The NHA said she came to the building and talked to both residents and staff but did not document any of the interviews. She said no staff witnessed the incident and neither resident involved remembered what date the event took place. Resident #32 did not report telling any other staff, so no other staff were interviewed. The NHA said she did not receive a written statement from Staff I, CNA. The NHA expressed that Resident #32 and Resident #90 stated this incident was consensual. The NHA said the 1:1 supervision was for a short period of time. When asked if Resident #32's call to 911 to report the event as a crime on 11/21/2023 indicated a consensual event took place for Resident #32, the NHA did not respond. On 01/11/24 at 1:15 p.m. a telephone call was made to Staff L, LPN who documented the report of abuse on 11/21/2023. Staff L, LPN did not answer and a message stating the phone number was not accepting messages received. Due to this, no voicemail could be left for a return call. On 01/11/24 at 1:36 p.m. a telephone call was placed to the weekend nurse supervisor/Staff N, RN related to Staff I, CNA's report to her of a sexual abuse allegation by Resident #32 on 11/18/23. A voicemail message was left but no return call was received prior to exiting the facility on 1/12/24. Review of Resident #90's progress note, dated 11/21/2023 at 8:38 p.m. and signed by Staff L, LPN revealed, this resident was reported by another resident of inappropriately touching her. Resident #90 stated that he accidentally brushed his hand against a female resident's breast. He explained that he jokingly asked the resident if she would like to be harassed, and she answered yes. He then reached to touch her shoulder and he accidentally touched her breast. The incident was reported as per facility policy. skin check completed. patient placed on 1:1 for safety. Review of Resident #90's most recent Quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating cognitively intact. The MDS did not reveal any behaviors. Resident #90's clinical record was void of any documentation of 1:1 supervision in November 2023 or December 2023 and no orders for 1:1 supervision for this time frame could be found. Continued review of the abuse log revealed Resident #90 had another resident to resident incident on 12/26/23 involving Resident #100. Review of Resident #90's progress note, dated 12/26/2023 at 3:13 p.m., indicated resident observed in a confused resident's room this afternoon touching the resident. Resident voiced understanding but stated, even if she asked for it. The resident was placed on a 1:1 and police were notified. Resident will be moved to a different hallway. Medical Doctor, Responsible Party (RP), and NHA notified. Review of Resident # 90's Social Service note, dated 12/29/2023 at 1:28 p.m., revealed the Social Services Director and the Licensed Clinical Social Worker (LCSW) met with the resident to facilitate a BIMS. The resident scored a 15 of the BIMS. Impulsive behavior discussed during the meeting, Resident verbalized understanding regarding consequences of continued, inappropriate behavior. Resident verbalized agreement to cease the aforementioned behavior. DON consulted on this meeting. Social services will follow up as needed. Review of Resident #90's care plan following the 12/26/23 incident revealed a care plan for behavior was initiated on 12/29/23 for inappropriately touching female residents and staff. Interventions did not include any 1:1 supervision. The interventions documented were: Control\Minimize Outburst; Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care; Document episodes of behavior & review to determine the effectiveness of intervention; Psychiatry Services as needed; and Psychological Services as needed. Review of Resident #100's Admission Record revealed an admitted [DATE] with diagnoses to include cerebral infarction, hemiparesis and hemiplegia to left non-dominant side, diabetes mellitus type 2, chronic obstructive pulmonary disease (COPD), psychoactive substance abuse, anxiety disorder, major depressive disorder recurrent, congestive heart failure, gastro-esophageal reflux disease, and history of malignant neoplasm of the esophagus. Review of the Admission MDS, dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. A review of the resident's care plan revealed a care plan for communication difficulty was initiated on 11/10/23. Review of Resident #100's progress note, dated 12/26/23 at 3:10 p.m. and written by the DON revealed, following an event with another resident a skin check was performed. Resident's skin is clean, dry, and intact. No open areas and no redness noted. Resident was questioned if another resident touched her inappropriately anywhere, resident declined and stated they were just talking to each other. RP and NHA notified. Review of Resident #100's progress note, dated 12/27/23 at 11:24 a.m. and written by the DON revealed, a phone call was made to resident's RP to inform him of the events that occurred 12/26/23. RP did not have any questions or concerns at this time. On 01/12/24 at 2:21 p.m. an attempt was made to contact Resident #100's RP but the voicemail was not set up to receive messages. During an interview on 1/9/24 at 5:58 p.m. the Law Enforcement Officer (LEO), who responded to the facility following the event on 12/26/2023, reported he interviewed Resident #100 about the incident and she stated that she consented, but for most of the interview her responses were inappropriate other than stating her name. He also reported that other staff at the facility told him the alleged perpetrator, Resident #90 had a previous history of this behavior but due to Resident #100's responses he was not able to take further action. During an interview with Resident #90 on 01/10/24 at 8:16 a.m. he was observed in bed with a staff member providing 1:1 supervision. Resident #90 said the incident from about a month ago was blown out of proportion and his side of the story was very different from the other person. He also said that he had someone with him 1:1 for a few days after that. When asked about the 1:1 today, he said that was permanent now, even though he doesn't agree with it, but he has no choice. He denied that any other interventions had been discussed with him or were attempted. He denied any involvement of his doctor, or discussion about or changes in medications or other treatments. 25821 During an interview on 1/09/24 at 3:20 p.m., Staff X, CNA stated she was aware of abuse in the facility. Staff X, CNA said the abuse occurred two weeks ago with Resident #6. Staff X, CNA said the police came and took the staff (Staff W, CNA) away the next day. During an interview on 1/09/24 at 3:29 p.m., Staff Y, CNA said about two or three weeks ago she heard a staff was abusive with Resident #6. During an interview on 1/10/24 at 8:25 a.m., Resident #6 said last month a staff (Staff W, CNA) hit him in the face. He said he reported this to staff and his [spouse]. He started to tear up during the interview. When asked if it hurt, he said yes. He said the staff member had not worked with him since the incident. A review of Resident #6's progress notes revealed an event note, dated 12/15/2023 at 7:00 p.m., that documented: The following event has occurred: resident complaint of abuse by staff. The event took place in Resident #6's room. Resident informed Staff V, CNA, and Speech Therapy that another CNA had hit him early this AM. When questioned, the resident was difficult to understand, however he did state, I pushed call light to get changed. When she came in, she had an attitude and asked why I cannot use a urinal. Resident became upset and more difficult to understand and stated, the b**** hit me in the face. The report indicated he was hit in the face with a pillow by Staff. The description of the event provided by licensed staff earlier in the day on 12/15/2023 when incident occurred revealed Resident #6 told staff he was slapped by a staff member. Other: I was informed by staff that resident made a complaint that he was slapped by a staff member. No complaints of (c/o) discomfort. The resident's practitioner was notified on 12/15/2023 at 9:00 AM with new orders to monitor the resident. The RP for Resident #6 was notified on 12/15/2023 at 9:14 AM. Review of Resident #6's progress note, dated 12/15/2023 at 1:15 p.m., revealed the resident informed speech therapy that a CNA had hit him early this morning. When questioned, the resident was difficult to understand, however he did state, I pushed call light to get changed. When she came in she had an attitude and asked why I can't use a urinal. Resident became upset and made an allegation of abuse. Head to toe assessment revealed no open areas, no redness, no swelling or bruising noted to any part of his body. Review of Resident #6's most recent Quarterly MDS assessment, dated 10/27/23, revealed a BIMS score of 15 indicating the resident was cognitively intact. Review of the MDS Section J - Health Conditions revealed active diagnoses included aphasia, need for assistance with personal care, and cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke. During an interview on 01/10/24 at 8:31 a.m., Staff V, CNA recalled working in the room across the hall from Resident #6 in December 2023 during the 11 PM to 7AM night shift. Staff V, CNA did not see Staff W, CNA hit the resident, but Staff V, CNA did hear Staff W, CNA tell Resident #6 not to call her a [explicative]. Staff V, CNA stepped out of doing patient care in the room across the hall and saw Staff W, CNA leaving Resident #6's room. Staff W told one of the nurses she needed to report Resident #6 and document him calling her a [explicative]. Staff V, CNA entered Resident #6's room and asked Resident #60 (roommate to Resident #6) if he was OK. Resident #60 nodded toward Resident #6. Resident #6 told Staff V, CNA the girl that was working with him, hit him with a pillow. Staff W, CNA tried to discuss the incident with Staff V, but Staff V, CNA did not want to talk to Staff W, CNA. Staff V, CNA stated she overheard Staff W, CNA say not to call her a [explicative], but she did not witness the interaction between Resident #6 and Staff W to include the alleged physical abuse of the resident. On 1/10/24 at 8:42 a.m. Staff W, CNA was called, and no answer was received. During an interview on 1/10/24 at 9:15 a.m. with the NHA and DON, the NHA stated she completed the required State Agency reporting on 12/15/2023 at 11:10 a.m. The local police came to the facility and spoke to Staff V, CNA and Staff W, CNA. The NHA reported the Law Enforcement Officer (LEO) told her Resident #6 said staff had pushed his arm. The NHA said she did tell the LEO Resident #6 reported to facility staff, he was hit by Staff W. The NHA said Staff W, CNA was suspended from 12/15/2023 to 12/22/2023. The NHA informed Resident #6's RP, Staff W, CNA would not work with Resident #6 anymore. The DON provided documentation of Staff W's training, which was done over the phone (OTP) on 12/22/2023. Review of the document titled, INDIVIDUALIZED STAFF EDUCATION, contain Staff W's name, the date of 12/22/23, the Issue was Policy attached . The form included a printed statement: I received one on one education today concerning the issue above. I understand my responsibility, what to do in the future, and how my actions impacted the residents, staff, and the facility in general. I understand that a copy of this training will go in my personal file in case this becomes an issue again. Disciplinary action may be taken in the future if indicated. The line for Employee signature contained a handwritten note Education OTP. The line for Educator signature contained the DON's signature and the signature of Staff H, LPN/UM. The DON confirmed Staff W, CNA did not have a copy of the Abuse Prevention Program policy and procedure (P&P) during the phone training. Review of Staff W's assignment sheets and payroll records revealed she worked the night shift (11 PM to 7AM) on 01/06/2024, 01/07/2024, and 01/08/2024, without being provided in person training for abuse prevention prior to returning to direct contact/care of residents. On 01/10/24 at 10:49 a.m., the NHA provided a copy of facility staff training on the Abuse Prevention Program P&P dated 12/20/2023 with the signature of 24 staff members. The NHA confirmed the facility had not provided any additional training after this 12/20/23 training to 24 staff members. During an interview on 01/10/24 at 4:04 p.m., the DON confirmed Staff W, CNA was not reported to the Florida CNA Registry due to the facility's determination of unsubstantiated abuse. During a telephone interview on 01/12/24 at 9:25 a.m. the LEO, who investigated the allegation of abuse of Resident #6 on 12/15/23, revealed the resident reported to the LEO, he was grabbed by the arm by Staff W, CNA. The LEO interviewed Staff W, CNA by phone, and she denied the altercation occurred. Staff W, CNA denied ever being in the resident's room and made no mention of the resident calling her a derogatory term. Staff V, CNA reported to the LEO she was at the other end of the hall working when the incident occurred. The LEO had been unable to get Resident #6's [spouse] to come and assist him in getting additional information so he closed the case as informational. The LEO stated that because there were only two CNAs on the hall, there were no other staff to confirm what happened. The LEO did confirm the NHA reported that Resident #6 had accused Staff W of striking him in the face. During a second attempt at a telephone interview on 01/12/24 at 1:25 p.m. with Staff W the call disconnected after the surveyor requested to discuss the 12/15/23 incident. Immediately following the disconnection, a third attempt to call Staff W was made. The call went directly to voice mail. No return call from Staff W was ever received. A follow-up interview was conducted with Resident #6 on 01/12/24 at 1:42 p.m. The resident reported he was hit with a hand and not a pillow during the 12/15/23 incident involving Staff W, CNA. The resident was observed to slap his hand to his face when interviewed. 43453 A review of the facility's abuse log revealed Resident #164 made an allegation of abuse on 9/19/23. During an interview on 01/10/24 at 12:16 p.m. the Nursing Home Administrator (NHA) confirmed an allegation of abuse was made by Resident #164 on 09/19/23 and a federal report was completed. The resident reported his Certified Nursing Assistant (CNA), Staff R poisoned his coffee. The resident stated he witnessed the CNA remove his coffee and put an unknown substance in his coffee. An investigation was initiated. The NHA stated she could not find the statements she obtained from the CNA. She stated she spoke to the nurse who worked that day as well but could not find that statement either. A follow-up interview with the NHA on 01/10/24 at 12:38 p.m., revealed she misplaced the entire file related to Resident #164's abuse investigation to include witness statements. The NHA said Staff R, CNA was suspended for 5 days and education was conducted for all staff on Abuse and Neglect but no documentation of the training could be provided. Review of Resident #164's Admission Record revealed he was admitted on [DATE] with diagnoses to include muscle wasting and atrophy, epilepsy, unspecified dementia with agitation, and adult failure to thrive. The resident's admission Minimum Data Set assessment dated [DATE] revealed a BIMS score of 7, indicating severe cognitive impairment. The resident exhibited no signs of psychosis or behaviors. The resident had no new orders received on 9/19/23 following the allegation and no pain assessments completed. The admission record revealed the resident was discharged on [DATE] with no discharge location documented. On 01/09/24 at 3:43 p.m., an interview was conducted with Resident #36. She reported she was verbally abused by a staff member. Resident #36 stated a staff member yelled at her. She was scared to report the incident, but she told the Social Services Director (SSD) the first time it happened. She stated this happened before Christmas. Resident #36 said, The CNA yelled at me because of a fan. She called me out. Her name is [Staff T, CNA]. She stated she spoke to the DON and SSD about it. Resident #36 stated [Staff T] had gotten into her face about a fan at night. She said, She was just rude and disrespectful. She called me names. I don't want to say much about it. I don't want them to come after me. Then today, it's [Staff R, CNA]. This morning she [Staff R] came up again and said she will not assist me with my shower, and she won't change me. She said if you don't stop that [expletive] you will get into more trouble. Review of a grievance/concern report dated 12/23/23 for Resident #36 completed by Staff R, CNA revealed, Resident was upset when I came in this morning. I asked her what was wrong. She said an overnight CNA [Staff T, CNA] came in her room and took her fan out of her room. She told her to shut up she is tired of her shit and that it was her fan. Review of the grievance completed by the DON showed under facility follow-up Resident was informed the fan was the CNA's. A section on the form asked if this was an allegation of abuse. The box was left blank, indicating facility did not consider verbal abuse towards the resident abuse. The resolution of grievance /concerns section showed the grievance was not confirmed. Under the findings summary it showed, Resident voiced understanding the fan was not hers. The SSD signed off the grievance and indicated the resident was satisfied with the grievance resolution. On 01/09/24 at 4:09 p.m., an interview was conducted with Staff R, CNA with the DON present. Staff R stated she worked the back hall where Resident #36's room is located. She stated she had not had any negative interaction with the resident. She stated the previous week, Resident #36 reported someone took her fan. Resident #36 reported the staff member walked into the room to get her fan and that she used some words to her and her roommate, Resident #81. Staff R said, I submitted a grievance to the DON because the two residents [#36 and #81] were upset. Staff R stated Resident #36 was upset. She said, I asked her, and she said a CNA [Staff T] told her to shut up and mind her own business. Staff R stated the CNA Resident #36 was referring to was Staff T, CNA who worked the same assignment area during the 3 p.m. to 11 p.m. shift. Staff R said, This morning, she did not want to get out of bed, she was upset. She first told me she said she did not want to shower. I left her and then came back and took care of her. I was not rude or mean to her. She was upset with [Staff T]. On 01/09/24 at 4:15 p.m., an interview was conducted with the DON. She said, When the fan was taken, I questioned [Staff T, CNA] regarding the fan. Staff T said the fan was hers, and she was letting the resident borrow the fan. She stated the resident reported [Staff T] was rude to her when she took the fan back. The DON said, It was the way she took the fan. She [Staff T] told her she was taking it because it was not hers. She apparently told her to shut up. We questioned her [Resident #36] about the incident. It was a couple days after the grievance was documented. I went there with the SSD. Her other roommates were in the room. Resident #36 denied the abuse incident at that time. She did not say [Staff T] used choice words. I don't know why she changed her story. She had first reported the incident to [Staff R] the morning it happened. The DON stated she did not initiate abuse al [TRUNCATED]

Based on observation, interviews with residents, facility staff, resident representatives, the Clinical Manager of a dialysis facility, and the Medical Director, and review of policy and procedures, clinical records, training records and incident logs, it was determined the facility failed to identify, investigate, prevent, and take corrective action for the neglect of two (#308 and #106) of 12 residents reviewed for abuse and neglect. The facility failed to ensure wound care orders were implemented for Resident #308 and #106 resulting in the worsening of the wounds, and failed to investigate the cause of a fracture of unknown origin for one (#12) of 12 residents. The facility failed to ensure six (#6, #32, #36, #90, #100, and #164) residents with allegations of physical, verbal, psychological, psychosocial and sexual abuse out of 12 residents reviewed for abuse and neglect had investigations initiated, thorough investigations conducted, documentation of a thorough investigation maintained, protective measures implemented, and corrective actions taken to prevent further abuse. These systemic failures resulted in Immediate Jeopardy which began on 09/19/23 and was ongoing at the time of survey exit on 01/12/2024. Findings included: Cross reference: F600, F726, and F867. A review of the facility's Abuse Prevention Program with an effective date of 2012 and a most recent change date of August 2022 revealed: POLICY: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burnout, or resident behavior which may increase the likelihood of such events. PROCEDURE The facility has implemented the following processes in an effort to provide residents, visitors and staff with a safe and comfortable environment. o The Administrator is responsible for designating an Abuse Coordinator. o The designated shift supervisor is identified as responsible for immediate initiation of the reporting process. o The Administrator, DON and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. o The Administrator, DON and/or designated individual are also ultimately responsible for the following: o Implementation o Ongoing monitoring o Investigation o Reporting o Tracking and Trending IMPLEMENTATION and ONGOING MONITORING: o TRAINING Facility orientation program & ongoing training programs will include, but may not be limited to: o 483.95(c): Freedom from abuse, neglect, & exploitation requirements in 483.13. o 483.95(c): Activities that constitute abuse, neglect, exploitation, & misappropriation of resident property as set forth in 483.12. o 483.95(c): Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. o 483.95(c): Dementia management & resident abuse prevention. o Elder Justice Act, (See Elder Justice Act Policy & Procedure). o Identification of abuse, neglect, mistreatment, exploitation and misappropriation. o Utilization of appropriate interventions to manage resident behaviors that might result in harm to the resident or staff, aggressive &/or catastrophic reactions of residents. Refer to Behavior Management Program and Code CAT process for further information. o How staff should report their knowledge related to allegations without fear of reprisal. o How to provide protection for residents. o Components of a complete and thorough investigation. o Methods to reduce the risk of abuse, neglect, mistreatment, misappropriation, and exploitation that may include, but may not be limited to, recognizing signs of burnout, frustration and stress, stress management and relaxation techniques. Refer to Human Resource (HR) Manual for identifying and managing staff burnout, and Employee Assistance Program ([NAME]) availability. o Staff training will be documented and maintained with facility education records. o PREVENTION o The facility will post a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property, noncompliance with Advance Directives requirements, and requests for information regarding returning to the community. o The facility will post information & contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advanced directives requirements and requests for information regarding returning to the community. o Residents and families are encouraged to report concerns, incidents and grievances without fear of retribution. o Staff are instructed to report concerns, incidents, and grievances without fear of retaliation. o Employees are educated regarding not using mobile phones in resident areas, not taking photographs of residents and the facility Social Media policy. o Signage is posted reminding visitors of resident privacy related to photography. o Facility leadership will identify situations in which abuse, neglect, mistreatment, exploitation, misappropriation may be more likely to occur, such as: Residents with needs/behaviors which might lead to conflict or abuse/neglect. Staff burnout o Analyze the occurrences to determine what changes are needed, if any, to policies & procedures and education to prevent further occurrences. o IDENTIFICATION o Events of injuries of unknown origin/source, such as suspicious bruising occurrences, patterns & trends or other resident injury that may constitute abuse, neglect, or mistreatment are identified and thoroughly investigated, with appropriate reporting as indicated. o Use of resident property without explicit permission of a resident is defined as exploitation, or misappropriation of resident property. These events are identified and thoroughly investigated, with appropriate reporting. o An Event Report is initiated upon identification of actual, suspected, and/or alleged abuse. o Should the issue be reported initially on a Concern/Grievance report and later identified as actual, suspected or alleged abuse, neglect, mistreatment, exploitation and/or misappropriation, the Concern/Grievance Report and Grievance Log will be notated Referred to Risk Management. o Event Reports and Resident Concern/Grievance Reports are reviewed, tracked and trended for indicators suspicious for abuse, neglect, mistreatment, exploitation and/or misappropriation. o PROTECTION o Upon identification of actual, suspected, or alleged abuse, neglect, mistreatment, exploitation, and/or misappropriation, systems are in place to provide for the protection of the resident. These systems may include, but may not be limited to: o Suspension (investigatory Leave) for accused, suspected employee(s), pending the outcome of the investigation to protect the alleged victim and the alleged abuser from retaliation. o Initiation of discharge process if the resident is a danger to him/herself or others. o Moving resident to another room or unit if indicated. o Provision of 1:1 monitoring, or enhanced supervision as indicated. o Initiation of behavioral interventions per Behavior Management Program as indicated. o During the delivery of personal care, staff must remove residents from public view and provide clothing or draping to prevent unnecessary exposure of body parts. o INVESTIGATION: o An Event Report is initiated. o NHA or designee is notified and will initiate and conclude a complete and thorough investigation within the specified timeframe. o Investigation may include, but may not be limited to: Resident statements/interviews; Employee statements/interviews; Visitor statements/interviews; Observation of resident(s), staff, environment; Document review i.e. chart reviews, policy review, education programs, appropriate resource review (such as medical literature); and Re-enactment of event. o REPORTING o The facility will identify person(s) responsible for the reporting and investigating. o The facility will follow Federal regulations and State specific reporting requirements. o Department of Children and Families (DCF) will be notified promptly. o The administrator of the facility and/or designee will be notified immediately. o An Immediate report will be filed with the Agency for Health Care Administration (AHCA) for alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source that is suspicious of abuse or neglect, and misappropriation of resident property: o not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or o not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. o Notify Law Enforcement if a crime is suspected such as with actual or alleged physical or sexual abuse, misappropriation of resident property, and in the event of unexplained death (please see State and Federal Reporting: Medical Examiner Reporting). o Should the resident be [AGE] years of age, or older, and local Law Enforcement identify the allegation as a crime and take the issue for investigation, the facility will file a Suspected Crime Report within 2 hours of the alleged event if there is a serious bodily injury, or within 24 hours of the alleged event if there is no serious bodily injury. Refer to the Elder Justice Policy & Procedure. o Should Law Enforcement determine that the issue does not meet their criteria for a crime the Suspected Crime Report is not required. o At the conclusion of the investigation, and within 5 business days of the event, a final report will be submitted, detailing the facility findings, to include whether the allegation is substantiated. o Should there be a perpetrator involved and identified, this will be indicated on all reporting. o A 15 Day State Adverse Report may be required - please reference Adverse Incident Reporting. o The facility reports alleged violations & substantiated incidents to the state agency & to other agencies as required, & takes necessary corrective actions depending on the results of the investigation. o Report will be made to the licensing board/ authority or other licensing agency, as appropriate if the facility has any knowledge of any actions by a court of law which would indicate an employee is unfit for service. o Resident responsible party is notified if the resident lacks capacity; if the resident has capacity the facility will request resident permission prior to notification of resident representative. o Resident's physician is notified. A review of Resident #308's Admission MDS, dated [DATE], revealed the resident was originally admitted on [DATE] with diagnoses to include cerebral infarction, pneumonia, septicemia, wound infection, diabetes mellitus, aphasia, cerebrovascular accident (CVA), epilepsy, respiratory failure, and two unhealed stage 4 pressure sores upon admission. A review of Resident #308's Quarterly MDS, dated [DATE], revealed the resident still had two unhealed stage 4 pressure sores that were present upon admission on 05/04/23, and also had a new known unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. Continued review of the MDS assessments revealed the resident had an unplanned discharge on 11/29/23 to an acute care hospital and returned to the facility over one month later, on 1/4/24. During a telephone interview on 01/08/24 at 12:17 p.m., the Responsible Party (RP) for Resident #308 stated Resident #308 was supposed to have a wound vac, but the facility was limited on electrical outlets. The RP stated he was concerned because an air mattress was plugged in, an oxygen concentrator, and other things. He stated the facility needed to figure this out. He voiced concern that his [spouse] would not be able to have the needed wound vac because of the lack of electrical outlets. Review of the article titled, What is a Vacuum-Assisted Wound Closure? retrieved from Vacuum-Assisted Wound Closure: How It Helps, When It's Used, and What to Expect (webmd.com) on 1/17/24 revealed, a Vacuum-assisted closure is a treatment that applies gentle suction to a wound to help it heal. The Wound Vac therapy promotes healing by removing excess fluid, reduces bacteria stating Infection is not only dangerous, but it can also keep the wound from healing. The body must focus on clearing the bacteria away from the wound and can't move on to the next stage of wound repair. Wound Vac therapy helps the body by removing some of the bacteria. This lowers your risk of wound infection and allows healing to move forward. And improves blood flow. Good perfusion, or blood flow, is needed to bring repair cells to the wound, take bacteria and dead cells away, and deliver oxygen to the area. An interview was conducted on 01/09/24, at approximately 8:51 a.m., with the wound care team nurses which consisted of Staff G, Registered Nurse and [NAME] Side Unit Manager (RN/UM) and Staff H, Licensed Practical Nurse and East Side Unit Manager (LPN/UM). When asked about the wound vac for Resident #308, they stated they didn't have any orders on the 3008 Transfer Form (Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form, AHCA [Agency for Health Care Administration] Form 5000-3008) when the resident returned from the hospital on 01/04/24. Staff G and Staff H reported Resident #308 had a wound vac in place when she originally transferred out to the hospital (prior to 11/29/23), but through the course of the hospitalization , it was removed and no orders related to the wound vac were received upon her return. Staff G and Staff H confirmed the wound vac was returned back to the facility when the resident was readmitted to the facility on [DATE] but not currently in use. Staff G and Staff H said the facility does not have a wound doctor, but they can refer residents out to the wound care clinic when needed. They said this had been the plan for Resident #308 prior to her going to the hospital. A general progress note on 11/28/23 at 3:30 p.m. revealed, During wound rounds it was observed that sacral wound is now larger measuring 11.5 cm x 6.5 cm x 4.5 cm increase in percentage of slough tissue noted, also wound to left ischium is larger measuring 7 cm x 3 cm x 5 cm with more slough tissue noted, both wounds have a slight foul odor after cleansing. Medical Doctor (MD) notified with new order for wound care consult. RP notified of worsening wounds and agrees with new order for wound care consult. Review of the Post Event Note, dated 11/28/23 at 3:35 p.m., revealed, This is an initial event note for [Resident #308]. The following event has occurred: worsening wounds to left ischium and sacrum. The note showed the practitioner was notified and included the name of the attending physician for the resident. This attending physician is also the facility's Medical Director. Review of the Hospital Transfer Evaluation Summary, dated 11/29/23 at 12:17 PM, indicated the resident had a temperature of 104.9 degrees and that she had stage 4 pressure wounds to her sacrum, right ischium and left ischium. Review of the general surgeon physician's progress note from the resident's most recent hospitalization , dated 12/28/23 at 4:54 p.m., and retrieved from the resident's medical record in the facility revealed the following plan: -general surgery will sign off -please contact General surgery if patient needs debridement in the future otherwise we will continue wound VAC management per wound care team -follow-up with me as an outpatient. -okay to discharge patient standpoint and follow up as an outpatient. Review of the AHCA Form 3008 Patient Transfer Form from the hospital back to the facility and signed by the physician on 1/3/24 for readmission of Resident #308 to the facility on [DATE]; revealed the resident had a stage 4 sacral wound and an x was marked in the box showing a wound vac treatment device was in use. This document was present in Resident #308's current clinical record. A review of the admission/readmission note, dated 1/4/24 at 10:27 p.m., showed the sacrum/coccyx wound measurements were 12 cm x 8 cm x 5 cm along with several other wounds. No use of a wound vac was documented. Review of a progress note, dated 1/8/24 at 1:56 p.m., showed, Note Text: abdominal incision noted with 19 staples, area slightly pink, no foul odor, no redness or drainage observed, MD notified, new order to remove every other staple in 1 week, wait an additional 3 days and then remove remainder staples, currently resident receiving wet to dry dressings to sacral wound, left ischium wound and right ischium wound, MD in agreeance with current wound care orders, will re-evaluate on Tuesday 01/09/24 during IDT [interdisciplinary] wound rounds for appropriateness to apply wound vac. [spouse] notified and agrees with current plan of care. Review of a weekly wound note, dated 1/9/24 at 4:31 p.m., revealed, IDT weekly wound rounds completed. Resident has pressure wounds present upon admission. Wound to sacrum is a pressure injury stage 4 that measures 11.5 cm x 9.5 cm x 4.5 cm. Wound edges are slightly macerated and slightly rolled. Peri-wound area is clean, dry, and intact. Wound bed appears red/granulation tissue noted, draining moderate serosanguinous drainage. Granulation tissue present and muscle. 25% of dark necrotic tissue noted, 75% granulation tissue. No tunneling or undermining noted at this time. Cleansed wound with normal saline, applied skin prep to peri wound area, and placed calcium alginate dressing to wound bed and covered with bordered gauze. MD and RP aware. Wound to right buttock/ischium measures 8 cm x 8.5 cm x 2.8 cm with some rolled edges noted. Peri wound area clean, dry and intact. Wound bed appears to be 15% bone and 15% granulation and 15% slough and 55% muscle tissue. Moderate amount of serosanguinous drainage observed. Wound base. Cleansed wound with normal saline, no odor noted after cleansing. Autolytic debridement achieved using calcium alginate to wound bed and covered with a foam dressing. Resident tolerated well with no complaints of pain at this time. Unstageable wound to left ischium currently 9 cm x 3 cm x 3cm. Peri wound area clean, dry, and intact. Moderate amount of serosanguinous drainage noted. Wound bed red/pink. 65% granulation tissue observed. No tunneling or undermining. Cleansed with normal saline, no odor noted. Wiped peri wound area with skin prep. autolytic debridement achieved using calcium alginate, covered with a foam dressing. Wound to right great toe, present on arrival from hospital, scab to right great toe measuring 0.5 cm x 0.5 cm, closed scab. Cleansed with normal saline, patted dry, applied skin prep to area. Wound to left heel DTI [Deep Tissue Injury], wound present on admission from hospital, measures 3.5 cm x 3 cm. Peri wound edges intact and of normal color. Dark purple in color cleansed with normal saline, patted dry, placed skin prep to area and back inpotis [sic] boot. MD and RP in agreement with current plan of care. New orders in place. On 1/10/24 at approximately 12:05 p.m., an observation of wound care for Resident #308 by Staff G, RN/UM and Staff H, LPN/UM was conducted. Staff H, LPN/UM, stood on the far side of the bed and Staff G, RN/UM, stood on the other side of the bed closest to the door. Staff G, assisted with turning the resident toward her. Observed at this time were two dressings, one white and clearly dated 1/09/24 located over the sacrum and the other on the left ischium. The left ischium dressing was a light brown color and had a date that was difficult to read but Staff H, verified the date as 1/9/24. The dressing over the left ischium was removed, and the packing material was removed from inside the wound. The wound was the size of a large orange. The dressing, and the packing material removed, were saturated with serosanguineous drainage. Staff H, used one of the pink vials of normal saline (NS) to flush the wound and 4x4 gauze to wipe the wound bed. She then used calcium alginate to pack the wound, wiped the edges with skin prep and applied a foam dressing. She then began treatment to the sacrum wound. She removed the old dressing and revealed a large grapefruit size open wound with a dark area noted at the bottom edge of the wound. The wound had a packing material that had a light green color saturating the gauze. No odors were noted at this time. The nurse removed her soiled gloves, sanitized her hands and went to the wound cart to obtain more pink vials of NS. She returned to the bedside, sanitized her hands and donned clean gloves. She then used the NS to saturate the wound bed and wipe dry with clean 4x4s. She used her left index finger to push the gauze deep into an area located above the wound moving up toward the resident's upper torso. She was able to insert her entire index finger into the area of the wound. The nurse was asked if this was tunneling and she (Staff H, LPN/UM) stated it was undermining not tunneling and proceeded to pack this area with calcium alginate. Staff H used additional calcium alginate to pack the rest of the wound, wiped the edges of the wound with skin prep and covered with a foam dressing. No wound vac was observed to be in use. The nurses were asked about the use of a wound vac, and they reported the resident was sent out to the hospital for about a month because her wound had increased in size but no orders for a wound vac were currently in place. On 1/11/24 at approximately 12:00 p.m. a follow up interview was conducted with Staff G, RN/UM, and Staff H, LPN/UM, in the presence of the DON. They reported Resident #308 was transferred to the hospital for evaluation on 11/29/23 because she had a fever of 104 degrees. Staff H reported she had notified the Medical Director and explained to him that she felt the resident was septic, and the resident's wounds had deteriorated in that last week. She stated they were not sure why the wound had gotten so bad but thought it was because of the disease process. Staff H, LPN/UM clarified neither her, nor Staff G were wound care nurses, but they were a part of the Interdisciplinary Team in charge of wound measurements and keeping track of wounds. They report to the IDT if there are issues identified during the weekly wound rounds. They stated neither of them have specialized training in wound care. However Staff H, LPN/UM stated when she first started in her role, a representative for a wound supply company would offer periodic training's. They further reported when Resident #308 came back from the hospital on 1/4/24 there were wet to dry dressings for her wounds and stated the admitting nurse would have obtained these orders. Staff H stated admission orders are obtained from the 3008 patient transfer form and there was not an order for the wound vac on the form. At this time, the 3008 signed by the physician on 1/3/24 for discharge to the facility on [DATE], was obtained and presented to Staff G, Staff H, and the DON indicating a wound vac treatment device order was in place. The staff were also shown the note on the hospital discharge record, dated 12/28/23, showing the plan was to continue with the wound vac. Staff H stated the wound vac should have been continued and this had been missed by the admission nurse, herself and the person who conducted the 24 hour chart check following the resident's readmission on 1/4/24. A review of the physician progress notes for the Medical Director, who is also the primary care physician (PCP) for Resident #308, revealed one progress note dated 9/9/23. The progress note provided no documentation of Resident #308's wounds nor did it make mention of any skin care or any skin conditions. The section for Derm had a circle noted around the words warm and dry. The note revealed, [AGE] year old with a past medial history of CVA (Cerebral Vascular Accident), pneumonia, uropathy, DM (diabetes), anemia, seizures and CAD (Coronary Artery Disease). Wounds were not identified. No other progress notes could be located in the resident's clinical record. A review of Resident #106's Admission Record revealed an original admitted [DATE] and a discharge date to an acute care hospital on 10/26/23. A review of the Admission/Readmission note, dated 10/13/23 at 11:39 p.m., revealed the resident had an admitting diagnosis of diabetic ulcer, and had surgical incisions to his right iliac crest (front) that measured 82x1x0.5 cm; right lower leg (front) measured 7.5x0.5x0.5. He had blisters to his right thigh, lower leg; right ankle, and had a surgical graft to the bottom of his right foot that measured 9.5x10x0.5. A review of the AHCA-3008 Patient Transfer Form from the hospital, signed by the physician on 10/13/23, for admission of Resident #106 to the facility on [DATE], indicated 3 wounds: 1. Rt (right) groin incision 2. Wound Vac (incision) rt heel wound 3. Sacrum wound. Under the section Treatment/Devices, a Wound Vac was marked. A review of the nurse progress note, dated 10/14/23 at 7:41 p.m., showed, Patient with a surgical incision to right lower extremity, from groin to inner ankle staples area clean intact, with no drainage. Right lateral leg with 10 stitches clean no drainage or redness around the area. Right lateral outer knee with 5 stitches intact. Right lateral foot with wound has artificial allograft, secured with staples minimum amount of blood in the dressing, area was clean apply Vaseline gauze and covered with clean dressing no edema or redness around resident and family was oriented about the wound care and wound vac system the DON are going to clarify the order with the doctor. Resident has 2 blood filled blisters to right inner thigh, calf area and inner ankle. Stage 1 pressure sore to sacrum, and multiple bruising to bilateral upper extremities. All the area was clean under sterile measures. Continue on ABT [antibiotic] for osteomyelitis piccline [peripherally inserted central catheter] on the right upper arm. A review of the progress note, dated 10/16/23 at 3:46 p.m. by Staff G, RN/UM, revealed, Removed resident's dressing to right foot/leg. Resident has the presence of 77 staples from right hip to ankle. Incision line is well approximated, no open areas or areas of dehiscence noticed. Right lateral lower leg has incision with approximately 8 sutures well approximated, no drainage noted or open areas noted. To medial side of suture line is multiple small areas of tape burns. Skin prep to entire area and left open to air. Right posterior/lateral foot noted to have 5th digit removed. with two skin graft areas stapled in place. No open areas noted. Lateral wound noted to be darker red in color and posterior to be slightly bruised in color. Both appear good. Staples intact to both, no open areas noted. Placed oil emulsion gauze to area, non-adherent pad and wrapped with rolled gauze and secured with tape. Resident tolerated well w/o [without] complaints of pain at this time. Notified son of change in wound care and he verbalized agreement. MD notified and in agreement with current plan of care. A review of the physician orders, dated 10/16/23, showed cleanse surgical right lateral foot with NS, place sterile 4x4s, cover with rolled gauze and secure with tape. Change dressing daily and as needed for soilage. every day shift every Tue [Tuesday], Thu [Thursday], Sat [Saturday] for skin impairment AND as needed. A review of the weekly wound note, dated 10/17/23 at 12:17 p.m., documented by the DON, revealed the resident had 4 surgical wounds present on admission. Wound on the resident's right (R) lateral knee measured 0.3 cm x 1.8 cm and had 3 sutures in place. Scant amount of serous drainage. Wound bed red/pink. No odor noted. Applied skin prep to wound and left open to air. Wound on R lateral leg 8 cm x 0.3 cm. 9 sutures in place. Scant amount of serous drainage. Wound bed pink/red. No odor noted. Applied skin prep to wound and left open to air. Wound to Right foot currently 10 cm x 9 cm. With skin graft in place with 16 staples. Wound bed red and purple. Scant amount of serous drainage noted. No odor noted. Cleansed with normal saline, applied skin prep to peri wound area, placed oil emulsion and covered with rolled gauze and secure with tape. Wound to Right medial leg currently 78.5 cm x 0.3 cm. 77 staples present. Scant amount of serous drainage noted. Wound bed red and pink. No odor noted. Applied skin prep to wound bed and left open to air. MD and RP notified and updated. New orders in place. A review of the progress note, dated 10/26/23 at 4:29 p.m., revealed, call placed to [name] wound care center in [city] where patient had a follow up apt [appointment] this morning, as per nurse, patient was sent to [name of hospital] ER [emergency room ] for possible wound infection. An interview was conducted with Staff G, RN/UM, and Staff H, LPN/UM on 01/12/24 at approximately 12:03 p.m. They reported Resident #106 was admitted status post-surgery in which a specific kind of skin graft was placed, the hospital had requested a wound vac, but their facility did not use wound vacs on that kind of skin graft. They reported the evening shift supervisor verified the admission orders but did not address the wound vac noted on the 3008 form. Staff H recalled a discussion about Resident #106's wound vac on 10/13/23, the day the resident was admitted , but she was not sure where this was documented. Resident #106's clinical record was reviewed with Staff H and no documentation related to a wound vac discussion could be located. Staff G and Staff H were asked if it was appropriate to accept a resident for admission when the ordered care could not be provided? They stated they would not have known about the wound vac for that specific wound until after the resident arrived. They stated the wound vac was used to create negative pressure in a wound, stimulate granulation of tissue and helped with drainage. They then verified that not using the wound vac put the resident at a greater risk for infection, and confirmed the resident was transferred to the ER for a possible wound infection, but stated they never received confirmation of an infection. During an interview with the Medical Director, who was also the PCP for Resident #308 and Resident #106, on 1/12/24 at approximately 3:05 p.m., he stated the Unit Managers (UMs) and the DON were expected to be proactive in caring for the residents as the floor staff were too busy to review clinical status. He verified Staff H, LPN/UM does all the wound care and would notify him if a wound was getting worse. He stated he has not heard of any issues with abuse and has not been involved in or notified of concerns with abuse. He reported that he was involved in the Quality Assurance Performance Improvement (QAPI) program via monthly meetings and will overhear if there are concerns. He will give advice on nurse and family education, family notification, etc. He clarified nursing communication needed to be proactive and not reactive. He stated that he sees all short-term rehabilitation residents weekly; however, only sees the long-term residents when the DON advises him there is a concern. He stated he was not involved in the admission process as it goes thr

Based on observations, staff interviews, medical record reviews personnel record reviews and training records, the facility failed to have competent staff to identify abuse, protect residents during abuse investigations and investigate abuse allegations to prevent reoccurring abuse; the facility failed to have competent staff to accurately assess residents' medical conditions and to provide care and treatment to prevent worsening of conditions, for pressure ulcers, and significant change in condition after a fall. The facility failed to provide ongoing staff training and monitoring to ensure nursing skills and competencies to provide safe and adequate care for the residents to achieve their highest practicable level of well-being for 10 residents (#164, #207 #90, #100, #32, #12, #308, #6, #36, and #106) of 112 residents in the facility census. These failures created situations that resulted in worsened conditions and the likelihood for serious injury and or death to residents (#164, #207 #90, #100, #32, #12, #308, #6, #36 and #106) and resulted in the determination of Immediate Jeopardy determined to be ongoing at the time of facility exit on 01/12/2024. Findings included: Cross reference F600, F610, F686, and F835 During a survey conducted 01/08/24 to 01/12/24 non-compliance was found for 9 of 12 residents reviewed for abuse and neglect. Review of records, interview with facility staff, families and medical director revealed concerns with facility's reporting, investigation, and implementation of safety processes to prevent abuse and neglect. Resident #164 reported that Staff R, Certified Nursing Assistant (CNA) poisoned his coffee on 09/19/23. This resident was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included muscle wasting and atrophy, not elsewhere classified, multiple sites, epilepsy, unspecified, not intractable, without status epilepticus and unspecified dementia, unspecified severity, with agitation. A Quarterly Minimum Data Set (MDS), dated [DATE], showed a BIMS (Brief Interview of Mental Status) score of 07 indicating severe cognitive impairment. Resident #32 reported allegations of sexual abuse by another resident on 11/18/23. This resident was admitted on [DATE] with diagnoses to include post-traumatic stress disorder, chronic, schizoaffective disorder, unspecified anxiety disorder and major depressive disorder. An MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. Resident #90 was identified on 11/21/23 to be involved in a resident-to-resident abuse incident. This resident was admitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction, occlusion and stenosis of right carotid artery, personal history of transient ischemic accident (TIA), history of falling, and muscle wasting. An MDS, dated [DATE], revealed a BIMS score of 15 indicating intact mental cognition. Resident #6 reported allegations of physical abuse by Staff W, Certified Nursing Assistant (CNA) on 12/15/23. This resident was admitted to the facility on [DATE] with diagnoses to include other sequelae or other cerebrovascular disease and aphasia. A Quarterly MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. Resident #100 was involved in a resident-to-resident sexual abuse incident on 12/26/23. This resident was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, hemiparesis and hemiplegia to left non-dominant side, diabetes mellitus type 2, chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder recurrent, congestive heart failure, gastro-esophageal reflux disease, and history of malignant neoplasm of the esophagus. An Admission MDS, dated [DATE], showed a BIMS score of 03 indicating severe cognitive impairment. Resident #36 was involved in a verbal abuse incident by a staff member on 12/23/23. This resident was admitted to the facility on [DATE] with diagnoses to include muscle wasting, COPD, other abnormalities of gait, seizures, bipolar disorder, major depressive disorder. A Quarterly MDS, dated [DATE], showed a BIMS score of 13 indicating intact cognition. Resident #308 failed to receive goods and services resulting in worsening of wounds identified on 11/29/23. This resident was readmitted to the facility on [DATE] with diagnoses to include encephalopathy unspecified, pneumonia unspecified, sepsis, cellulitis, local infection of the skin and subcutaneous tissue, acute respiratory failure, cerebral infarction unspecified and muscle wasting among others. A Quarterly MDS, dated [DATE], showed the resident had a BIMS score of 99 indicating the resident was unable to complete cognition interview. Resident #106 was involved in an allegation of neglect related to wound care on 10/24/23. This resident was admitted to the facility on [DATE] with diagnoses to include partial amputation of right foot, other specified local infections of the skin and subcutaneous tissue, type 2 diabetes, cellulitis, osteomyelitis, sepsis, other kidney failure, and muscle wasting, Resident #12 was involved in an allegation of possible neglect related to a failure to complete a full investigation following a possible fall with a fracture on 12/4/23. This resident was originally admitted to the facility on [DATE] and readmitted on [DATE] following a 10-day hospitalization . The resident was readmitted with a primary diagnosis of unspecified fracture of upper end or right tibia, sequela and prior diagnoses to include legal blindness, end stage renal disease, contracture of right hand, contracture of right wrist, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, unspecified convulsions, and psychotic disorder with delusions due to unknown physiological condition. Review of the Admission Record for Resident #207 revealed an original admitted [DATE] and a readmitted on 12/26/23 with diagnoses to include repeated falls, pain in right arm, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified lack of coordination, difficulty in walking, and unsteadiness on feet. Review of The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities (https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html#:~:text=1.-,Evaluate%20and%20Monitor%20Resident%20for%2072%20Hours%20After%20the%20Fall,provide%20immediate%20treatment%20if%20necessary) showed: Chapter 2. Fall Response 1. Evaluate and Monitor Resident for 72 Hours After the Fall Immediate evaluation by the nurse after a resident fall should include a review of the resident systems and description of injuries. Upon evaluation, the nurse should stabilize the resident and provide immediate treatment if necessary. Evaluation of the resident's condition before, during or immediately after the fall provides clues to possible causes. 6. Complete Falls Assessment In addition to the clues discovered during immediate resident evaluation and increased monitoring, the FMP (Falls Management Program) Falls Assessment is used for a more in-depth look at fall risk. Five areas of risk accepted in the literature as being associated with falls are included. Because the Falls Assessment will include referrals for further workup by the primary care provider or other health care professionals, contact with the appropriate persons should be made quickly. A review of Resident #207's SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, dated 1/1/2024 at 3:15 a.m., revealed: Situation: The Change In Condition (CIC)/s reported on this CIC Evaluation are/were: Falls, Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: No changes observed - Functional Status Evaluation: Fall - Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: resident found sitting on floor next to bed in room. Stated the gas is on nonskid socks on, bed was in lowest position. No injuries noted. Neuro checks initiated. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: NNO (No New Orders). Review of a Post Event Note, dated 1/1/2024 at 3:15 a.m. documented, Note Text: This is an Initial Event Note for: (Resident #207) The following event has occurred: Unwitnessed Fall The noted date and time of the event are as follows: 01/01/2024 3:15 AM The event took place in the following location: resident's room Mental status was evaluated and the resident is noted to be oriented to the following: Oriented to person The following are noted to be the most recent Vital Signs: T (temperature) 97.8 - 1/1/2024 03:15 Route: Forehead (non-contact) P (pulse) 78 - 1/1/2024 03:15 Pulse Type: Regular R (respirations) 16.0 - 1/1/2024 03:15 BP (blood pressure) 104/64 - 1/1/2024 03:15 Position: Lying l/arm O2 (oxygen saturation) 96.0 % - 1/1/2024 03:15 Method: Room Air The resident displayed Active ROM (range of motion). The body parts ROM was completed on include the following: extremities Regarding LOC (level of consciousness), the resident is noted to be alert. Regarding mobility, the resident is noted to be wheelchair dependent. The resident's left pupil was evaluated and can be described as: Brisk. The resident's right pupil was evaluated and can be described as: Brisk. The left hand grasp is greater than the right. The following are the extremities that the resident can move: The resident can move the left arm. The resident can move the left leg. The resident is cognitively impaired, and evaluation of facial expression indicates there is no pain. The resident's response to pain is described as: Appropriate. The findings of the Skin Check that was completed include the following: intact. The description of the event as provided by licensed staff is as follows: resident found sitting on floor next to bed in room The resident has provided the following description of the event: the gas on The resident was assisted from the floor. The resident was noted to be able to transfer from the floor with the assistance of a mechanical lift. The last time the resident was toileted: 01/01/2024 1:00 AM The name of the practitioner notified is: (Physician's name) The date and time of practitioner notification: 01/01/2024 3:25 AM The name of the Resident Representative notified: (name of family member). The date and time the Resident's Representative was notified: 01/01/2024 4:00 AM. Review of a Neuro Check Note, dated 1/1/2024 at 3:15 a.m., documented: The left hand grasp is noted to be greater than the right. The following are the extremities that the resident can move: The resident can move the left arm. The resident can move the left leg. Movement of the noted extremities is described as left greater than right. The resident's response to pain is noted to be appropriate. Review of a Neuro Check Note, dated 1/1/2024 at 3:30 a.m., documented: The left hand grasp is noted to be greater than the right. The following are the extremities that the resident can move: The resident can move the left arm. The resident can move the left leg. Movement of the noted extremities is described as left greater than right. The resident's response to pain is noted to be appropriate. Review of a Post Event Note, dated 1/3/2024 at 1:12 a.m., documented: A fall event occurred .Neuro Checks were completed and there is no change in orientation, cognition, or consciousness noted A Skin Check was completed and no redness, swelling, bruising, or other concern is noted There is noted to be no change in ROM (Range of Motion). No pain is noted when performing ROM, The intervention initiated related to this fall has been reviewed and remains in place. Review of a Post Event Note, dated 1/4/2024 at 4:59 a.m., documented: A fall event occurred .Neuro Checks were completed and there is no change in orientation, cognition, or consciousness noted A Skin Check was completed and no redness, swelling, bruising, or other concern is noted There is noted to be no change in ROM. No pain is noted when performing ROM The intervention initiated related to this fall has been reviewed and remains in place. Review of a Post Event Note, dated 1/5/2024 at 2:53 a.m., documented: A fall event occurred to [Resident #207] The most recent Vital Signs are as follows: Neuro Checks were completed and there is no change in orientation, cognition, or consciousness noted A Skin Check was completed and no redness, swelling, bruising, or other concern is noted There is noted to be no change in ROM. No pain is noted when performing ROM The intervention initiated related to this fall has been reviewed and remains in place. Review of nursing progress notes for assessment completed from 1/1/2024 to 01/10/2024 did not indicate a swollen condition to either shoulder. During an observation on 01/10/2024 at 2:17 p.m. Resident #207 was in his room in bed sleeping, with a sheet over him. During an interview on 01/10/2024 at 12:23 p.m. Staff Z, Licensed Practical Nurse (LPN) was asked if Resident #207's shoulders were swollen and when Staff Z, LPN checked she confirmed his right shoulder was swollen. Review of the electronic medical record showed on 01/10/2024 at 4:43 p.m., the record was silent of documentation related to Resident 207's swollen right shoulder. During a record review on 01/10/2024 at 5:18 p.m. Staff B, Director of Nursing (DON) was interviewed related to Resident #207's right swollen shoulder and she said there was no notification to her that Resident #207's shoulder was swollen. There was no progress note documented about Staff Z, LPN's finding or a right swollen shoulder. During an interview on 01/12/2024 at 8:06 a.m. Staff Z, LPN was asked why she did not document on 01/10/2024 the confirmation of Resident #207's right swollen shoulder. She said she was waiting to get guidance, but she did tell Staff G, Registered Nurse (RN)/Unit Manager (UM) about the swollen shoulder. During an interview on 01/12/2024 at 8:10 a.m. Staff G, RN/UM said Staff Z, LPN did inform her of the swollen shoulder, and she submitted an order for an X-ray. She was requested to provide a copy of when she submitted the X-ray request. On 01/12/24 at 11:52 a.m. Staff C, RN/Regional Nurse Consultant provided a copy of the submitted request to [name of company] for X-Ray, dated 01/10/2024 at 5:37 p.m. (after interview with Staff B, DON at 5:18 p.m.). During an interview on 01/11/2024, Staff B, DON (Director of Nursing) said the facility does not have competency for completing a head-to-toe assessment. Staff B, DON said Staff Z and Staff AA are LPNs (Licensed Practical Nurse) and based on their LPN license they should have come to the facility with skills to do a head-to-toe assessment. When asked if the facility completes any follow-up monitoring of nursing skills, she indicated just the annual skills fair completed in September, but it did not include head to toe assessment. Staff Z/LPN's Hire Date is 08/07/2022. Staff AA/LPN's Hire Date is 08/15/2012. Review of personnel files revealed Staff Z, LPN had a new employee orientation checklist that did not include nursing skill assessment/evaluations or change in condition evaluation. Staff Z, LPN had no competency training in her personnel file. Review of Staff AA, LPN's personnel file revealed no competency training in her personnel file. During an interview on 01/11/2024 at 12:41 p.m., Staff H, LPN/Unit Manager East (110 and 200 Halls) and Staff G, RN(Registered Nurse)/Unit Manager [NAME] (300 and 400 Halls) said the Staffing Coordinator drafts the schedule and assigns the RNs and LPNs; the CNAs(Certified Nursing Assistant) select their assignment based on history and choice and familiarity with the resident on the hall. The Unit Managers will make staff assignment adjustments of staff on duty based on the needs of the residents. The facility uses Per Patient Day (PPD) to determine the number of staff assigned to work on each day and shift. The Nursing Home Administrator (NHA) and Staffing Coordinator/Central Supply determine how many staff need to be assigned per day to the facility. During an interview on 01/11/2024 at 2:19 p.m., Staff B, DON said Staff Z, LPN and Staff AA, LPN do not have orientation packets in their personnel files. Nursing annual training was completed in September 2023 for competencies. The training competencies provided in September were reviewed during the interview and none addressed the head-to-toe assessment/evaluation of residents. Staff B, DON said based on discussions during the survey the facility identified the need to develop and implement a competency for head-to-toe assessment/evaluation of residents. During an interview on 01/11/2024 at 4:31 p.m., the NHA and Staffing Coordinator/Central Supply said the facility has a staffing meeting every day at 11:00 a.m. to ensure the schedule is covered if we have any call offs. The Staffing Coordinator/Central Supply had her draft paper filled out based on the master and has scheduled day and she completed the day based on the master. When there are open shifts, we have a group chat she sends out to nursing and CNAs to make sure there is never a hole on the schedule and if there is a hole the NHA and nursing team, Unit Mangers, and Staff B, DON and the 3-11 Supervisor will make sure it is covered. We look at the resident acuity to determine staffing. To provide 1 one on one staff you have 2 additional staff. When they have one on one, they have regularly assigned staff cover if one on one staff needs to take a break. The acuity level for identified residents are discussed every time at the 11:00 a.m. meeting. When asked if the facility has a tool to assist them to identify what level of acuity is required for a resident, they indicated there is no tool used, it is based on nursing management staff knowledge of the residents. When asked if there was any training they had to identify a specific resident acuity level the NHA and Staffing Coordinator/Central Supply were not sure if there was a guide for accurate identification of a specific resident's acuity level/need. The NHA confirmed there was no current formal training or guide to identify a specific resident's acuity level. On 01/11/24 at 10:44 a.m. the DON entered the conference room with a laptop computer and showed a copy of the [NAME] Manual 9th Edition, which was described to be the nursing procedure manual. When asked how often this is updated she said she thinks corporate loads the most recent version. The DON said she had not used this manual before and uses the competencies. When asked how staff are trained to access the material, she said she thinks the NHA tells them and is supposed to have a hard copy. The DON described that she had worked in the facility since January 2023 and was in the position of ADON (assistant director of nursing) from May 2023 until December 2023 when she was promoted to DON. When asked if she does the training, she said no, that is typically the ADON. She said competencies are on the company electronic portal and gave the example of showing new staff in orientation how to access the dress code. She said she had not shown nurses specifically how to access the portal. She was not sure if the nurses knew how to access the competencies on the portal. She described there was a schedule provided by corporate that she follows for new employee orientation. After the 3-day orientation they are sent on the floor to a nurse preceptor for 3 days. The DON did not know who the nurse preceptors were or if they are given training to be considered preceptors. When asked who the nurses can go to if they need clinical assistance, she said the manager and if she doesn't know an answer she will go to the regional consultant. The DON did not refer to the nursing procedure manual as a resource for clinical guidance. When asked how often nurses are required to demonstrate competency, the DON responded, Typically annually, but sometimes we do it more often. We had a skills fair in September. The DON confirmed the nurse and CNA annual competencies should be in the employee file. During the interview, a review of the employee file for Staff K, LPN revealed no annual competency and the orientation competency dated 08/2022 was signed by the employee, but the signature block for the training supervisor was blank. The DON confirmed there was no annual competency in the file. During the interview a review of the employee file of Staff L, LPN revealed no annual competency. Staff L's file contained a New Employee Orientation checklist signed by the employee on 7/19/2022. There was no signature for the employee services coordinator or the staff development person. A nursing administration orientation checklist dated 7/27/2022 was signed by the employee but no signature in the blank for the nursing administrator. The DON said, During the time that I was the ADON, I never was part of an annual competency. I don't remember being told that, but it might be in my job description. If I was told I needed to do an annual competency for everyone in the building, I would have done it, but I don't know. I'll ask if that was kept somewhere else. A review of the facility assessment included a date of completion as 09/27/2023. The facility assessment described the resident population as consisting of capacity of 120 residents, ages 25 - 85+ years old, including bariatric residents. Resident conditions included but was not limited to post-surgical neuro, colostomy, infections, dementia, psychiatric disorders, tracheostomy, IV (intravenous) antibiotics, PICC (peripherally inserted central catheter) lines, urinary catheters, PEG/J-tube (percutaneous endoscopic gastrostomy and jejunostomy), wounds (surgical/pressure), hospice, and outpatient hemodialysis. Equipment needed for residents listed was standing scale, wheelchair scale, O2 (oxygen) concentrators, tanks, PD (peritoneal dialysis) equipment, hoyer lifts, sit to stand lifts, walkers, wheelchairs, door security, translation services, and communication boards. Under the column describing personnel, the Infection Preventionist and Risk Manager positions were listed as N/A for tenure, education, experience, and meets licensure/certification requirements. 39374 43453

Based on interviews, record reviews and review of job descriptions, the facility's administration failed to utilize resources to ensure adequate supervision to effectively implement a systematic process to carry out the facility's abuse policy for seven residents (#32, #90, #100, #6, #36, #12, #164), failed to ensure the facility staff provided care and services to prevent the worsening of wounds for two residents (#308 and #106), failed to ensure hot water temperatures were maintained at a comfortable level for residents on one hallway (Hall 100), and failed to ensure oversight of nurse competency training with the potential to affect a total census of 112 residents. These systemic failures resulted in Immediate Jeopardy which began on 09/19/23 and was ongoing at the time of survey exit on 01/12/2024. Findings included: Cross reference to F584, F600, F610, F686, F726 and F867. During a survey conducted on 01/08/24 to 01/12/24 non-compliance was found for abuse and neglect for incidents/allegations to include resident to resident physical/sexual abuse (#32, #90, #100), staff to resident physical abuse (#6, #164), staff to resident verbal abuse (#36), and neglect resulting in worsening of wounds (#308, #106), and failure to investigate a fracture of unknown origin (#12). 1. Resident #164 reported that Staff R, Certified Nursing Assistant (CNA) poisoned his coffee on 09/19/23. This resident was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included unspecified dementia, unspecified severity, with agitation. A Quarterly Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 07 indicating severe cognitive impairment. During an interview on 01/10/24 at 12:16 p.m. the Nursing Home Administrator (NHA) confirmed an allegation of abuse was made by Resident #164 on 09/19/23 and a federal report was completed. The resident reported his CNA, Staff R poisoned his coffee. The resident stated he witnessed the CNA remove his coffee and put an unknown substance in his coffee. An investigation was initiated. The NHA stated she could not find the statements she obtained from the CNA. She stated she spoke to the nurse who worked that day as well but could not find that statement either. A follow-up interview with the NHA on 01/10/24 at 12:38 p.m., revealed she misplaced the entire file related to Resident #164's abuse investigation to include witness statements. The NHA said Staff R, CNA was suspended for five days and education was conducted for all staff on Abuse and Neglect but no documentation of the training could be provided. 2. Resident #32 reported allegations of sexual abuse by another resident (#90) on 11/18/23. Resident #32 was admitted on [DATE] with diagnoses including post-traumatic stress disorder, chronic, schizoaffective disorder, unspecified anxiety disorder and major depressive disorder. An MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. Resident #90 was identified on 11/21/23 to be involved in a resident-to-resident abuse incident. This resident was admitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction, occlusion and stenosis of right carotid artery, personal history of transient ischemic accident (TIA), history of falling, and muscle wasting. An MDS, dated [DATE], revealed a BIMS score of 15 indicating intact mental cognition. Resident #100 was involved in a resident-to-resident sexual abuse incident involving Resident #90 on 12/26/23. This resident was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, hemiparesis and hemiplegia to left non-dominant side, anxiety disorder, major depressive disorder recurrent. An admission MDS, dated [DATE], showed a BIMS score of 03 indicating severe cognitive impairment. During an interview on 01/10/24 at 3:05 p.m. Resident #32 said Resident #90 came up and asked if I wanted to be sexually harassed. I thought he was joking and then he groped my breast. When asked if she thought the touch on her breast could have been an accident, Resident #32 replied, I never told anyone it was an accident. Resident #32 continued to describe the events and said, Staff I, Certified Nursing Assistant (CNA) overheard me say to Resident #90, there will be no more of that, and asked what I was talking about. Resident #32 reported she told Staff I, CNA about Resident #90 touching her breast. Staff I then came to my room and helped me write a grievance. This was all reported to Staff I, CNA on the day it occurred, but I found out about four days after the incident, on 11/21/2023, that the grievance had been lost. I became hysterical and called the police. The police came and talked to me. This was on 11/21/2023, four days after the incident, and four days after Staff I, CNA helped me write the grievance. When I called the police, I heard Resident #90 was immediately placed on 1:1 (one to one) supervision, but I heard he got caught with someone else and was put on 1:1 again. An interview was conducted with the NHA on 01/11/2024 at 5:58 p.m. to discuss the incident between Resident #32 and #90 and the investigation of the incident. The NHA said she first learned of the incident when Resident #32 called law enforcement on 11/21/2023 and the evening unit manager, Staff L, Licensed Practical Nurse (LPN) called her. The NHA said she came to the building and talked to both residents and staff but did not document any of the interviews. She said no staff witnessed the incident and neither resident involved remembered what date the event took place. Resident #32 did not report telling any other staff, so no other staff were interviewed. The NHA said she did not receive a written statement from Staff I, CNA. The NHA expressed that Resident #32 and Resident #90 stated this incident was consensual. The NHA said the 1:1 supervision was for a short period of time. When asked if Resident #32's call to 911 to report the event as a crime on 11/21/2023 indicated a consensual event took place for Resident #32, the NHA did not respond. 3. Resident #36 was involved in a verbal abuse incident by a staff member on 12/23/23. This resident was admitted to the facility on [DATE] with diagnoses to include muscle wasting, COPD, other abnormalities of gait, seizures, bipolar disorder, major depressive disorder. A quarterly MDS, dated [DATE], showed a BIMS score of 13 indicating intact cognition. On 01/09/24 at 3:43 p.m., an interview was conducted with Resident #36. She reported she was verbally abused by a staff member. Resident #36 stated a staff member yelled at her. She was scared to report the incident, but she told the Social Services Director (SSD) the first time it happened. She stated this happened before Christmas. Resident #36 said, The CNA yelled at me because of a fan. She called me out. Her name is [Staff T, CNA]. She stated she spoke to the DON (Director of Nursing) and SSD about it. Resident #36 stated [Staff T] had gotten into her face about a fan at night. She said, She was just rude and disrespectful. She called me names. I don't want to say much about it. I don't want them to come after me. Then today, it's [Staff R, CNA]. This morning she [Staff R] came up again and said she will not assist me with my shower, and she won't change me. She said if you don't stop that [expletive] you will get into more trouble. On 01/09/24 at 4:15 p.m., an interview was conducted with the DON. She said, When the fan was taken, I questioned [Staff T, CNA] regarding the fan. Staff T said the fan was hers, and she was letting the resident borrow the fan. She stated the resident reported [Staff T] was rude to her when she took the fan back. The DON said, It was the way she took the fan. She [Staff T] told her she was taking it because it was not hers. She apparently told her to shut up. We questioned her [Resident #36] about the incident. It was a couple days after the grievance was documented. I went there with the SSD. Her other roommates were in the room. Resident #36 denied the abuse incident at that time. She did not say [Staff T] used choice words. I don't know why she changed her story. She had first reported the incident to [Staff R] the morning it happened. The DON stated she did not initiate abuse allegation for Resident #36 related to the 12/23/23 grievance because when she went to question the resident, she denied the abuse even though it was already documented. The DON stated she focused on the fan. The DON stated she did not talk to the resident privately. She stated she did not obtain witness statements from other residents or staff regarding the verbal abuse because the resident withdrew her statement. She stated, I don't know why she would have reported abuse and then withdrew it. I did not follow-up. I did not ask other staff about it. On 01/09/24 at 4:55 p.m., an interview was conducted with the NHA and the DON. The NHA stated regarding the fan incident on 12/23/23 with Staff T, the DON resolved the grievance after she spoke to the resident and the resident denied any abuse related to this incident. The NHA stated she did not have any witness statements. The DON stated she did not speak to the nurse who worked that night. She did not interview the roommates. The DON stated she did not document the resident's response related to denying that someone abused her verbally. She stated she did not document any of the interviews. She stated she did not know that she needed to document any of that information. The DON stated she did not know she needed to ask other staff or other residents about the verbal abuse allegations. The DON stated she did not follow-up with Staff R regarding the initial grievance submitted on 12/23/23 on Resident #36's behalf. A follow-up interview was conducted on 01/10/24 at 4:26 p.m. with the DON and the NHA. The DON said, At the time of my investigation they said it did not occur. I did not revisit the issue. I did not think to look further. I did not focus on the verbiage used when the grievance was documented because the residents said it did not happen. I don't know why they changed their story. Now I see how I should have investigated it further. I did not interview other staff or residents. I did not know she still had issues with that incident. 4. Resident #12 was involved in an allegation of possible neglect related to a failure to complete a full investigation following a possible fall with a fracture on 12/4/23. This resident was originally admitted to the facility on [DATE] and readmitted on [DATE] following a 10-day hospitalization . The resident was readmitted with a primary diagnosis of unspecified fracture of upper end or right tibia, sequela and prior diagnoses to include legal blindness, end stage renal disease (ESRD), contracture of right hand, contracture of right wrist, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, unspecified convulsions, and psychotic disorder with delusions due to unknown physiological condition. On 01/12/24 at 10:16 a.m., an interview was conducted with the ESRD facility's Clinical Manager where Resident #12 received dialysis. She confirmed Resident #12 was their resident and attended dialysis at their facility every Monday, Wednesday, and Friday. The Clinical Manager stated, She [Resident #12] arrived at the facility on 12/4/23. She had no incidents. Patient comes to our facility under the care of the transport company. She arrives in a stretcher, and then they transfer her into a chair. She never ambulates. The transport puts her in the treatment chair. She never gets out of the treatment chair. The Clinical Manager stated she never received a phone call from the facility. She stated , I was told on 12/6/23 that she was not coming to dialysis because she was hospitalized for a wound infection. The Clinical Manager stated she did not know anything about the patient falling. She said, She probably fell at [name of the nursing home]. She never walks. I received a call from some insurance people while she was at the hospital. They wanted to know the date of the incident. I told them, she did not fall at dialysis. I have not heard from them again. The Clinical Manager confirmed the facility never contacted her to inquire about the resident's fall or an injury she may have sustained at the ESRD facility. On 01/12/24 12:37 p.m. an interview was conducted with the Risk Manager Consultant (RMC), and the Regional Nurse Clinical (RNC). The RMC stated he had reviewed the investigation file. He stated it showed Resident #12 had a BIMS 14 and she reported that she fell at the dialysis center. He stated the paper he was reviewing was undated. He confirmed Resident #12 was transferred out because her X-rays came back positive for a leg fracture. The RMC read a progress note dated 12/4/23 showing, the resident said nobody hurt her and no one abused her. He stated there were two notes from the nurse which read, On 12/4/23 resident alert, she complained of leg pain and pain medication given. Right leg was not swollen but she did complain when I moved it through ROM (range of motion). CNA made me aware she was complaining of pain in her right leg. A CNA report read, I was giving care to [Resident #12] when I moved her leg, she was in pain. I informed the nurse who was on duty. The RMC stated the NHA Investigation summary showed the resident's knee x-ray results showed fracture of right fibula and tibia. It showed the PCP (primary care physician), DON and NHA were notified. The NHA interviewed the patient and she denied anybody was abusing her. She admits to falling at dialysis center. Medical Doctor (MD) ordered transfer to the ED. She left a voice mail with patient's [family member] and was waiting for a call back. The RMC said, I cannot conclude what happened. I agree there is an incomplete investigation. On 01/12/24 12:48 p.m. The RNC stated, The NHA talked to the patient who has a BIMS of 14 there does not seem a reason why we would not trust that patient. I did not know she was blind. I do understand that the patient suffered a significant injury. She reported it happened at dialysis. I agree, there is no evidence that follow-up calls were made to figure out what happened. Further investigation should have been conducted. You are right, dialysis or dialysis company should have been contacted. I don't know if the incident was reported. 01/12/24 at 3:16 p.m. an interview was conducted with the facility's Medical Director (MD), who is also Resident #12's PCP. The MD stated he did not have any recollection of any recent injury reports that resulted in a hospitalization . He could not recollect a fall with injury for Resident #12 and stated I would know. The MD did not remember being notified. The MD stated if there was a significant injury, he would have expected to be notified. The MD said, I would remember if a resident had significant injuries. It should be documented if I had a follow-up visit. Review of physician notes showed Resident #12 was seen by the MD on 04/12/23, 04/26/23 and 09/09/23. There were no physician notes documented on or around the time of Resident #12's injury on 12/04/23 or after she returned from the hospital on 12/14/23. 5. Resident #6 reported allegations of physical abuse by Staff W, Certified Nursing Assistant (CNA) on 12/15/23. This resident was admitted to the facility on [DATE] with diagnoses to include other sequelae or other cerebrovascular disease and aphasia. A Quarterly MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. During an interview on 1/10/24 at 8:25 a.m., Resident #6 said last month a staff member (Staff W, CNA) hit him in the face. He said he reported this to staff and his [spouse]. He started to tear up during the interview. When asked if it hurt, he said yes. He said the staff member had not worked with him since the incident. During an interview on 1/10/24 at 9:15 a.m. with the NHA and DON, the NHA stated she completed the required State Agency reporting on 12/15/2023 at 11:10 a.m. The local police came to the facility and spoke to Staff V, CNA and Staff W, CNA. The NHA reported the Law Enforcement Officer (LEO) told her Resident #6 said staff had pushed his arm. The NHA said she did tell the LEO Resident #6 reported to facility staff, he was hit by Staff W. The NHA said Staff W, CNA was suspended from 12/15/2023 to 12/22/2023. The NHA informed Resident #6's RP, Staff W, CNA would not work with Resident #6 anymore. The DON provided documentation of Staff W's training, which was done over the phone (OTP) on 12/22/2023. Review of the document titled, INDIVIDUALIZED STAFF EDUCATION, contain Staff W's name, the date of 12/22/23, the Issue was Policy attached . The form included a printed statement: I received one on one education today concerning the issue above. I understand my responsibility, what to do in the future, and how my actions impacted the residents, staff, and the facility in general. I understand that a copy of this training will go in my personal file in case this becomes an issue again. Disciplinary action may be taken in the future if indicated. The line for Employee signature contained a handwritten note Education OTP. The line for Educator signature contained the DON's signature and the signature of Staff H, LPN/UM. The DON confirmed Staff W, CNA did not have a copy of the Abuse Prevention Program policy and procedure (P&P) during the phone training. Review of Staff W's assignment sheets and payroll records revealed she worked the night shift (11 PM to 7AM) on 01/06/2024, 01/07/2024, and 01/08/2024, without being provided in person training for abuse prevention prior to returning to direct contact/care of residents. On 01/10/24 at 10:49 a.m., the NHA provided a copy of facility staff training on the Abuse Prevention Program P&P dated 12/20/2023 with the signature of 24 staff members. The NHA confirmed the facility had not provided any additional training after this 12/20/23 training to 24 staff members. During an interview on 01/10/24 at 4:04 p.m., the DON confirmed Staff W, CNA was not reported to the Florida CNA Registry due to the facility's determination of unsubstantiated abuse. 6. Resident #308 failed to receive goods and services resulting in worsening of wounds identified on 11/29/23. This resident was readmitted to the facility on [DATE] with diagnosis to include encephalopathy unspecified, pneumonia unspecified, sepsis, cellulitis, local infection of the skin and subcutaneous tissue, acute respiratory failure, cerebral infarction unspecified and muscle wasting among others. A Quarterly MDS, dated [DATE], showed the resident had a BIMS score of 99 indicating the resident was unable to complete cognition interview. Review of the Agency for Health Care Administration (AHCA) Form 3008 Patient Transfer Form from the hospital back to the facility signed by the physician on 1/3/24 for readmission of Resident #308 to the facility on [DATE] revealed the resident had a stage 4 sacral wound and an x was marked in the box showing a wound vac treatment device was in use. This document was present in Resident #308's current clinical record. A review of the admission/readmission note dated 1/4/24 at 10:27 p.m. showed the sacrum/coccyx wound measurements were 12 cm (centimeters) x 8 cm x 5 cm along with several other wounds. No use of a wound vac was documented. An interview was conducted on 01/09/24, at approximately 8:51 a.m., with the wound care team nurses which consisted of Staff G, Registered Nurse and [NAME] Side Unit Manager (RN/UM) and Staff H, Licensed Practical Nurse and East Side Unit Manager (LPN/UM). When asked about the wound vac for Resident #308, they stated they didn't have any orders on the 3008 Transfer Form when the resident returned from the hospital on 01/04/24. Staff G and Staff H reported Resident #308 had a wound vac in place when she originally transferred out to the hospital (prior to 11/29/23), but through the course of the hospitalization , it was removed and no orders related to the wound vac were received upon her return. Staff G and Staff H confirmed the wound vac was returned back to the facility when the resident was readmitted to the facility on [DATE] but not currently in use. Staff G and Staff H said the facility does not have a wound doctor, but they can refer residents out to the wound care clinic when needed. They said this had been the plan for Resident #308 prior to her going to the hospital, but then the resident was sent out with an abdominal wall infection, which was not related to the pressure wound. Review of the general surgeon physician's progress note from the resident's most recent hospitalization dated 12/28/23 at 4:54 p.m., and retrieved from the resident's medical record in the facility revealed the following plan: -general surgery will sign off -please contact General surgery if patient needs debridement in the future otherwise we will continue wound VAC management per wound care team -follow-up with me as an outpatient. -okay to discharge patient standpoint and follow up as an outpatient. Review of a progress note dated 1/8/24 at 1:56 p.m. showed Note Text: abdominal incision noted with 19 staples, area slightly pink, no foul odor, no redness or drainage observed, MD notified, new order to remove every other staple in 1 week, wait an additional 3 days and then remove remainder staples, currently resident receiving wet to dry dressings to sacral wound, left ischium wound and right ischium wound, MD in agreeance with current wound care orders, will re-evaluate on Tuesday 01/09/24 during IDT [interdisciplinary] wound rounds for appropriateness to apply wound vac. [spouse] notified and agrees with current plan of care. On 1/10/24 at approximately 12:05 p.m. an observation of wound care for Resident #308 by Staff G, RN/UM and Staff H, LPN/UM was conducted . Observed at this time were two dressings, one white and clearly dated 1/09/24 located over the sacrum and the other on the left ischium. The left ischium dressing was a light brown color and had a date that was difficult to read but Staff H, verified the date as 1/9/24. The dressing over the left ischium was removed, and the packing material was removed from inside the wound. The wound was the size of a large orange .She then began treatment to the sacrum wound. She removed the old dressing and revealed a large grapefruit size open wound with a dark area noted at the bottom edge of the wound. The wound had a packing material that had a light green color saturating the gauze. No odors were noted at this time . She was able to insert her entire index finger into the area of the wound. The nurse was asked if this was tunneling and she (Staff H, LPN/UM) stated it was undermining not tunneling and proceeded to pack this area with calcium alginate. Staff H used additional calcium alginate to pack the rest of the wound, wiped the edges of the wound with skin prep and covered with a foam dressing. No wound vac was observed to be in use. The nurses were asked about the use of a wound vac, and they reported the resident was sent out to the hospital for about a month because her wound had increased in size but no orders for a wound vac were currently in place. On 1/11/24 at approximately 12:00 p.m. a follow up interview was conducted with Staff G, RN/UM, and Staff H, LPN/UM, in the presence of the Director of Nursing (DON). They reported that Resident #308 was transferred to the hospital for evaluation on 11/29/23 because she had a fever of 104 degrees. Staff H reported she had notified the Medical Director and explained to him that she felt the resident was septic, and that the resident's wounds had deteriorated in that last week. She stated they were not sure why the wound had gotten so bad but thought it was because of the disease process. Staff H, LPN/UM clarified that neither she nor Staff G were wound care nurses, but they were a part of the Interdisciplinary Team in charge of wound measurements and keeping track of wounds. They report to the IDT if there are issues identified during the weekly wound rounds. They stated that neither of them have specialized training in wound care. However Staff H, LPN/UM stated that when she first started in her role, a representative for a wound supply company would offer periodic trainings. They further reported that when Resident #308 came back from the hospital on 1/4/24 there were wet to dry dressings for her wounds and stated that the admitting nurse would have obtained these orders. Staff H stated that admission orders are obtained from the 3008 patient transfer form and there was not an order for the wound vac on the form. At this time, the 3008 signed by the physician on 1/3/24 for discharge to the facility on [DATE] was obtained and presented to Staff G, Staff H, and the DON indicating a wound vac treatment device order was in place. The staff were also shown the note in the hospital discharge record dated 12/28/23 showing the plan was to continue with the wound vac. Staff H, stated the wound vac should have been continued and this had been missed by the admission nurse, herself and the person who conducted the 24 hour chart check following the resident's readmission on 1/4/24. A review of the physician progress notes for the Medical Director revealed one progress note dated 9/9/23. The progress note provided no documentation of Resident #308's wounds nor did it make mention of any skin care or any skin conditions. The section for Derm had a circle noted around the words warm and dry. The note revealed [AGE] year old with a past medial history of CVA (Cerebral Vascular Accident), pneumonia, uropathy, DM (diabetes), anemia, seizures and CAD (Coronary Artery Disease). Wounds were not identified. No other progress notes could be located in the resident's clinical record. 7. Resident # 106 was involved in an allegation of neglect related to wound care on 10/24/23. This resident was admitted to the facility on [DATE] with diagnoses to include partial amputation of right foot, other specified local infections of the skin and subcutaneous tissue, type 2 diabetes, cellulitis, osteomyelitis, sepsis, other kidney failure, and muscle wasting, On 01/12/24 at approximately 12:03 p.m. an interview was conducted with Staff G, RN/UM and Staff H, LPN/UM. They reported Resident #106 was admitted status post-surgery in which a specific kind of skin graft was placed, the hospital had requested a wound vac, but their facility did not use wound vacs on that kind of skin graft. They stated the evening shift supervisor had verified the orders but did not address the wound vac noted on the 3008. Staff H stated the wound vac was discussed prior to her leaving the day the resident was admitted but she was not sure where the documentation of this was within the facility's electronic medical record. After reviewing the resident's record in the electronic medical record Staff H verified that any documentation of the wound vac discussion was not in the electronic medical record. At this time Staff G and H were asked if it was appropriate to accept a resident for admission when you could not provide the ordered care and they stated they would not have known the wound vac was for that specific wound until after the resident arrived. They offered the wound vac is used to create negative pressure in a wound, stimulates granulation of tissue and helps with drainage. They then verified that not using the wound vac put the resident as a greater risk for infection, and the resident was transferred to the ER (emergency room ) for a possible wound infection but stated they never received confirmation of an infection. During an interview with the Medical Director on 1/12/24 at approximately 3:05 p.m. he stated the Unit Managers (UMs) and the DON were expected to be proactive in caring for the residents as the floor staff were too busy to review clinical status. He verified that Staff H, LPN/UM does all the wound care and would notify him if a wound was getting worse. He clarified that nursing communication needed to be proactive and not reactive. He stated that he sees all short-term rehabilitation residents weekly; however, only sees the long-term residents when the DON advises him there is a concern. He stated he was not involved in the admission process as it goes through nursing and stated that he would assume they would contact him if there was a concern. He referred back to Staff H, LPN/UM as the wound care nurse when asked about wound vacs. He verified that he documented his visits on the form Progress Notes and turns the forms into medical records after each visit. He stated that the facility has all of his progress notes. 8. On 01/08/24 at 10:17 a.m., the residents in Rooms 101, 103, 105 and 106 reported Hall 100 has had water issues for an unknown period of time. They reported the water was cold and this had been going on for a long time. A resident in room [ROOM NUMBER] stated it had been probably three to six months. The residents stated the CNAs (certified nursing assistants) knew of the problem. The resident in room [ROOM NUMBER] stated a grievance was filed during a Resident Council meeting. The resident stated the CNAs complained about cold water when giving residents showers. Review of the Grievance Logs August 2023 to January 8, 2024, revealed no grievances were filed from Resident Council meetings. On 01/09/24 at 1:36 p.m., an interview was conducted with the Director of Maintenance (DOM) and the Regional DOM. They confirmed plumbing issues in Hall 100. The DOM said, Here has been no hot water issues, nothing out of the regular. We had a plumber here today to fix water in one the wings because the water was cold. He stated the problem was the circulating pump. He stated he became aware of the hot water problems the day before. He stated he was notified in the afternoon through a work order submitted in the [maintenance software for documenting work orders]. He stated the problem was in Hall 100. He stated it was the first time he heard about water being cold. He stated the plumber said he would require a new pump. The DOM stated he normally tests hot water once or twice week. He stated he had tested the previous week, and the water temperatures were good. The Regional DOM stated the appropriate water temperature should be 110 to 112 , maximum 115 . On 01/09/24 at 2:11 p.m., a facility tour was conducted with both the DOM and Regional DOM. The facility's DOM conducted water temperatures for a sample of rooms/areas as follows: Hall 300: room [ROOM NUMBER] = 109 Shower room =109 , Hall 200: room [ROOM NUMBER] =106 Shower room [ROOM NUMBER] and Hall 100: room [ROOM NUMBER] = 86 room [ROOM NUMBER] = 86 . On 01/10/24 at 4:45 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and she stated she did not know the residents had been reporting on-going concerns for six months. She heard about it yesterday. We will fix it ASAP (as soon as possible). She stated the nursing staff should have put in a work order. 9. Review of nurse employee files failed to demonstrate oversight for competency training. On 01/11/24 at 10:44 a.m. the DON confirmed the nurse and CNA annual competencies should be in the employee file. The employee file for Staff K, LPN did not have an annual competency and the orientation competency, dated 08/2022, was signed by the employee, but the signature block for the training supervisor was blank. The DON confirmed there was no annual competency in the file. The employee file for Staff L, LPN was reviewed and was silent of an annual competency. Staff L's file contained a New Employee Orientation checklist signed by the employee on 7/19/2022. There was no signature for the employee services coordinator or the staff development person. A nursing administration orientation checklist, dated 7/27/2022, was signed by the employee but no signature in the blank for the nursing administrator. On 01/10/24 at 4:31 p.m. a follow-up interview was conducted with the NHA and the DON. The NHA said, We do not have a PIP [performance improvement plan] on abuse and neglect. We had not identified a

Based on observations, interviews, and record review, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) process to investigate, develop, and implement an effective Performance Improvement Plan (PIP) to ensure the facility was free from abuse and neglect. During a survey conducted on 01/08/24 to 01/12/24 non-compliance was found for 9 of 12 residents reviewed for abuse and neglect. The incidents/allegations included resident to resident physical/sexual abuse (#32, #90, #100), staff to resident physical abuse (#6, #164), staff to resident verbal abuse (#36), and neglect resulting in worsening of wounds (#308, #106), and failure to investigate a fracture of unknown origin (#12). Review of records, interview with facility staff, family members, and the Medical Director revealed concerns with facility's reporting, investigation, protection, and implementation of safety/corrective processes to prevent further and future abuse and neglect from occurring. The facility placed all current residents (census: 112) at risk of serious injury and/or death due to the systemic failure to identify patterns of occurring abuse and neglect incidents/allegations and not initiating a PIP to address the on-going concerns, resulting in the determination of Immediate Jeopardy which began on 09/19/23 and was ongoing at the time of survey exit on 01/12/2024. Findings included: Cross reference F600, F610, F726 and F835. Review of a facility document presented by the Nursing Home Administrator (NHA) revealed 57 reportable incidents of abuse and/or neglect had occurred since the last recertification survey completed on 1/27/2022. Review of the facility's survey history revealed a complaint survey was conducted on 5/23/2022 to 5/26/2022, which identified findings of Immediate Jeopardy at F600 related to resident neglect and F726 related to staff competency for failing to assess, identify resident changes in condition, carry out facility procedures, and administer prescribed treatments. A review of the facility's accepted plan of correction to correct and maintain compliance for F600 and F726 for the survey ending on 5/26/2022 revealed: The DON (Director of Nursing)/Designee educated staff on abuse, neglect, exploitation & misappropriation. The DON/designee educated clinical staff on frequent routine rounding including identification and reporting of concerns with a posttest to confirm understanding. The nurses were educated by the DON/designee on providing prescribed treatments per the provider orders when medications, treatments or interventions are scheduled and the importance of accuracy in documentation. The DON/designee will audit adherence to prescribed treatments by the nurses 3 times weekly in the morning clinical meeting. The audits will be presented to the QA&A (Quality Assurance and Assessment)committee for further recommendations for a period of three months or until substantial compliance is achieved. Adherence to prescribed treatments will be audited for compliance with notifications and adjustments made as prescribed. Results of the Quality of Care (QOC) compliance will be reported to QA&A monthly for recommendations. During a survey conducted on 01/08/24 to 01/12/24 non-compliance was found for 9 of 12 residents reviewed for abuse and neglect. Review of records, interview with facility staff, families and medical director revealed concerns with facility's reporting, investigation, and implementation of safety processes to prevent abuse and neglect. Resident #164 reported that Staff R, Certified Nursing Assistant (CNA) poisoned his coffee on 09/19/23. This resident was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included muscle wasting and atrophy, not elsewhere classified, multiple sites, epilepsy, unspecified, not intractable, without status epilepticus and unspecified dementia, unspecified severity, with agitation. A Quarterly Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 07 indicating severe cognitive impairment. Resident #32 reported allegations of sexual abuse by another resident on 11/18/23. This resident was admitted on [DATE] with diagnoses to include post-traumatic stress disorder, chronic, schizoaffective disorder, unspecified anxiety disorder and major depressive disorder. An MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. Resident #90 was identified on 11/21/23 to be involved in a resident-to-resident abuse incident. This resident was admitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction, occlusion and stenosis of right carotid artery, personal history of transient ischemic accident (TIA), history of falling, and muscle wasting. An MDS, dated [DATE], revealed a BIMS score of 15 indicating intact mental cognition. Resident #6 reported allegations of physical abuse by Staff W, Certified Nursing Assistant (CNA) on 12/15/23. This resident was admitted to the facility on [DATE] with diagnoses to include other sequelae or other cerebrovascular disease and aphasia. A Quarterly MDS, dated [DATE], showed a BIMS score of 15 indicating intact cognition. Resident #100 was involved in a resident-to-resident sexual abuse incident on 12/26/23. This resident was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, hemiparesis and hemiplegia to left non-dominant side, diabetes mellitus type 2, chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder recurrent, congestive heart failure, gastro-esophageal reflux disease, and history of malignant neoplasm of the esophagus An Admission MDS, dated [DATE], showed a BIMS score of 03 indicating severe cognitive impairment. Resident #36 was involved in a verbal abuse incident by a staff member on 12/23/23. This resident was admitted to the facility on [DATE] with diagnoses to include muscle wasting, COPD (chronic obstructive pulmonary disease), other abnormalities of gait, seizures, bipolar disorder, major depressive disorder. A Quarterly MDS, dated [DATE], showed a BIMS score of 13 indicating intact cognition. Resident #308 failed to receive goods and services resulting in worsening of wounds identified on 11/29/23. This resident was readmitted to the facility on [DATE] with diagnoses to include encephalopathy unspecified, pneumonia unspecified, sepsis, cellulitis, local infection of the skin and subcutaneous tissue, acute respiratory failure, cerebral infarction unspecified and muscle wasting among others. A Quarterly MDS, dated [DATE], showed the resident had a BIMS score of 99 indicating the resident was unable to complete cognition interview. Resident #106 was involved in an allegation of neglect related to wound care on 10/24/23. This resident was admitted to the facility on [DATE] with diagnoses to include partial amputation of right foot, other specified local infections of the skin and subcutaneous tissue, type 2 diabetes, cellulitis, osteomyelitis, sepsis, other kidney failure, and muscle wasting, Resident #12 was involved in an allegation of possible neglect related to a failure to complete a full investigation following a possible fall with a fracture on 12/4/23. This resident was originally admitted to the facility on [DATE] and readmitted on [DATE] following a 10-day hospitalization . The resident was readmitted with a primary diagnosis of unspecified fracture of upper end or right tibia, sequela and prior diagnoses to include legal blindness, end stage renal disease, contracture of right hand, contracture of right wrist, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, unspecified convulsions, and psychotic disorder with delusions due to unknown physiological condition. On 01/10/24 at 3:40 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the DON. The NHA stated they meet monthly, the 3rd Tuesday of every month for Quality Assurance. She stated they follow the same agenda each month which included a risk management agenda item which is reviewed monthly. She stated this included event tracking/trending/RCA (root cause analysis), reportable incidents, review or development of PIPs and an audit plan/report of the incidents. On 01/10/24 at 4:22 p.m. an interview was conducted with the NHA. She stated that for allegations of abuse they investigate, make sure the resident is safe, and suspend the employee pending the investigation. She stated if an allegation was verified, they terminate the employee and report them to the board. The NHA stated all staff training was conducted in small groups normally. She said sometimes we would do it via phone if they cannot come in. For general employee training, we conduct monthly training per the training calendar. Typically, the DON, unit managers or department heads conduct these training's. On 01/10/24 at 4:31 p.m. a follow-up interview was conducted with the NHA and the DON regarding what patterns they were addressing and what PIPs (performance improvement plans) were currently in place. The NHA stated they had a PIP on PASRRs (Preadmission Screening and Resident Review), wounds, and they finished one on labs. The NHA said, We do not have a PIP on abuse and neglect. We had not identified a pattern. We did not see it as so and the residents have not voiced any fear. The NHA stated residents sometimes change their stories during an investigation. She said, It has not been a red flag. I did not know staff were afraid to speak up. We have considered team building community with staff and resident. I have not discussed concerns related to resident to resident or staff abuse allegations with Resident Council. I will now. We did not see it as such a large scale. The NHA stated they had competencies on interviewing protocol. She stated they had a checklist. The NHA stated she would provide the surveyors with this checklist. The checklist was not provided. The DON stated she had received training at a sister facility for one day with another DON. She stated she was the ADON (Assistant Director of Nursing) at this facility at the time. She stated she went to a Nursing Summit, a 2-day training. She provided examples of what was covered during the Nursing Summit to include adequately checking files, auditing some things and supporting staff. The NHA stated the facility's SSD (Social Services Director) receives residents' grievances. She stated residents can turn in their grievances anonymously. She said, We have a compliance line. It used to go to an outside company, now the management company is receiving the anonymous calls. She stated she did not know residents' grievances that were discussed in Resident Council were not documented. The NHA stated they would start documenting. She confirmed they should fill out a grievance form for all complaints. On 01/11/24 at 09:00 a.m. an interview was conducted with the facility's Risk Manger Consultant. He stated he had recently been re-assigned to this facility and was filling in. He stated prior to the reassignment, he would review recommendations of falls and events. He stated he had a tool that he used and the facility's policy. He stated he had consulted with the facility on resident-to-resident interactions. He stated he advised the team on how to handle the on-going abuses. He stated he reviewed the trends for QA quarterly. The Risk Manager Consultant provided a blank form stating it was the tool he used. He stated he did not have any documentation of previous visits to the facility or any specific incidents he had consulted on. 01/12/24 at 03:04 p.m. a telephone interview was conducted with the facility's Medical Director (MD). He stated he attend the facility's QAPI meeting monthly. He stated he attended in person. He stated if he overhears there are particular issues related to nursing, education, he gives advice. He stated he would reach out to family members about particular concerns. He stated he did not know if the facility had a PIP to address abuse allegations. Review of a facility policy titled, Quality Assurance Improvement (QAPI) Plan, dated October 2017, showed the facility will develop a QAPI plan to describe how the facility will track and measure performance, establish goals and thresholds for performance measurement, identify and prioritize deviations for performance and other problems in issues, systematically investigate and analyze to determine underlying causes of systemic problems and adverse events, develop and implement corrective actions or performance improvement activities, monitor/evaluate the effects of corrective actions/performance activities. The QAPI plan is reported to QA&A (Quality Assurance & Assessment) compliance committee with regular updates regarding progress with improvement activity, or corrective actions when there is unplanned or unexpected response to such activities It is the responsibility of the QA&A compliance committee to consider all data presented by the improvement team(s) and to direct the team(s) to continue change or conclude the assignment. Procedure: track and measure performance. Clinical areas are tracked through: Weekly reporting of specific clinical indicators to include ulcers, falls, returns to hospital. Quality measures (QM) to include overall staffing and QM's. Incidents e.g. falls. Survey we're finding such as repeat citations, high severity citations, failure to clear at first revisit. Other areas that are tracked may include but are not limited to: Grievances Reportable incident outcomes such as substantiated abuse or neglect . that was within the facilities [sic] control. Concierge around findings such as environmental concerns, staffing concerns such as . any other area identified as a concern requiring investigation and corrective action.

Based on interviews, record review and policy review, the facility failed to provide necessary treatment and services to prevent worsening of a pressure ulcer for 1 of 2 residents sampled for pressure ulcers (Resident #308). Findings included: A review of Resident #308's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was originally admitted on [DATE] with diagnoses to include cerebral infarction, pneumonia, septicemia, wound infection, diabetes mellitus, aphasia, cerebrovascular accident (CVA), epilepsy, respiratory failure, and two unhealed stage 4 pressure sores upon admission. A review of the weekly wound notes for November 2023, just prior to the 11/29/23 hospital transfer revealed: On 11/7/23 Resident #308 was observed to have several wounds including a stage 4 pressure injury to her sacrum that measured 4.5cm (centimeters) x (by) 6.5 cm x 5 cm. Wound edges were slightly macerated and slightly rolled. Wound bed appears red/granulation tissue noted, draining moderate serosanguinous drainage, 90% granulation tissue present and 10% muscle. No tunneling or undermining. Wound vac was noted as set to 125 mmHg (millimeters of mercury) negative pressure. On 11/14/23 the stage 4 pressure injury to the sacrum measured 4.6 cm x 6.8 cm x 5 cm. wound vac set to 125 mmHg. On 11/21/23 the sacrum wound measured 4.8 cmx 6.9 cm x 5 cm. and the wound vac was noted as set to 125 mmHg negative pressure. On 11/28/23 at 2:42 PM the sacrum wound measured 11.5 cm x 6.5 cm x 4.5 cm. A general progress note on 11/28/23 at 3:30 PM revealed During wound rounds it was observed that sacral wound is now larger measuring 11.5 cm x 6.5 cm x 4.5 cm increase in percentage of slough tissue noted, also wound to left ischium is larger measuring 7 cm x 3 cm x 5 cm with more slough tissue noted, both wounds have a slight foul odor after cleansing. Medical Doctor (MD) notified with new order for wound care consult. RP notified of worsening wounds and agrees with new order for wound care consult. Review of the Post Event Note dated 11/28/23 at 3:35 PM revealed This is an initial event note for [Resident #308]. The following event has occurred: worsening wounds to left ischium and sacrum. The note showed that the practitioner was notified and included the name of the Medical Director. Review of the Hospital transfer evaluation summary dated 11/29/23 at 12:17 PM, indicated the resident had a temperature of 104.9 degrees and that she had stage 4 pressure wounds to her sacrum, right ischium and left ischium. The note made no mention of an abdominal wound. A review of Resident #308's quarterly MDS dated [DATE] revealed the resident still had two unhealed stage 4 pressure sores that were present upon admission on 05/04/23 and also had a new known unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. Continued review of the MDS assessments revealed the resident had an unplanned discharge on 11/29/23 to an acute care hospital and returned to the facility over one month later, on 1/4/24. During a telephone interview on 01/08/24 at 12:17 PM, the Responsible Party (RP) for Resident #308 stated Resident #308 was supposed to have a wound vac, but the facility was limited on electrical outlets. The RP stated he was concerned because an air mattress was plugged in, an oxygen concentrator, and other things. He stated that the facility needed to figure this out. He voiced concern that his wife would not be able to have the needed wound vac because of the lack of electrical outlets. Review of the Agency for Health Care Administration (AHCA) form 3008 Patient Transfer Form from the hospital back to the facility signed by the physician on 1/3/24 for readmission of Resident #308 to the facility on [DATE] revealed the resident had a stage 4 sacral wound and an x was marked in the box showing a wound vac treatment device was in use. This document was present in Resident #308's current clinical record. A review of the admission/readmission note dated 1/4/24 at 10:27 PM showed the sacrum/coccyx wound measurements were 12 cm x 8 cm x 5 cm along with several other wounds. No use of a wound vac was documented. An interview was conducted on 01/09/24, at approximately 8:51 AM, with the wound care team nurses which consisted of Staff G, Registered Nurse and [NAME] Side Unit Manager (RN/UM) and Staff H, Licensed Practical Nurse and East Side Unit Manager (LPN/UM). When asked about the wound vac for Resident #308, they stated they didn't have any orders on the 3008 Transfer Form when the resident returned from the hospital on 01/04/24. Staff G and Staff H reported Resident #308 had a wound vac in place when she originally transferred out to the hospital (prior to 11/29/23), but through the course of the hospitalization , it was removed and no orders related to the wound vac were received upon her return. Staff G and Staff H confirmed the wound vac was returned back to the facility when the resident was readmitted to the facility on [DATE] but not currently in use. Staff G and Staff H said the facility does not have a wound doctor, but they can refer residents out to the wound care clinic when needed. They said that this had been the plan for Resident #308 prior to her going to the hospital, but then the resident was sent out with an abdominal wall infection, which was not related to the pressure wound. Review of the general surgeon physician's progress note from the resident's most recent hospitalization dated 12/28/23 at 4:54 PM, and retrieved from the resident's medical record in the facility revealed the following plan: -general surgery will sign off -please contact General surgery if patient needs debridement in the future otherwise we will continue wound VAC management per wound care team -follow-up with me as an outpatient. -okay to discharge patient standpoint and follow up as an outpatient Review of a progress note dated 1/8/24 at 1:56 PM showed Note Text: abdominal incision noted with 19 staples, area slightly pink, no foul odor, no redness or drainage observed, MD notified, new order to remove every other staple in 1 week, wait an additional 3 days and then remove remainder staples, currently resident receiving wet to dry dressings to sacral wound, left ischium wound and right ischium wound, MD in agreeance with current wound care orders, will re-evaluate on Tuesday 01/09/24 during IDT [interdisciplinary] wound rounds for appropriateness to apply wound vac. Husband notified and agrees with current plan of care. Review of a weekly wound note dated 1/9/24 at 4:31 PM revealed IDT weekly wound rounds completed. Resident has pressure wounds present upon admission. Wound to sacrum is a pressure injury stage 4 that measures 11.5 cm x 9.5 cm x 4.5 cm. Wound edges are slightly macerated and slightly rolled. Peri-wound area is clean, dry, and intact. Wound bed appears red/granulation tissue noted, draining moderate serosanguinous drainage. Granulation tissue present and muscle. 25% of dark necrotic tissue noted, 75% granulation tissue. No tunneling or undermining noted at this time. Cleansed wound with normal saline, applied skin prep to peri wound area, and placed calcium alginate dressing to wound bed and covered with bordered gauze. MD and RP aware. Wound to right buttock/ischium measures 8 cm x 8.5 cm x 2.8 cm with some rolled edges noted. Peri wound area clean, dry and intact. Wound bed appears to be 15% bone and 15% granulation and 15% slough and 55% muscle tissue. Moderate amount of serosanguineous drainage observed. Wound base. Cleansed wound with normal saline, no odor noted after cleansing. Autolytic debridement achieved using calcium alginate to wound bed and covered with a foam dressing. Resident tolerated well with no complaints of pain at this time. Unstageable wound to left ischium currently 9 cm x 3 cm x 3cm. Peri wound area clean, dry, and intact. Moderate amount of serosanguinous drainage noted. Wound bed red/pink. 65% granulation tissue observed. No tunneling or undermining. Cleansed with normal saline, no odor noted. Wiped peri wound area with skin prep. autolytic debridement achieved using calcium alginate, covered with a foam dressing. Wound to right great toe, present on arrival from hospital, scab to right great toe measuring 0.5 cm x 0.5 cm, closed scab. Cleansed with normal saline, patted dry, applied skin prep to area. Wound to left heel DTI [Deep Tissue Injury], wound present on admission from hospital, measures 3.5 cm x 3 cm. Peri wound edges intact and of normal color. Dark purple in color cleansed with normal saline, patted dry, placed skin prep to area and back in potis boot. MD and RP in agreement with current plan of care. New orders in place. On 1/10/24 at approximately 12:05 PM, an observation of wound care for Resident #308 by Staff G, RN/UM and Staff H, LPN/UM was conducted. Staff H, LPN/UM, stood on the far side of the bed and Staff G, RN/UM, stood on the other side of the bed closest to the door. Staff G, assisted with turning the resident toward her. Observed at this time were two dressings, one white and clearly dated 1/09/24 located over the sacrum and the other on the left ischium. The left ischium dressing was a light brown color and had a date that was difficult to read but Staff H, verified the date as 1/9/24. The dressing over the left ischium was removed, and the packing material was removed from inside the wound. The wound was the size of a large orange. The dressing, and the packing material removed, were saturated with serosanguineous drainage. Staff H, used one of the pink vials of normal saline (NS) to flush the wound and 4x4 gauze to wipe the wound bed. She then used calcium alginate to pack the wound, wiped the edges with skin prep and applied a foam dressing. She then began treatment to the sacrum wound. She removed the old dressing and revealed a large grapefruit size open wound with a dark area noted at the bottom edge of the wound. The wound had a packing material that had a light green color saturating the gauze. No odors were noted at this time. The nurse removed her soiled gloves, sanitized her hands and went to the wound cart to obtain more pink vials of NS. She returned to the bedside, sanitized her hands and donned clean gloves. She then used the NS to saturate the wound bed and wipe dry with clean 4x4s. She used her left index finger to push the gauze deep into an area located above the wound moving up toward the resident's upper torso. She was able to insert her entire index finger into the area of the wound. The nurse was asked if this was tunneling and she (Staff H, LPN/UM) stated it was undermining not tunneling and proceeded to pack this area with calcium alginate. Staff H used additional calcium alginate to pack the rest of the wound, wiped the edges of the wound with skin prep and covered with a foam dressing. No wound vac was observed to be in use. The nurses were asked about the use of a wound vac, and they reported the resident was sent out to the hospital for about a month because her wound had increased in size but no orders for a wound vac were currently in place. On 1/11/24 at approximately 12:00 PM, a follow up interview was conducted with Staff G, RN/UM, and Staff H, LPN/UM, in the presence of the Director of Nursing (DON). They reported that Resident #308 was transferred to the hospital for evaluation on 11/29/23 because she had a fever of 104 degrees. Staff member H, reported that she had notified the Medical Director and explained to him that she felt the resident was septic, and that the resident's wounds had deteriorated in that last week. She stated that they were not sure why the wound had gotten so bad but thought it was because of the disease process. Staff H, LPN/UM clarified that neither she nor Staff G, were wound care nurses, but they were a part of the Interdisciplinary Team in charge of wound measurements and keeping track of wounds. They report to the IDT if there are issues identified during the weekly wound rounds. They stated that neither of them have specialized training in wound care. However Staff H, LPN/UM stated that when she first started in her role, a representative for a wound supply company would offer periodic trainings. They further reported that when Resident #308 came back from the hospital on 1/4/24 there were wet to dry dressings for her wounds and stated that the admitting nurse would have obtained these orders. Staff H stated that admission orders are obtained from the 3008 patient transfer form and there was not an order for the wound vac on the form. At this time, the 3008 signed by the physician on 1/3/24 for discharge to the facility on [DATE] was obtained and presented to Staff G, Staff H, and the DON indicating a wound vac treatment device order was in place. The staff were also shown the note in the hospital discharge record dated 12/28/23 showing the plan was to continue with the wound vac. Staff H, stated the wound vac should have been continued and this had been missed by the admission nurse, herself and the person who conducted the 24 hour chart check following the resident's readmission on 1/4/24. A review of the physician progress notes for the Medical Director revealed one progress note dated 9/9/23. The progress note provided no documentation of Resident #308's wounds nor did it make mention of any skin care or any skin conditions. The section for Derm had a circle noted around the words warm and dry. The note revealed [AGE] year old with a past medial history of CVA (Cerebral Vascular Accident), pneumonia, uropathy, DM (diabetes), anemia, seizures and CAD (Coronary Artery Disease). Wounds were not identified. No other progress notes could be located in the resident's clinical record. Review of the website What is a Vacuum-Assisted Wound Closure? retrieved from Vacuum-Assisted Wound Closure: How It Helps, When It's Used, and What to Expect (webmd.com) on 1/17/24 revealed that a Vacuum-assisted closure is a treatment that applies gentle suction to a wound to help it heal. The Wound Vac therapy promotes healing by removing excess fluid, reduces bacteria Infection is not only dangerous, but it can also keep the wound from healing. The body must focus on clearing the bacteria away from the wound and can't move on to the next stage of wound repair. Wound Vac therapy helps the body by removing some of the bacteria. This lowers your risk of wound infection and allows healing to move forward. And improves blood flow. Good perfusion, or blood flow, is needed to bring repair cells to the wound, take bacteria and dead cells away, and deliver oxygen to the area. During an interview with the Medical Director on 1/12/24 at approximately 3:05 PM, he stated the Unit Managers (UM's) and the DON were expected to be proactive in caring for the residents as the floor staff were too busy to review clinical status. He verified that Staff H, LPN/UM does all the wound care and would notify him if a wound was getting worse. He clarified that nursing communication needed to be proactive and not reactive. He stated that he sees all short-term rehabilitation residents weekly; however, only sees the long-term residents when the DON advises him there is a concern. He stated that he was not involved in the admission process as it goes through nursing and stated that he would assume they would contact him if there was a concern. He referred back to Staff H, LPN/UM as the wound care nurse when asked about wound vacs. He verified that he documented his visits on the form Progress Notes and turns the forms into medical records after each visit. He stated that the facility has all of his progress notes. Review of the In-Service Training Record titled Nursing Summit sign-in sheet dated 5/31/23-6/1/23 includes the DON and Staff member H, LPN/UM and the sign-in sheet dated 6/28/23-6/29/23 included staff member G, RN/UM. During this training Skin Program was a topic reviewed with attendees. New Admission Chart Review The IDT team reviews all new admission charts following the admission checklist guidance that is initiated at time of admission and completed within 24 hours of admission. The IDT admission chart reviews includes: A completed 3008 and PASRR. Also included on the list is 2nd skin check completed by the UM and documented in (Electronic Record). Review of the Medical Directors Agreement dated as effective on 10/12/21 revealed an Objective that stated, The Medical Director shall ensure that residents at the facility receive quality medical care. The Objective goes on to state, These duties include, without limitation, implementing resident care policies and coordinating medical care in the facility. Responsibilities and Functions of Medical Director include, 1. Be responsible for the medical direction and overall coordination of medical care in the facility. 2. Review incident report trends, identify hazards to health and safety, and provide recommendations to the Facility's Administrator to ensure a safe and sanitary environment of residents, guest, and personnel. 7. Assure the support of essential medical consultants as needed. 12. Participate in identifying the need for, developing, amending, recommending, approving, implementing and monitoring written policies governing resident care including policies related to admissions, transfers, and discharges; infection control; use of restraints; physician privileges and practices; and responsibilities of non-physician health workers, (e.g., nursing, rehabilitation therapies, and dietary services in resident care, emergency care, and resident assessment and care planning). Medical Director is also responsible for policies related to accidents and incidents; ancillary services such as laboratory, radiology and pharmacy; use of medication, use and release of clinical information; and overall quality of care. Medical Director is responsible for ensure that these policies are implemented. 14. Advise the Facility's Administrator as to the adequacy of the Facility's resident care services and medical equipment, and participate in any review of care by the facility. 15. Conduct weekly rounds of the facility with the Director of Nursing or his or her designee at a mutually convenient day and time. Be available for consultation at all other times with the Facility's Administrator and Director of Nursing or their designee(s), in evaluating the adequacy of the Facility and its staff to meet the psychosocial as well as medical and physical needs of specific residents and of residents in general, and be available as a resource on resident care issues and developments. Review of the Job Description for the Unit Manager - RN under the Summary of Position The unit Manager - RN is responsible for overseeing direct nursing care to assigned residents/patients. The Unit Manager - RN assumes responsibility and accountability for the nursing care and services provided on the assigned unit. The Unit Manager - RN is responsible for and adheres to the standards of care for assigned Residents/Patients, assists with data collection, monitoring and implementation of physician orders based on individual resident/patient needs, managers the environment to maintain resident/patient safety, and supervises the resident/patient care activity performance by licensed nurses and certified nursing assistants. Included under Essential Duties and Responsibilities Oversees the assessments of the Resident/Patient admission process. Participates in the clinical admission process. Oversees resident care to promote the highest level of physical, mental and psychosocial functioning possible., Ensures assigned work area (i.e. nurse station, med. Cart medication room, etc), resident/patient care rooms and treatments areas are maintained in a clean and sanitary manner. Monitors supplies and orders as needed. Review of the website What is a Vacuum-Assisted Wound Closure? retrieved from Vacuum-Assisted Wound Closure: How It Helps, When It's Used, and What to Expect (webmd.com) on 1/17/24 revealed that a Vacuum-assisted closure is a treatment that applies gentle suction to a wound to help it heal. The Wound Vac therapy promotes healing by removing excess fluid, reduces bacteria stating Infection is not only dangerous, but it can also keep the wound from healing. The The body must focus on clearing the bacteria away from the wound and can't move on to the next stage of wound repair. Wound Vac therapy helps the body by removing some of the bacterial. This lowers your risk of wound infection and allows healing to move forward. And improves blood flow. Good perfusion, or blood flow, is needed to bring repair cells to the wound, take bacteria and dead cells away, and deliver oxygen to the area. 39374

Based on observations, review of medical records and facility policies, and interviews with facility staff, the Medical Director (MD), a family member, residents, and a hospital nurse, the facility neglected to provide services and supervision to one (Resident #1) of six residents sampled for high-risk elopement. Resident #1 was an ambulatory, vulnerable resident, who was unable to take food or liquids by mouth, required a walker to ambulate safely, and had expressed wishes to leave the facility. The facility neglected to re-assess Resident #1 following a significant improvement in mobility to determine elopement risk, neglected to monitor the resident's whereabouts and provide supervision, and neglected to provide physician prescribed medications, nutrition and hydration as ordered for Resident #1. Resident #1 was able to exit the facility unbeknownst to staff, fell in a parking lot, was found by a bystander, transported to the hospital by Emergency Medical Services (EMS), and remained in the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 left the facility unsupervised on 5/16/22, and had last been seen by facility staff at 11:45 a.m. Resident #1 walked across a parking lot without her walker as recommended for safe ambulation by her treating therapist and traveled across rough terrain, where she fell and was at risk of being struck by a vehicle and suffering serious injury or death. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was not identified as missing by facility staff for a period of about 5-6 hours. The likelihood of serious physical harm or death to Resident #1 as a result of the facility's neglect resulted in findings of Immediate Jeopardy on 05/16/22. The Immediate Jeopardy was removed on 05/26/22 with the scope and severity reduced to a D after verification of implementation of immediacy removal actions. Findings included: Cross Reference F689 and F726 Review of an Emergency Medical Services (EMS) run report dated 5/16/22 revealed a call was placed to 911 at 11:52 am. The EMS unit was dispatched to a sidewalk, 0.2 miles from the facility at 11:54 am. The EMS unit arrived on the scene at 12:06 p.m. The EMS report showed the CHIEF COMPLAINT/RESPONSE: The crew responded to a call for a [AGE] year Old Female . The complaint received by dispatch was Unconsciousness/[CONDITION(S)] /Near-[CONDITION(S)] (Emergent) .arrived OS [on scene] to located Pt [patient] A+O X 1 [alert and oriented to person] . Witness OS observed Pt laying on the ground foaming at the mouth. Pt was given water PTA [prior to arrival] and related that she felt better. PT knew her name, did not know what city she was in, did not know who the president was, thought the year was 1980, and remarked that she was busy walking to Kankakee, Illinois to visit her sister. Pt was slurring her words that she attributed to a previous stroke that she did not know how long ago it had occurred. Pt allowed initial vitals, but refused IV [intravenous] and further assessment. Pt was encouraged by [local police department] to allow transport to [local hospital] and agreed . The resident was treated on the scene and transported to the local hospital by 12:25 p.m. An Emergency Department (ED) note dated 5/16/22 at 12:28 p.m. revealed EMS found the patient passed out on a sidewalk. The patient stated she was hitch hiking and it was too hot, and she did not drink enough water and she fainted. Continued review of the ED Assessment and Plan revealed the resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Hospital Psychiatric Consult Note dated 05/20/22 for Resident #1 showed a history of present illness as patient states that she is in the hospital because of a medical issue Denies having any medical problems or history of psychiatric care can't recall the year but is able to say who the president is and that the day is Friday. A psychiatric Diagnostic Formulation showed the [AGE] year-old was with acute medical history but is unaware of her medical problems or complexity of her situation. Patient appears to tell a story about her recent history, but she has bouts of confusion. She does have support from sister and likely none from her son. She was previously living in a facility according to nurse, but patient is unable to recall this. She is unaware of her medications and lacks transportation and ability to decide how to acquire transportation and care. A recommendation plan showed patient is not competent to make decisions on own. Patient should be in a facility where she can get support medically and physically. An observation of the facility's main entrance area was conducted on 5/23/22 at 8:55 a.m. The observation revealed two white gates on both sides of the front porch area approximately 3 feet tall, propped open and without a latching mechanism. Photographic evidence was obtained. An observation was made of a resident sitting in the front porch area. Upon entrance to the facility, no staff member was available for screening of visitors or supervision of the resident on the front porch. A receptionist was observed entering the facility at 9:05 a.m. Random observations of the front porch area on 5/23/22 at 11:45 a.m. and 12:11 p.m. revealed residents re-entered the facility by pushing the wheelchair accessibility button which opened the front entry doors. No staff assistance was used to gain entry to the facility. A review of Resident #1's admission record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's Hospital Discharge Summary dated 3/30/22 (just prior to her admission to the facility) indicated patient has a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She was at home per EMS and had a fall and hit her head, the family called EMS as the patient is weak and having trouble ambulating, unknown what the actual time of onset is. The patient is a very difficult historian. Denied any pain, shortness of breath, nausea vomiting, black or bloody stools. Capacity attestation was placed in the chart and proxy assigned. CT scan head reported as no acute intracranial abnormalities, atrophy greater than expected for patient's age. Patient was admitted for stroke workup and neurology consultation obtained. MRI Brain revealed small area of acute [CONDITION(S)] in the left Basal ganglia region consistent with subacute or acute Lacunar infarction. Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedures performed during the hospital stay: insert Peg Tube on 3/22/22. A review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, reflecting severe cognitive impairment. The resident exhibited no wandering behaviors or risks and required extensive assistance by one person for activities of daily living (ADL's). The resident's balance during transitions and walking was not steady and she could only stabilize with staff assistance. The resident had not walked during the assessment observation period from 3/30/22 to 4/5/22. No additional MDS assessments had been initiated or completed during Resident #1's stay at the facility. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] · Diet NPO (nothing by mouth). · Enteral (intestinal) feed orders every 4 hours flush enteral tube with 150 ml (milliliters) H20 (water) · Enteral feed orders every shift [MEDICATION(S)] 1.5 via peg-tube at a rate of 60 ml/hr (hour) for a total volume of 1200 ml to be infused in 24 hours. May turn off for care/services. Start at 2 p.m. Verify infusion every shift. Clear the pump only when the total volume has been infused. · Cleanse G-tube site with soap and water daily as well as PRN (as needed) every night shift. · Flush feeding tube with 5 ml of water between meds every shift for patency and hydration. · Flush tube with 30 ml water before or after medication administration and feeding every shift for patency and hydration. · Resident could go on LOA (leave of absence) with escort for physical assistance. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, Sodium Chloride tablet 1 gm (gram) give 1 tablet via peg tube three times a day for [CONDITION(S)], scheduled at 1 pm was documented as administered on 5/16/22 . An enteral feed order to start [MEDICATION(S)] 1.5 via peg tube at 2 p.m. was documented as completed for day shift, 7a.m. - 3p.m. hours on 5/16/22. The order to flush feeding tube with 5 ml of water between medications for patency and hydration, due at 12 p.m. was documented as completed on 5/16/22. A review of a nursing progress note written by the Director of Nursing (DON) dated 5/16/22 at 21:48 (9:48 p.m.) with an effective date of 5/16/22 at 5:52 p.m. showed The hospital notified this writer that the resident who is alert and oriented x4 with a BIMS of 13 experienced a fall while LOA [on leave of absence] and was transported to [name] hospital for evaluation. The resident is her own responsible party and stated that she was going to her home when she fell and bumped her head. Facility MD notified of admission to the hospital while LOA. A review of the Physical Therapy (PT) discharge summary dated 5/8/22 revealed Resident #1 received PT from 3/31/22 to 4/29/22. The note stated patient made progress in ambulation from 50 feet with minimum assistance on start of care (SOC) to 200 feet with contact guard assist (CGA)/stand by assist (SBA) with rolling walker and more steady gait noted due to increase in bilateral lower extremity (BLE) strength to 3+/5 (Ability to complete test movement and/or hold test position against gravity and minimal (slight) pressure) from 3/5 (Ability to complete test movement and/or hold test position against gravity but cannot hold if even slight pressure is applied) on SOC. Functional mobility improved from CGA in SOC to SBA/set up decreasing burden of care. Discontinue PT per case manager request. Precautions for the patient included fall risk and confusion. The discharge plans and instructions noted patient to discharge to same skilled nursing facility (SNF) with instructions in safe mobility and gait with fair carryover. An interview was conducted with Staff A, Registered Nurse (RN) Supervisor on 5/23/22 at 3:27 p.m. Staff A, stated she was working on 5/16/22 on the 3 p.m. - 11 p.m. shift and was covering East and West units. Staff A confirmed that Resident #1 had been verbalizing wanting to leave the facility and did not let her sit outside at the front porch. Staff A said, I did not let her out because since she has been here, she has been wanting to leave. She told everyone that, even the administration knew she wanted to leave. It is very upsetting because she had been verbalizing wanting to leave. Staff A confirmed Resident #1 was not supposed to be let outside unsupervised. Staff A stated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff A stated on 05/16/22 before dinner, around 5 p.m., Staff D, Certified Nursing Assistant (CNA) reported Resident #1 was missing. Staff A stated they did a head count, twice and could not locate the resident. Staff D, CNA and Staff M, CNA, went around the perimeter of the building, looked in all rooms, and could not find Resident #1. Staff A stated she called Resident #1's sister to see if she had taken her out without signing her out, but the sister said no. Staff A stated she called the Director of Nursing (DON) who instructed her to call the hospital. Staff A expressed frustration with the previous shift for not knowing the resident was missing. Staff A stated it is a nursing expectation to assess residents every 2 hours. A follow-up interview with Staff A on 05/25/22 at 3:54 p.m. revealed administration told her they could not put a wander bracelet (an electronic monitoring device) on Resident #1 because the resident had a high BIMS score. Staff A said, To me, if anyone is saying they wanted to leave they should be considered at risk and placed on a wander guard [an electronic monitoring device]. An interview was conducted with Staff D, CNA on 05/23/22 at 3:50 p.m. Staff D stated she was assigned to care for Resident #1 on the second shift, 3 p.m. - 11:30 p.m. Staff D stated she arrived at the facility at 2:16 p.m. Staff D stated the first thing she did was update the staffing boards. Staff D stated her room assignment included Resident #1's room. Staff D stated she had worked with Resident #1 before. Staff D said, She [Resident #1] likes to wander throughout the facility. She likes to sit outside in the front porch. Staff D stated she did not notice anything unusual at first. Staff D stated her routine is to glance at the rooms and count heads. Staff D stated Resident #1 is normally in her room or at the front desk making calls. Staff D said, I did not see her at 2:30 p.m. I saw [Staff C RN]. I asked him where [Resident #1] was. He said to me, I don't know. She is somewhere here. Staff D stated she looked for Resident #1 in the dining room, looked outside and did not see her. Staff D stated when she walked in from outside, she saw there were call lights that needed her attention. Staff D stated she went to attend to the call lights first. Staff D stated by this time Staff G, LPN had relieved the first shift nurse. Staff D said, I asked her if she had seen the resident. She said she did not know where she is. I went back to work. Staff D stated around 5 p.m. the dinner trays come out. Staff D said, I took a tray to [Resident #1's] roommate. Staff D stated Resident #1 was not in her room. Staff D said, I did not find her, so I went to [Staff A], the supervisor and reported [Resident #1] was missing. Staff D stated she looked in the LOA book to see if she had signed out. Staff D said, no she did not sign out. She wasn't supposed to go alone. Staff D again stated Resident #1 is usually seen by the desk area all the time. Staff D stated it was unusual that she was not there. Staff D stated she heard Resident #1 say she wanted to get out before, meaning she wanted to leave the facility. Staff D stated when she notified Staff A, the search was initiated. Staff D said, I was searching everywhere. If I had not said anything, no one would have noticed. No one knew she was missing on 7 a.m. - 3 p.m. shift. Staff D stated later she heard Resident #1 had fallen on a sidewalk and was in the hospital. Staff D became emotional, wiping tears from her face. Staff D said, I care for my residents. That resident's mental status was not all the way there, but she never said she wanted to leave except once. I thought cognitively she wasn't okay because of her conversations with her roommates. She was confused. Staff D stated Resident #1 was a fall risk even though she had gotten better with time. Staff D stated she did not feel like they had enough staff to care for at risk residents. Staff D stated at risk meant residents who are verbalizing wanting to leave or have a lot of care needs. Staff D stated she thought the CNAs were not receiving adequate training. Staff D said she had heard the resident left the facility with a bag full of her clothes. Staff D said, I would have followed her if I saw her leave. Staff D stated Resident #1 had verbalized wanting to leave about a week before she eloped. Staff D stated she did not think Resident #1 would leave and that was why I did not report it right away. On 5/23/22 at 12:59 p.m., Staff M, CNA revealed she worked a double shift from 7:00 a.m. - 11:00 p.m. on 5/16/22. On the 3:00 p.m. - 11:00 p.m. shift she was scheduled to work on the hallway where Resident #1 resided but was not assigned to her room. Staff M stated there were two of us on that hallway. Around 4:30 p.m. - 5:00 p.m., the nurse asked me if I saw Resident #1. I told her no because I worked on the other side of the building on the morning shift. I stopped passing water and we (Staff D and Staff M) went to check all over for the resident. Staff D was assigned Resident #1 and said she had not seen the resident the whole shift. We checked the room, we checked the other halls, we checked outside, and then we did a head count of the residents. Resident #1 was still missing. After we did all the checks, there was an overhead code called and then the administrator, DON, Supervisors, and the day shift nurse were called. No one had seen the resident. I went to care for my residents and the administrator and DON took over from there. We have to go and check on the residents if they go outside. It is my responsibility to check on them and know where they are. I go to the nurse if I do not see the resident. On 05/24/22 at 10:04 a.m., an interview was conducted with Resident #1's sister. Resident #1's sister stated the resident was still in the hospital. The sister stated the hospital was keeping the resident pending recovery and finding alternative placement. Resident #1's sister stated she has not heard from the facility since 5/16/22, the night she disappeared and was contacted to see if the resident was with her. On 05/24/22 at 10:50 a.m. an interview was conducted with Resident #1's assigned RN at the hospital. The Hospital RN stated Resident #1 was her patient on this day (5/24/22). She stated the resident was alert and was able to understand simple communication. She stated the resident was currently under direct observation meaning she has a staff member in the room with her because the resident attempted to elope from the hospital on Sunday, 5/22/22. She had told the nurse she was going to the taco truck. The Hospital RN stated the resident was being treated with IV fluids and total nutrition and hydration was being provided by tube feeding. She stated the resident would remain in the hospital until a locked facility could be secured for her transfer. On 05/24/22 at 11:15 a.m., an interview was conducted with Resident #1 in the hospital. The door to Resident #1's hospital room had a sign stating NPO (nothing by mouth). Resident #1 was asked about her elopement from the skilled nursing facility on 05/16/22. She stated, I wanted to go home, and I told them I wanted to go home several times. The resident stated she did not tell anyone that she was going to leave because she was afraid they would try to stop me and call my sister who would then not let me go. The resident pointed to a bag on the floor and stated she packed up her stuff and walked out. The resident indicated she was not using a walker or any assistive device when she left the facility. She was not able to state who opened the door for her to leave the facility. The resident stated she started to walk down the street because I was going to hitchhike home to Sarasota She stated she fell , someone she did not know called for help, and the ambulance took her to the hospital. Her voice raised as she explained, there is nothing wrong with me, my brain and my health are just fine. I want to get out of here and away from my sister. She stated she was not receiving a tube feeding with nutrition and hydration, I eat regular food. An interview was conducted on 05/23/22 at 3:16 p.m. with Staff B, CNA. Staff B stated she was working day shift on 5/16/22, the 7 a.m. to 3:30 p.m. shift and was assigned to care for Resident #1. Staff B stated Resident #1 had become more independent with ADLs and had dressed herself that day. Staff B said, I saw her brush her teeth. I can't remember if her feeding tube was running or not at the time. It was after breakfast between 8 a.m. and 8:30 a.m. I was taking care of her roommates. Staff B stated Resident #1 left her room around 9 a.m. - 9:30 a.m., and she thought the resident was going to the dining room. Staff B stated she did not really know too much about Resident #1 and did not see her again after this. When asked if she had looked for Resident #1, Staff B said, Really, I did not. I probably should have. I felt she was independent. I didn't think she would leave. I just thought she was in the dining room. I did not provide her any care. Staff B stated she never saw Resident #1 with a nurse throughout the shift. Staff B stated she had noticed Resident #1's feeding tube pump was turned off when she went back to the room around 10 a.m. Staff B stated she changed Resident #1's bed linens and did not notice her belongings were not in the room. Staff B stated she did not check the resident's closet. Staff B stated she was in and out of the room throughout her shift attending to the other residents and ended her shift at 3:30 p.m. Staff B stated she did not see Resident #1 during those visits. Staff B stated she did not give report to the on-coming Aide. Staff B reported sometimes they give shift report and sometimes they did not. Staff B stated she was not notified Resident #1 had left the facility until the next day. Staff B stated no one called her that evening to inquire about Resident #1. Staff B stated she spoke to the DON and the Nursing Home Administrator (NHA) the following morning. Staff B confirmed that she never checked on Resident #1 throughout her shift and never reported her as missing. On 05/24/22 at 9:15 a.m., Staff C, RN Unit Manager confirmed he was assigned to care for Resident #1 on 5/16/22. Staff C stated he worked day shift, 7:00 a.m. to 3:00 p.m. but stayed over until around 4:00 p.m. Staff C stated Resident #1 was dependent on her feeding tube for all nutritional support. Staff C stated he last saw Resident #1 in her room between 11:30 a.m. and 12:00 p.m. on 05/16/22. Staff C stated he gave her medications, through the feeding tube, and the tube feeding was to be off at 10 a.m. and restarted at 2:00 p.m. Staff C stated Resident #1 had flushes scheduled every 4 hours. Staff C stated Resident #1 disconnected the tube feeding sometime in the morning. Staff C stated he could not remember if the resident had finished her tube feeding or not. Staff C stated at 2:00 p.m. when her scheduled flush was due, he did not go looking for her. Staff C stated he did not see Resident #1 after 11:45 a.m. Staff C said, I never saw her again. I left the facility at 4:00 p.m. I did not look for her. I had a lot of patients. I did not reconnect her tube feeding at 2:00 p.m. Staff C stated the CNAs did not tell him the resident was missing. Staff C stated the expectation was for CNAs and nurses to supervise the residents. Staff C said, We are all responsible for monitoring the residents. We all do rounds every 2-3 hours. It is not acceptable not to monitor residents. Staff C stated that day he had a lot of things going on. Staff C stated the second shift nurse called him around 6:00 p.m. asking where Resident #1 was. Staff C said, I told her I saw her in the morning, in the middle of the day around 11:45 a.m. That was the last time I saw her Staff C stated he was notified Resident #1 walked away from the facility, fell , and was in the hospital. Staff C stated Resident #1 always sat on the front porch without supervision. Staff C stated residents who were alert with a high BIMS score can sit outside. Staff C said, Yes, we should monitor and supervise when they are outside. I was on the [medication] cart. I did not supervise the residents. I was busy. An interview was conducted on 05/23/22 at 9:32 a.m. with the Director of Maintenance (DOM). The DOM stated he was aware a resident had eloped on 05/16/22 because he received a call and did not know how the resident left the facility. The DOM stated the following day (05/17/22) they checked all the doors and checked all ankle monitors to make sure they were working. The DOM said, We did not identify any doors that had problems. All alarms were working. Yes, I know residents sit out at the front patio with and without a staff member. The two gates are not supposed to be locked. They are supposed to be open. The DOM stated he checks the doors twice daily and logs his entries in their system. A tour of the front door area was conducted with the DOM. The DOM stated staff must enter a keypad pin to unlock the door. If a resident who has a wanderguard approaches the door, the alarm will sound. The door was observed with a wanderguard censor unit on the side of the main door. During the tour, a resident was observed sitting in her wheelchair in the front patio/porch area. The resident stated she likes to sit there and get fresh air. There was no staff observed in the area. The DOM stated some residents can be in the patio without supervision. The DOM stated if the residents want to come back inside from the patio, they push the wheelchair accessibility button and let themselves back in. The DOM did not know if that would stop other residents from exiting out the front door without staff knowledge. The DOM stated visitors must be let in and out by a staff member. The surveyor proceeded to hit the wheelchair accessibility button located in the exterior front patio area, which immediately opened the front entrance doors without staff inside having to enter a code to allow entry. The DOM did not comment on this security flaw. The DOM stated he had not participated in any elopement drills at this facility and had recently begun working at the facility. The DOM stated he had not received in-services since the elopement. The DOM said, I do not know how they conduct the elopement drills. On 5/25/22 at 3:45 p.m., the Physical Therapist (PT) was interviewed about Resident #1. The PT was familiar with Resident #1 and stated that when she was initially admitted she had a hard time walking and could only walk about 40 feet. She was very unsteady, due to repeated falls, but she improved and walked up to 200 ft with a walker. She could also walk without a walker while in the facility. Resident #1 was discharged from PT on 4/29/22 as she met her goals. The resident always said she wanted to leave. This was very common. The PT recalled Resident #1 being strong-willed but physically, she needed assistance of a walker when on uneven terrain. The PT stated Resident #1 had some short term memory problems and needed frequent reminders to use her walker. On 5/23/22 at 11:40 a.m., Staff R, RN/MDS Coordinator stated she was made aware of the elopement today during a morning meeting. Staff R stated she was told a resident left the facility, but she wouldn't call it an elopement. Staff R stated Resident #1 went on LOA. Staff R stated LOA means when they leave the facility either with a family member, or if they are authorized to sign out independently. Staff R stated if the resident was authorized, there would be an order that says they can leave supervised or unsupervised. Staff R stated the medical team determines the supervision level and a doctor would sign the order. Staff R stated she did not know if an elopement assessment had been conducted on Resident #1. Staff R stated she did the initial MDS on 4/5/22. Staff R stated she assessed Resident #1 with a series of questions and had scored a BIMS of 5 which meant her cognition was impaired. Staff R stated at the time of the admission MDS she required extensive assistance and was not ambulatory. Staff R stated she had made significant gains recently. Staff R stated at the time of admission, Resident #1 stayed in bed, was dependent on staff, and was not at risk of elopement. Staff R stated if a resident's status changes, they would re-evaluate. Staff R said, Because she is moving around more, she should be re assessed, yes to include risk of elopement. Staff R stated there should have been a Change in Condition and review of her full assessment. I was not here, so I can't say why it was not done. It should have been done . I apologize, it was not done. It should have been done. On 5/23/22 at 11:54 a.m., the Social Services Director (SSD) stated she was notified of the elopement on the day the event occurred (05/16/22). The SSD said, The DON called me, she said that we had one person that had eloped and asked me if I knew if this resident had gone out with the family. I told her no, I did not know. No one had notified me she was to be going anywhere. The SSD stated on her way to the facility on [DATE], she was notified Resident #1 was at the hospital. The SSD stated prior to the elopement she had met the resident and did an assessment. The SSD stated Resident #1 scored a BIMS of 13, indicating intact cognition. The SSD stated this assessment was three days before the elopement occurred. When asked what triggered the BIMS assessment, The SSD stated Resident #1 was walking around and wanted to sit outside. The SSD stated there is a limit on who can sit in the front. They have to be at a BIMS of 13 and above and alert and oriented. The SSD confirmed she conducted the BIMS assessment so that Resident #1 could sit outside independently. The SSD stated she did not conduct an elopement assessment. The SSD stated the DON should have conducted the elopement assessment. The SSD was not sure if one was done. The SSD said, The resident wanted to go outside to sit. She kept asking. She did not want to leave. She was not at risk of wandering. She just wanted to sit outside in the front. The SSD stated she had notified the team of the BIMS score change. The SSD said, With the new BIMS she could sit in the front, but still needed staff to keep an eye on her. On 5/23/22 at 1:41 p.m., an interview was conducted with the DON and the nursing Home Administrator (NHA). The DON stated Resident #1 came to the facility after a hospital stay and on admission showed slight confusion. She progressed well. Her deficits were not limiting, and the resident was known to sit on the front porch at different times. After her improvement, she would move about the whole facility. The DON stated if a resident has a BIMS score below 10, they would not be capable of being outside. The DON stated if they were exit-seeking, I would be concerned. The DON stated an elopement assessment should have been done, under the initial admission assessment on 3/30/22. The DON stated an elopement assessment should be conducted if a resident has triggers, such as alcohol dependence diagnosis. The DON stated Resident #1 did not elope. The DON stated Resident #1 was on a leave of absence, but she did not sign out. The DON stated Resident #1 had said she wanted to go home. The DON stated that was why they did not report her as an elopement. We investigated her as a missing person. The DON stated the day nurse had provided enteral feeding and medications were administered at 11:45 a.m. The DON stated the tube feeding should have been reconnected at 2:00 p.m., per orders. The DON stated she was called on 05/16/22 at 5:52 p.m. by a supervisor (Staff A) for the 3:00 p.m. to 11:00 p.m. shift. The DON said, She [Staff A] asked me, did you know if [Resident #1] was discharged or going anywhere? I said I did not. I started making calls. I told her to look around the facility and conduct a head count. I called the [SSD], and nurse on first shift duty, they all said she was not scheduled to go anywhere. I did not know where she was. The DON stated on 05/16/22 at 6:01 p.m. she notified the NHA, and everyone came in. The DON stated o

Based on observations, review of medical records, facility policies, and job descriptions, and interviews with facility staff, the Medical Director (MD), a family member, a hospital nurse and residents, the facility failed to provide supervision and services to prevent an unwitnessed exit from the facility for one (Resident #1) of six residents sampled for high risk elopement. Resident #1 was an ambulatory, vulnerable resident, unable to take food or liquids by mouth, required a walker to ambulate safely and had expressed wishes to leave the facility. The facility failed to supervise exits and outdoor spaces and failed to carry out procedures to locate Resident #1's whereabouts on a regular basis. Resident #1 was last seen by facility staff on 05/16/22 at approximately 11:45 a.m. A call was placed to 911 on 05/16/22 at 11:52 a.m. and Emergency Medical Services (EMS) arrived at 12:06 p.m. to find Resident #1 laying on the sidewalk of a business 0.2 miles away from the facility. Resident #1 was transported to the hospital where she remained during the course of the survey and received treatment for [CONDITION(S)], dehydration, elevated troponin, and a urinary tract infection ([CONDITION(S)]). Facility staff were unaware Resident #1 had eloped from the facility and did not notice she was missing until dinnertime, around 5:00 p.m. Resident #1 walked across a parking lot and rough terrain without her walker, where she fell and was at risk of being struck by a vehicle and suffering serious injury or death. The facility's failure to provide adequate supervision to prevent the elopement resulted in findings of Immediate Jeopardy on 05/16/22, and removed on 05/26/22, with the scope and severity reduced to a D after verification of implementation of immediacy removal actions. Findings included: Cross Reference F600 and F726 An interview was conducted with Staff D, Certified Nursing Assistant (CNA) on 05/23/22 at 3:50 p.m. Staff D stated she was assigned to care for Resident #1 on 5/16/22 during the second shift, 3 p.m. - 11:30 p.m. Staff D stated she arrived at the facility at 2:16 p.m. and updated the staffing boards. Staff D stated her room assignment included Resident #1's room. Staff D said, She [Resident #1] likes to wander throughout the facility. She likes to sit outside on the front porch. Staff D stated her normal work routine was to glance at the rooms and count heads. Staff D stated Resident #1 was normally in her room or at the front desk making calls. Staff D said, I did not see her at 2:30 p.m. I saw [Staff C RN]. I asked him where [Resident #1] was. He said, I don't know. She is somewhere here. Staff D stated she looked for Resident #1 in the dining room, and looked outside but did not see her. Staff D stated when she walked in from outside, she saw there were call lights that needed her attention and she went to attend to that. Staff D stated by this time Staff G, Licensed Practical Nurse (LPN) had relieved the first shift nurse. Staff D said, I asked [Staff G] if she had seen the resident. She said she did not know where she is. I went back to work. Staff D stated around 5 p.m. the dinner trays come out. Staff D said, I took a tray to [Resident #1's] roommate. Staff D stated Resident #1 was not in her room. Staff D said, I did not find her, so I went to [Staff A], the supervisor and reported [Resident #1] was missing. Staff D stated she looked in the LOA (leave of absence) book to see if she had signed out, but she had not signed out. She wasn't supposed to leave the facility alone. Staff D again stated Resident #1 was usually by the desk area, and it was unusual that she was not there. Staff D stated she heard Resident #1 say she wanted to leave the facility before. Staff D stated when she notified Staff A, the search was initiated. Staff D said, I was searching everywhere. If I had not said anything, no one would have noticed. No one knew she was missing on 7 a.m. - 3 p.m. shift. Staff D stated later she heard Resident #1 had fallen on a sidewalk and was in the hospital. Staff D became emotional, wiping tears from her face. Staff D said, I care for my residents. That resident's mental status was not all the way there, but she never said she wanted to leave except once. I thought cognitively she wasn't okay because of her conversations with her roommates. She was confused. Staff D stated Resident #1 was a fall risk even though she had gotten better with time. Staff D stated she did not feel like they had enough staff to care for at risk residents who verbalized wanting to leave or have a lot of care needs. Staff D stated she thought the CNAs were not receiving adequate training. Staff D said she had heard the resident left the facility with a bag full of her clothes. Staff D said, I would have followed her if I saw her leave. Staff D stated Resident #1 had verbalized wanting to leave about a week before she eloped. Staff D stated she did not think Resident #1 would leave and that was why she did not report it right away. On 05/24/22 at 9:15 a.m., Staff C, Registered Nurse (RN) Unit Manager confirmed he was assigned to care for Resident #1 on 5/16/22 during day shift, 7:00 a.m. to 3:00 p.m. but stayed over until around 4:00 p.m. Staff C stated Resident #1 was dependent on her feeding tube for all nutritional support. Staff C stated he last saw Resident #1 in her room between 11:30 a.m. and 12:00 p.m. on 05/16/22. Staff C stated he gave her medications, through the feeding tube, and the tube feeding was to be off at 10 a.m. and restarted at 2:00 p.m. Staff C stated Resident #1 had flushes scheduled every 4 hours. Staff C stated Resident #1 disconnected the tube feeding sometime in the morning. Staff C stated he could not remember if the resident had finished her tube feeding or not. Staff C stated at 2:00 p.m. when her scheduled flush was due, he did not go look for her. Staff C stated he did not see Resident #1 after 11:45 a.m. on 05/16/22. Staff C said, I never saw her again. I left the facility at 4:00 p.m. I did not look for her. I had a lot of patients. I did not reconnect her tube feeding at 2:00 p.m. Staff C stated the CNAs did not tell him the resident was missing. Staff C stated the expectation was for CNAs and nurses to supervise the residents. Staff C said, We are all responsible for monitoring the residents. We all do rounds every 2-3 hours. It is not acceptable not to monitor residents. Staff C stated that day he had a lot of things going on. Staff C stated the second shift nurse called him around 6:00 p.m. on 5/16/22 asking where Resident #1 was. Staff C said, I told her I saw her in the morning, in the middle of the day around 11:45 a.m. That was the last time I saw her. Staff C stated he was notified Resident #1 walked away from the facility, fell , and was in the hospital. Staff C stated Resident #1 always sat on the front porch without supervision. Staff C stated residents who were alert with a high Brief Interview for Mental Status (BIMS) score could sit outside. Staff C said, Yes, we should monitor and supervise when they are outside. I was on the [medication] cart. I did not supervise the residents. I was busy. On 5/23/22 at 4:12 p.m., Staff G, Licensed Practical Nurse (LPN) revealed she had worked on 5/16/22 during the 3:00 p.m. to 11:00 p.m. on the hall where Resident #1 resided. Staff G stated she arrived to work around 4:00 p.m. and took over from the day shift nurse (Staff C, RN Unit Manager). Staff G stated Staff C did not report any abnormalities or anything unusual on the day shift. Staff G stated Staff D, CNA reported that Resident #1 was not in her room. Staff G stated she asked Staff D to check in therapy, outside, and in the dining room. Staff G stated Staff D, CNA did not initiate the search. Staff D went to assist other residents that needed care. Staff G said, It did not alarm me at that time. Later, we realized we can't find her around 5:00 p.m. We started to look for her. We looked around the building. She was not inside the building, not in therapy. We alerted the supervisor. Staff G stated somebody must have opened the door for the resident to get out. Staff G stated residents who are alert can sit outside on the front porch. Staff G said, you still check on them at least every 30 minutes. An interview was conducted with Staff A, RN Supervisor on 5/23/22 at 3:27 p.m. Staff A, stated she worked on 5/16/22 on the 3 p.m. - 11 p.m. shift and was covering East and West units. Staff A confirmed that Resident #1 had been verbalizing wanting to leave the facility, and she did not let her sit outside on the front porch. Staff A said, I did not let her out because since she has been here, she has been wanting to leave. She told everyone that, even the administration knew she wanted to leave. It is very upsetting because she had been verbalizing wanting to leave. Staff A confirmed Resident #1 was not supposed to be let outside unsupervised. Staff A stated physician orders stated the resident could only go out with physical assistance. Staff A stated on 05/16/22 before dinner, around 5 p.m., Staff D, Certified Nursing Assistant (CNA) reported Resident #1 was missing. Staff A stated they did a head count, twice and could not locate the resident. Staff D, CNA and Staff M, CNA, went around the perimeter of the building, looked in all rooms, and could not find Resident #1. Staff A stated she called Resident #1's s sister to see if she had taken her out without signing her out, but the sister said no. Staff A stated she called the Director of Nursing (DON) who instructed her to call the hospital. Staff A expressed frustration with the previous shift for not knowing the resident was missing. Staff A stated it is a nursing expectation to assess residents every 2 hours. A follow-up interview with Staff A on 05/25/22 at 3:54 p.m. revealed administration told her they could not put a wander bracelet (an electronic monitoring device) on Resident #1 because the resident had a high Brief Interview of Mental Status (BIMS) score. Staff A said, To me, if anyone is saying they wanted to leave they should be considered at risk and placed on a wanderguard [an electronic monitoring device]. On 5/23/22 at 12:59 p.m., Staff M, CNA revealed she worked a double shift from 7:00 a.m. - 11:00 p.m. on 5/16/22. On the 3:00 p.m. - 11:00 p.m. shift she was scheduled to work on the hallway where Resident #1 resided but was not assigned to her room. Staff M stated there were two of us on that hallway. Around 4:30 p.m. - 5:00 p.m., the nurse asked me if I saw Resident #1. I told her no because I worked on the other side of the building on the morning shift. I stopped passing water and we (Staff D and Staff M) went to check all over for the resident. Staff D was assigned Resident #1 and said she had not seen the resident the whole shift. We checked the room, we checked the other halls, we checked outside, and then we did a head count of the residents. Resident #1 was still missing. After we did all the checks, there was an overhead code called and then the administrator, DON, Supervisors, and the day shift nurse were called. No one had seen the resident. I went to care for my residents and the administrator and DON took over from there. We have to go and check on the residents if they go outside. It is my responsibility to check on them and know where they are. I go to the nurse if I do not see the resident. An interview was conducted on 05/23/22 at 3:16 p.m. with Staff B, CNA. Staff B stated she was working day shift on 5/16/22, the 7 a.m. to 3:30 p.m. shift and was assigned to care for Resident #1. Staff B stated Resident #1 had become more independent with activities of daily living (ADLs) and had dressed herself that day. Staff B said, I saw her brush her teeth. I can't remember if her feeding tube was running or not at the time. It was after breakfast between 8 a.m. and 8:30 a.m. I was taking care of her roommates. Staff B stated Resident #1 left her room around 9 a.m. - 9:30 a.m., and she thought the resident was going to the dining room. Staff B stated she did not really know too much about Resident #1 and did not see her again after this. When asked if she had looked for Resident #1, Staff B said, Really, I did not. I probably should have. I felt she was independent. I didn't think she would leave. I just thought she was in the dining room. I did not provide her any care. Staff B stated she never saw Resident #1 with a nurse throughout the shift. Staff B stated she had noticed Resident #1's feeding tube pump was turned off when she went back to the room around 10 a.m. Staff B stated she changed Resident #1's bed linens and did not notice her belongings were not in the room. Staff B stated she did not check the resident's closet. Staff B stated she was in and out of the room throughout her shift attending to the other residents and ended her shift at 3:30 p.m. Staff B stated she did not see Resident #1 during those visits. Staff B stated she did not give report to the on-coming Aide. Staff B reported sometimes they give shift report and sometimes they did not. Staff B stated she was not notified Resident #1 had left the facility until the next day. Staff B stated no one called her that evening to inquire about Resident #1. Staff B stated she spoke to the DON and the Nursing Home Administrator (NHA) the following morning. Staff B confirmed that she never checked on Resident #1 throughout her shift and never reported her as missing. On 5/23/22 at 11:40 a.m., Staff R, RN/Minimum Data Set (MDS) Coordinator stated she had just been informed of Resident #1's elopement that day during the morning meeting. Staff R stated she wouldn't call it an elopement. Staff R stated Resident #1 went on Leave of Absence (LOA). Staff R stated LOA means they leave the facility either with a family member, or independently if they are authorized to sign themselves out. Staff R stated if the resident was authorized, there would be a physician order that says they can leave supervised or unsupervised. Staff R stated the medical team determines the supervision level and a doctor would sign the order. Staff R stated she did not know if an elopement assessment had been conducted on Resident #1. Staff R stated she did the admission MDS assessment on 4/5/22. Staff R stated Resident #1 had scored a BIMS of 5 which meant her cognition was impaired. Staff R stated at the time of the admission MDS, the resident required extensive assistance and was not ambulatory. Staff R stated Resident #1 had made significant gains recently. Staff R stated at the time of admission, Resident #1 stayed in bed, was dependent on staff, and was not at risk of elopement. Staff R stated if a resident's status changes, they would re-evaluate. Staff R said, Because she is moving around more, she should be re-assessed, yes to include risk of elopement. Staff R stated there should have been a Change in Condition and review of her full assessment. I was not here, so I can't say why it was not done. It should have been done . I apologize, it was not done. It should have been done. On 5/25/22 at 3:45 p.m , the Physical Therapist (PT) was interviewed about Resident #1. The PT was familiar with Resident #1 and stated that when she was initially admitted she had a hard time walking and could only walk about 40 feet. She was very unsteady, due to repeated falls, but she improved and walked up to 200 ft with a walker. She could also walk without a walker while in the facility. Resident #1 was discharged from PT on 4/29/22 as she met her goals. The resident always said she wanted to leave. This was very common. The PT recalled Resident #1 being strong-willed but physically, she needed assistance of a walker when on uneven terrain. The PT stated Resident #1 had some short term memory problems and needed frequent reminders to use her walker. On 5/23/22 at 11:54 a.m., the Social Services Director (SSD) stated she was notified of the elopement on the day the event occurred (05/16/22). The SSD said, The DON called me, she said that we had one person that had eloped and asked me if I knew if this resident had gone out with the family. I told her no, I did not know. No one had notified me she was to be going anywhere. The SSD stated on her way to the facility on [DATE], she was notified Resident #1 was at the hospital. The SSD stated prior to the elopement she had met the resident and did an assessment. The SSD stated Resident #1 scored a BIMS of 13, indicating intact cognition. The SSD stated this assessment was three days before the elopement occurred. When asked what triggered the BIMS assessment, The SSD stated Resident #1 was walking around and wanted to sit outside. The SSD stated there is a limit on who can sit in the front. They have to be at a BIMS of 13 and above and alert and oriented. The SSD confirmed she conducted the BIMS assessment so that Resident #1 could sit outside independently. The SSD stated she did not conduct an elopement assessment. The SSD stated the DON should have conducted the elopement assessment. The SSD was not sure if one was done. The SSD said, The resident wanted to go outside to sit. She kept asking. She did not want to leave. She was not at risk of wandering. She just wanted to sit outside in the front. The SSD stated she had notified the team of the BIMS score change. The SSD said, With the new BIMS she could sit in the front, but still needed staff to keep an eye on her. On 05/24/22 at 11:15 a.m., an interview was conducted with Resident #1 in the hospital. The door to Resident #1's hospital room had a sign stating NPO (nothing by mouth). Resident #1 was asked about her elopement from the skilled nursing facility on 05/16/22. She stated, I wanted to go home, and I told them I wanted to go home several times. The resident stated she did not tell anyone that she was going to leave because she was afraid they would try to stop me and call my sister who would then not let me go. The resident pointed to a bag on the floor and stated she packed up her stuff and walked out. The resident indicated she was not using a walker or any assistive device when she left the facility. She was not able to state who opened the door for her to leave the facility. The resident stated she started to walk down the street because I was going to hitchhike home to Sarasota She stated she fell , someone she did not know called for help, and the ambulance took her to the hospital. Her voice raised as she explained, there is nothing wrong with me, my brain and my health are just fine. I want to get out of here and away from my sister. She stated she was not receiving a tube feeding with nutrition and hydration, I eat regular food. On 05/24/22 at 10:50 a.m. an interview was conducted with Resident #1's assigned RN at the hospital. The Hospital RN stated Resident #1 was her patient on this day (5/24/22). She stated the resident was alert and was able to understand simple communication. She stated the resident was currently under direct observation meaning she has a staff member in the room with her because the resident attempted to elope from the hospital on Sunday, 5/22/22. She had told the nurse she was going to the taco truck. The Hospital RN stated the resident was being treated with IV fluids and total nutrition and hydration was being provided by tube feeding. She stated the resident would remain in the hospital until a locked facility could be secured for her transfer. On 05/24/22 at 10:04 a.m., an interview was conducted with Resident #1's sister. Resident #1's sister stated the hospital was keeping the resident pending recovery and finding alternative placement. Resident #1's sister stated she has not heard from the facility since 5/16/22, the night she disappeared and was contacted to see if the resident was with her. On 5/23/22 at 1:41 p.m , an interview was conducted with the DON and the nursing Home Administrator (NHA). The DON stated Resident #1 came to the facility after a hospital stay and on admission showed slight confusion. She progressed well. Her deficits were not limiting, and the resident was known to sit on the front porch at different times. After her improvement, she would move about the whole facility. The DON stated if a resident has a BIMS score below 10, they would not be capable of being outside. The DON stated if they were exit-seeking, I would be concerned. The DON stated an elopement assessment should have been done, under the initial admission assessment on 3/30/22. The DON stated an elopement assessment should be conducted if a resident has triggers, such as alcohol dependence diagnosis (which Resident #1 has). The DON stated Resident #1 did not elope. The DON stated Resident #1 was on a leave of absence, but she did not sign out. The DON stated Resident #1 had said she wanted to go home. The DON stated that was why they did not report her as an elopement. We investigated her as a missing person. The DON stated the day nurse had provided enteral feeding and medications at 11:45 a.m. The DON stated the tube feeding should have been reconnected at 2:00 p.m., per orders. The DON stated she was called on 05/16/22 at 5:52 p.m. by a supervisor (Staff A) for the 3:00 p.m. to 11:00 p.m. shift. The DON said, She [Staff A] asked me, did you know if [Resident #1] was discharged or going anywhere? I said I did not. I started making calls. I told her to look around the facility and conduct a head count. I called the [SSD], and nurse on first shift duty, they all said she was not scheduled to go anywhere. I did not know where she was. The DON stated on 05/16/22 at 6:01 p.m. she notified the NHA, and everyone came in. The DON stated on her way to the facility, she called the hospital and found Resident #1 had been admitted . The DON stated she visited Resident #1 at the hospital and asked her what happened. The DON stated Resident #1 said she wanted to leave. She wanted to go home. The DON stated Resident #1 reported she was walking across the street, and fell on the sidewalk of [name of store] parking lot, about 1/10th of a mile from the facility. We treated it as a crisis, that I do not know where the resident is. The DON stated they investigated and were still within their five-day reporting timeline. We went through our reportable tree on 5/16/22. We revised residents BIMS scores as of 5/16/22. She had a BIMS of 13, and we determined she left without signing out. When asked why Resident #1 had not been seen by facility staff for a period of approximately 6 hours, the DON stated it was part of their investigation but, she confirmed the resident should have been observed. The DON said, She should have been seen by a CNA. She should have let us know. She should have had someone with her if she wanted to leave the facility. She fell and hurt herself and was admitted to the hospital. She was gone for 5 hours and was missing and that was a problem. The facility policy titled, elopement- overview dated October 2021 was reviewed with the NHA and DON. The policy stated an elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and or any necessary supervision to do so. The DON stated the 3008 (hospital transfer form) they received said the resident was her own person. Her BIMS score was high, and she expressed she wanted to leave. The NHA stated they had filed an allegation of neglect after DCF (Department of Children and Families) came in on Friday, 5/20/22. The NHA stated the resident had a fall while out of the facility, and that was why they reported it as neglect. The NHA stated the resident did not receive supervision. The NHA said, she [Resident #1] was not checked on. The NHA stated per their findings, they identified concerns related to the resident not being observed from 12 noon to around 5:00 p.m. The NHA stated they were conducting an investigation and were educating their staff. During a follow -up interview on 05/24/22 at 9:44 a.m., the DON said, I have a problem with the fact that the nurse did not see the resident all day long. We cannot have that. We are conducting an investigation and have started in-services. Our goal is to ensure that our residents are safe, and we maintain their rights. The DON confirmed Resident #1 expressed that she did not want to be at the facility and did not want to be placed in long term care. The DON said, I agree, she did not receive supervision, she was not supervised appropriately. Nobody knew where she was from 11:45 a.m. to 6:00 p.m., that concerns me. On 5/24/22 at 9:54 a.m., a telephone interview was conducted with the facility's Medical Director (MD). The MD was Resident #1's primary care physician during her stay at the facility from 3/30/22 - 5/16/22. The MD stated when she [Resident #1] arrived at the facility at the end of March, she was limited due to a stroke, had a low BIMS score and was not ambulatory. The MD stated Resident #1 had improved very well with therapy. The MD stated Resident #1 started ambulating and her BIMS score had improved. The MD stated Resident #1 liked to sit outside on the front porch. The MD stated he was notified she left the facility without permission around lunch. The MD stated Resident #1 left when CNAs were busy, wandered the facility and fell in the parking lot at [name of store]. The MD stated he was aware the resident was not seen at all during day shift. The MD stated he was made aware it took quite a few hours for them to realize the resident was missing. The MD stated, the expectation is for staff to keep an eye on the residents, whether it's a nurse or CNA, even if they are independent. The MD stated they were looking at corrective action, assessing residents when they are outside on the porch, make sure that it is documented, and someone is documenting their entry and exit. The MD stated we cannot prevent 100% of elopements in the future but education on elopement, reporting and supervising residents, and assessing residents every so often will help. The MD stated someone had to open the door for her. The MD said, someone at the entrance should be better trained. An observation of the facility's main entrance area was conducted on 5/23/22 at 8:55 a.m. The observation revealed two white gates on both sides of the front porch area approximately 3 feet tall, propped open and without a latching mechanism. Photographic evidence was obtained. An observation was made of a resident sitting in the front porch area. Upon entrance to the facility, no staff member was available for screening of visitors or supervision of the resident on the front porch. A receptionist was observed entering the facility at 9:05 a.m. Random observations of the front porch area on 5/23/22 at 11:45 a.m. and 12:11 p.m. revealed residents re-entered the facility by pushing the wheelchair accessibility button which opened the front entry doors. No staff assistance was used to gain entry to the facility. An interview was conducted on 05/23/22 at 9:32 a.m. with the Director of Maintenance (DOM). The DOM stated he was aware a resident had eloped on 05/16/22 because he received a call and did not know how the resident left the facility. The DOM stated the following day (05/17/22) they checked all the doors and checked all ankle monitors to make sure they were working. The DOM said, We did not identify any doors that had problems. All alarms were working. Yes, I know residents sit out at the front patio with and without a staff member. The two gates are not supposed to be locked. They are supposed to be open. The DOM stated he checks the doors twice daily and logs his entries in their system. A tour of the front door area was conducted with the DOM. The DOM stated staff must enter a keypad pin to unlock the door. If a resident who has a wanderguard approaches the door, the alarm will sound. The door was observed with a wanderguard censor unit on the side of the main door. During the tour, a resident was observed sitting in her wheelchair in the front patio/porch area. The resident stated she likes to sit there and get fresh air. There was no staff observed in the area. The DOM stated some residents can be in the patio without supervision. The DOM stated if the residents want to come back inside from the patio, they push the wheelchair accessibility button and let themselves back in. The DOM did not know if that would stop other residents from exiting out the front door without staff knowledge. The DOM stated visitors must be let in and out by a staff member. The surveyor proceeded to hit the wheelchair accessibility button located in the exterior front patio area, which immediately opened the front entrance doors without staff inside having to enter a code to allow entry. The DOM did not comment on this security flaw. The DOM stated he had not participated in any elopement drills at this facility and had recently begun working at the facility. The DOM stated he had not received in-services since the elopement. The DOM said, I do not know how they conduct the elopement drills. A review of Resident #1's admission record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses to include cerebral infarction unspecified, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting Right dominant side, repeated falls, muscle wasting and atrophy, need for assistance with personal care, [CONDITION(S)] of skin, and anxiety disorder. A review of Resident #1's Hospital Discharge Summary dated 3/30/22 (just prior to her admission to the facility) indicated patient has a past medical history of right thyroidectomy for benign thyroids with [CONDITION(S)], moderately differentiated [CONDITION(S)] of the right anterior two thirds of the tongue extending to posterior of the tongue and across midline status post right tongue biopsy status post chemoradiation, chronic alcohol abuse, and [CONDITION(S)] who presented to [name of hospital] after a fall, right side weakness, and right facial drop. She was at home per EMS and had a fall and hit her head, the family called EMS as the patient is weak and having trouble ambulating, unknown what the actual time of onset is. The patient is a very difficult historian. Denied any pain, shortness of breath, nausea vomiting, black or bloody stools. Capacity attestation was placed in the chart and proxy assigned. CT scan head reported as no acute intracranial abnormalities, atrophy greater than expected for patient's age. Patient was admitted for stroke workup and neurology consultation obtained. MRI brain revealed small area of acute [CONDITION(S)] in the left basal ganglia region consistent with subacute or acute lacunar infarction. Discharge Diagnoses showed, Acute epiglottitis without obstruction ., [CONDITION(S)] ., Fall at home ., Generalized weakness, right sided weakness, History of alcohol . Procedures performed during the hospital stay: insert peg tube on 3/22/22. A review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, reflecting severe cognitive impairment. The resident exhibited no wandering behaviors or risks and required extensive assistance by one person for activities of daily living (ADL's). The resident's balance during transitions and walking was not steady and she could only stabilize with staff assistance. The resident had not walked during the assessment observation period from 3/30/22 to 4/5/22. No additional MDS assessments had been initiated or completed during Resident #1's stay at the facility. A review of the Physician Order Summary dated 3/30/22 to 5/17/22 revealed the resident could go on LOA with escort for physical assistance. A review of the Physical Therapy (PT) discharge summary dated 5/8/22 revealed Resident #1 received PT from 3/31/22 to 4/29/22. The note stated patient made progress in ambulation from 50 feet with minimum assistance on start of care (SOC) to 200 feet with contact guard assist (CGA)/stand by assist (SBA) with rolling walker and more steady gait noted due to increase in bilateral lower extremity (BLE) strength to 3+/5 (Ability to complete test movement and/or hold test position against gravity and minimal (slight) pressure) from 3/5 (Ability to complete test movement and [TRUNCATED]

Based on observations, review of medical records, facility policies and job descriptions, and interviews with facility staff, the Medical Director (MD), a family member, a hospital nurse, and residents, the facility failed to ensure staff competently assessed, identified changes in condition that required new interventions, carried out procedures to locate residents whereabouts on a regular basis and administer prescribed treatments when due for one (Resident #1) of six residents sampled for high risk elopement. When Resident #1's condition changed, the facility staff failed to appropriately assess and modify interventions to ensure the resident's safety. Facility staff failed to locate the resident on a regular basis, during shift change and when scheduled medications and enteral feedings were due for administration. Resident #1 was able to exit the facility unnoticed, fell in a neighboring business parking lot, was found by a bystander, and sent to a local hospital via emergency medical services (EMS). The resident was out of the facility for over five hours before facility staff recognized the resident was missing. The likelihood of serious physical harm or death to Resident #1 as a result of the facility's failure to assure staff competence to prevent elopement resulted in findings of Immediate Jeopardy on 05/16/22. The Immediate Jeopardy was removed on 05/26/22 with the scope and severity reduced to a D after verification of implementation of immediacy removal actions. Findings included: Cross Reference F600 and F689 An interview was conducted on 05/23/22 at 3:16 p.m. with Staff B, CNA. Staff B stated she was working day shift on 5/16/22, the 7 a.m. to 3:30 p.m. shift and was assigned to care for Resident #1. Staff B stated Resident #1 had become more independent with ADLs and had dressed herself that day. Staff B said, I saw her brush her teeth. I can't remember if her feeding tube was running or not at the time. It was after breakfast between 8 a.m. and 8:30 a.m. I was taking care of her roommates. Staff B stated Resident #1 left her room around 9 a.m. - 9:30 a.m., and she thought the resident was going to the dining room. Staff B stated she did not really know too much about Resident #1 and did not see her again after this. When asked if she had looked for Resident #1, Staff B said, Really, I did not. I probably should have. I felt she was independent. I didn't think she would leave. I just thought she was in the dining room. I did not provide her any care. Staff B stated she never saw Resident #1 with a nurse throughout the shift. Staff B stated she had noticed Resident #1's feeding tube pump was turned off when she went back to the room around 10 a.m. Staff B stated she changed Resident #1's bed linens and did not notice her belongings were not in the room. Staff B stated she did not check the resident's closet. Staff B stated she was in and out of the room throughout her shift attending to the other residents and ended her shift at 3:30 p.m. Staff B stated she did not see Resident #1 during those visits. Staff B stated she did not give report to the on-coming Aide. Staff B reported sometimes they give shift report and sometimes they did not. Staff B stated she was not notified Resident #1 had left the facility until the next day. Staff B stated no one called her that evening to inquire about Resident #1. Staff B stated she spoke to the DON and the Nursing Home Administrator (NHA) the following morning. Staff B confirmed that she never checked on Resident #1 throughout her shift and never reported her as missing. On 05/24/22 at 9:15 a.m., Staff C, RN Unit Manager confirmed he was assigned to care for Resident #1 on 5/16/22. Staff C stated he worked day shift, 7:00 a.m. to 3:00 p.m. but stayed over until around 4:00 p.m. Staff C stated Resident #1 was dependent on her feeding tube for all nutritional support. Staff C stated he last saw Resident #1 in her room between 11:30 a.m. and 12:00 p.m. on 05/16/22. Staff C stated he gave her medications, through the feeding tube, and the tube feeding was to be off at 10 a.m. and restarted at 2:00 p.m. Staff C stated Resident #1 had flushes scheduled every 4 hours. Staff C stated Resident #1 disconnected the tube feeding sometime in the morning. Staff C stated he could not remember if the resident had finished her tube feeding or not. Staff C stated at 2:00 p.m. when her scheduled flush was due, he did not go looking for her. Staff C stated he did not see Resident #1 after 11:45 a.m. Staff C said, I never saw her again. I left the facility at 4:00 p.m. I did not look for her. I had a lot of patients. I did not reconnect her tube feeding at 2:00 p.m. Staff C stated the CNAs did not tell him the resident was missing. Staff C stated the expectation was for CNAs and nurses to supervise the residents. Staff C said, We are all responsible for monitoring the residents. We all do rounds every 2-3 hours. It is not acceptable not to monitor residents. Staff C stated that day he had a lot of things going on. Staff C stated the second shift nurse called him around 6:00 p.m. asking where Resident #1 was. Staff C said, I told her I saw her in the morning, in the middle of the day around 11:45 a.m. That was the last time I saw her. Staff C stated he was notified Resident #1 walked away from the facility, fell , and was in the hospital. Staff C stated Resident #1 always sat on the front porch without supervision. Staff C stated residents who were alert with a high BIMS score can sit outside. Staff C said, Yes, we should monitor and supervise when they are outside. I was on the [medication] cart. I did not supervise the residents. I was busy. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, Sodium Chloride tablet 1 gm (gram) give 1 tablet via peg tube three times a day for [CONDITION(S)], scheduled at 1 pm was documented as administered on 5/16/22. An enteral feed order to start [MEDICATION(S)] 1.5 via peg tube at 2 p.m. was documented as completed for day shift, 7a.m. - 3p.m. hours on 5/16/22. The order to flush feeding tube with 5 ml of water between medications for patency and hydration, due at 12 p.m. was documented as completed on 5/16/22. An interview was conducted with Staff D, CNA on 05/23/22 at 3:50 p.m. Staff D stated she was assigned to care for Resident #1 on the second shift, 3 p.m. - 11:30 p.m. Staff D stated she arrived at the facility at 2:16 p.m. Staff D stated the first thing she did was update the staffing boards. Staff D stated her room assignment included Resident #1's room. Staff D stated she had worked with Resident #1 before. Staff D said, She [Resident #1] likes to wander throughout the facility. She likes to sit outside in the front porch. Staff D stated she did not notice anything unusual at first. Staff D stated her routine is to glance at the rooms and count heads. Staff D stated Resident #1 is normally in her room or at the front desk making calls. Staff D said, I did not see her at 2:30 p.m. I saw [Staff C RN]. I asked him where [Resident #1] was. He said to me, I don't know. She is somewhere here. Staff D stated she looked for Resident #1 in the dining room, looked outside and did not see her. Staff D stated when she walked in from outside, she saw there were call lights that needed her attention. Staff D stated she went to attend to the call lights first. Staff D stated by this time Staff G, LPN had relieved the first shift nurse. Staff D said, I asked her if she had seen the resident. She said she did not know where she is. I went back to work. Staff D stated around 5 p.m. the dinner trays come out. Staff D said, I took a tray to [Resident #1's] roommate. Staff D stated Resident #1 was not in her room. Staff D said, I did not find her, so I went to [Staff A], the supervisor and reported [Resident #1] was missing. Staff D stated she looked in the LOA book to see if she had signed out. Staff D said, no she did not sign out. She wasn't supposed to go alone. Staff D again stated Resident #1 is usually seen by the desk area all the time. Staff D stated it was unusual that she was not there. Staff D stated she heard Resident #1 say she wanted to get out before, meaning she wanted to leave the facility. Staff D stated when she notified Staff A, the search was initiated. Staff D said, I was searching everywhere. If I had not said anything, no one would have noticed. No one knew she was missing on 7 a.m. - 3 p.m. shift. Staff D stated later she heard Resident #1 had fallen on a sidewalk and was in the hospital. Staff D became emotional, wiping tears from her face. Staff D said, I care for my residents. That resident's mental status was not all the way there, but she never said she wanted to leave except once. I thought cognitively she wasn't okay because of her conversations with her roommates. She was confused. Staff D stated Resident #1 was a fall risk even though she had gotten better with time. Staff D stated she did not feel like they had enough staff to care for at risk residents. Staff D stated at risk meant residents who are verbalizing wanting to leave or have a lot of care needs. Staff D stated she thought the CNAs were not receiving adequate training. Staff D said she had heard the resident left the facility with a bag full of her clothes. Staff D said, I would have followed her if I saw her leave. Staff D stated Resident #1 had verbalized wanting to leave about a week before she eloped. Staff D stated she did not think Resident #1 would leave and that was why I did not report it right away. On 5/23/22 at 12:59 p.m., Staff M, CNA revealed she worked a double shift from 7:00 a.m. - 11:00 p.m. on 5/16/22. On the 3:00 p.m. - 11:00 p.m. shift she was scheduled to work on the hallway where Resident #1 resided but was not assigned to her room. Staff M stated there were two of us on that hallway. Around 4:30 p.m. - 5:00 p.m., the nurse asked me if I saw Resident #1. I told her no because I worked on the other side of the building on the morning shift. I stopped passing water and we (Staff D and Staff M) went to check all over for the resident. Staff D was assigned Resident #1 and said she had not seen the resident the whole shift. We checked the room, we checked the other halls, we checked outside, and then we did a head count of the residents. Resident #1 was still missing. After we did all the checks, there was an overhead code called and then the administrator, DON, Supervisors, and the day shift nurse were called. No one had seen the resident. I went to care for my residents and the administrator and DON took over from there. We have to go and check on the residents if they go outside. It is my responsibility to check on them and know where they are. I go to the nurse if I do not see the resident. On 5/23/22 at 4:12 p.m., Staff G, Licensed Practical Nurse (LPN) revealed she had worked on 5/16/22 during the 3:00 p.m. to 11:00 p.m. on the hall where Resident #1 resided. Staff G stated she arrived to work around 4:00 p.m. and took over from the day shift nurse (Staff C, RN Unit Manager). Staff G stated Staff C did not report any abnormalities or anything unusual on the day shift. Staff G stated Staff D, CNA reported that Resident #1 was not in her room. Staff G stated she asked Staff D to check in therapy, outside, and in the dining room. Staff G stated Staff D, CNA did not initiate the search. Staff D went to assist other residents that needed care. Staff G said, It did not alarm me at that time. Later, we realized we can't find her around 5:00 p.m. We started to look for her. We looked around the building. She was not inside the building, not in therapy. We alerted the supervisor. Staff G stated somebody must have opened the door for the resident to get out. Staff G stated residents who are alert can sit outside on the front porch. Staff G said, you still check on them at least every 30 minutes. An interview was conducted with Staff A, Registered Nurse (RN) Supervisor on 5/23/22 at 3:27 p.m. Staff A, stated she was working on 5/16/22 on the 3 p.m. - 11 p.m. shift and was covering East and West units. Staff A confirmed that Resident #1 had been verbalizing wanting to leave the facility and did not let her sit outside at the front porch. Staff A said, I did not let her out because since she has been here, she has been wanting to leave. She told everyone that, even the administration knew she wanted to leave. It is very upsetting because she had been verbalizing wanting to leave. Staff A confirmed Resident #1 was not supposed to be let outside unsupervised. Staff A stated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff A stated on 05/16/22 before dinner, around 5 p.m., Staff D, Certified Nursing Assistant (CNA) reported Resident #1 was missing. Staff A stated they did a head count, twice and could not locate the resident. Staff D, CNA and Staff M, CNA, went around the perimeter of the building, looked in all rooms, and could not find Resident #1. Staff A stated she called Resident #1's sister to see if she had taken her out without signing her out, but the sister said no. Staff A stated she called the Director of Nursing (DON) who instructed her to call the hospital. Staff A expressed frustration with the previous shift for not knowing the resident was missing. Staff A stated it is a nursing expectation to assess residents every 2 hours. A follow-up interview with Staff A on 05/25/22 at 3:54 p.m. revealed administration told her they could not put a wander bracelet (an electronic monitoring device) on Resident #1 because the resident had a high BIMS score. Staff A said, To me, if anyone is saying they wanted to leave they should be considered at risk and placed on a wander guard [an electronic monitoring device]. During a follow -up interview on 05/24/22 at 9:44 a.m., the DON said, I have a problem with the fact that the nurse did not see the resident all day long. We cannot have that. We are conducting an investigation and have started in-services. Our goal is to ensure that our residents are safe, and we maintain their rights. The DON confirmed Resident #1 expressed that she did not want to be at the facility and did not want to be placed in long term care. The DON said, I agree, she did not receive supervision, she was not supervised appropriately. Nobody knew where she was from 11:45 a.m. to 6:00 p.m., that concerns me. On 5/24/22 at 9:54 a.m., a telephone interview was conducted with the facility's Medical Director (MD). The MD was Resident #1's primary care physician during her stay at the facility from 3/30/22 - 5/16/22. The MD stated when she [Resident #1] arrived at the facility at the end of March, she was limited due to a stroke, had a low BIMS score and was not ambulatory. The MD stated Resident #1 had improved very well with therapy. The MD stated Resident #1 started ambulating and her BIMS score had improved. The MD stated Resident #1 liked to sit outside on the front porch. The MD stated he was notified she left the facility without permission around lunch. The MD stated Resident #1 left when CNAs were busy, wandered the facility and fell in the parking lot at [name of store]. The MD stated he was aware the resident was not seen at all during day shift. The MD stated he was made aware it took quite a few hours for them to realize the resident was missing. The MD stated, the expectation is for staff to keep an eye on the residents, whether it's a nurse or CNA, even if they are independent. The MD stated they were looking at corrective action, assessing residents when they are outside on the porch, make sure that it is documented, and someone is documenting their entry and exit. The MD stated we cannot prevent 100% of elopements in the future but education on elopement, reporting and supervising residents, and assessing residents every so often will help. The MD stated someone had to open the door for her. The MD said, someone at the entrance should be better trained. Review of a facility policy titled, Inservice Education, dated December 2014, revealed: Policy: Regular in-service education is provided annually and as needed to ensure the continuing competence of the employee in their job performance. Inservice training assists in maintaining continuing competence of the employee by providing: · Employee education on areas that need improvement or if a deficient practice is identified on the employee's performance evaluation. · Education on new or revised policies and or procedures. · Regularly scheduled in services to maintain CNA's competence in practice and meeting the state / federal mandatory 12-hour continuing education requirements. · Education in areas that need improvement indicated by the performance improvement committee. · Employee education on compliance topics that may be general, specific, or as needed. · One-to -one employee education when deficient practice is observed. Procedure: 1. Complete performance reviews every 12 months. Identify in-service education areas that need improvement. 2. Provide a minimum of 12 hours in service education annually for nursing assistants to maintain competency and certification. 3. Conduct in-service education on areas that need attention or actions taken to correct system failures identified by the performance improvement committee. 4. Provide annual training on topics to maintain knowledge and standards of practice. These in-services may include but are not limited to: .e. Emergency procedures .4) Elopement drills / missing resident 5. Provide in-service education one-to-one if deficient practice is observed. On 5/23/22 at 11:40 a.m., Staff R, RN/MDS Coordinator stated she was made aware of the elopement today during a morning meeting. Staff R stated she was told a resident left the facility, but she wouldn't call it an elopement. Staff R stated Resident #1 went on LOA. Staff R stated LOA means when they leave the facility either with a family member, or if they are authorized to sign out independently. Staff R stated if the resident was authorized, there would be an order that says they can leave supervised or unsupervised. Staff R stated the medical team determines the supervision level and a doctor would sign the order. Staff R stated she did not know if an elopement assessment had been conducted on Resident #1. Staff R stated she did the initial MDS on 4/5/22. Staff R stated she assessed Resident #1 with a series of questions and had scored a BIMS of 5 which meant her cognition was impaired. Staff R stated at the time of the admission MDS she required extensive assistance and was not ambulatory. Staff R stated she had made significant gains recently. Staff R stated at the time of admission, Resident #1 stayed in bed, was dependent on staff, and was not at risk of elopement. Staff R stated if a resident's status changes, they would re-evaluate. Staff R said, Because she is moving around more, she should be re assessed, yes to include risk of elopement. Staff R stated there should have been a Change in Condition and review of her full assessment. I was not here, so I can't say why it was not done. It should have been done . I apologize, it was not done. It should have been done. On 5/25/22 at 3:45 p.m., the Physical Therapist (PT) was interviewed about Resident #1. The PT was familiar with Resident #1 and stated that when she was initially admitted she had a hard time walking and could only walk about 40 feet. She was very unsteady, due to repeated falls, but she improved and walked up to 200 ft with a walker. She could also walk without a walker while in the facility. Resident #1 was discharged from PT on 4/29/22 as she met her goals. The resident always said she wanted to leave. This was very common. The PT recalled Resident #1 being strong-willed but physically, she needed assistance of a walker when on uneven terrain. The PT stated Resident #1 had some short term memory problems and needed frequent reminders to use her walker. On 5/23/22 at 11:54 a.m., the Social Services Director (SSD) stated she was notified of the elopement on the day the event occurred (05/16/22). The SSD said, The DON called me, she said that we had one person that had eloped and asked me if I knew if this resident had gone out with the family. I told her no, I did not know. No one had notified me she was to be going anywhere. The SSD stated on her way to the facility on [DATE], she was notified Resident #1 was at the hospital. The SSD stated prior to the elopement she had met the resident and did an assessment. The SSD stated Resident #1 scored a BIMS of 13, indicating intact cognition. The SSD stated this assessment was three days before the elopement occurred. When asked what triggered the BIMS assessment, The SSD stated Resident #1 was walking around and wanted to sit outside. The SSD stated there is a limit on who can sit in the front. They have to be at a BIMS of 13 and above and alert and oriented. The SSD confirmed she conducted the BIMS assessment so that Resident #1 could sit outside independently. The SSD stated she did not conduct an elopement assessment. The SSD stated the DON should have conducted the elopement assessment. The SSD was not sure if one was done. The SSD said, The resident wanted to go outside to sit. She kept asking. She did not want to leave. She was not at risk of wandering. She just wanted to sit outside in the front. The SSD stated she had notified the team of the BIMS score change. The SSD said, With the new BIMS she could sit in the front, but still needed staff to keep an eye on her. An observation of the facility's main entrance area was conducted on 5/23/22 at 8:55 a.m. The observation revealed two white gates on both sides of the front porch area approximately 3 feet tall. Both gates were propped open and without a latching mechanism. Photographic evidence was obtained. An observation was made of a resident sitting in the front porch area. Upon entrance to the facility, no staff member was available for screening of visitors or supervision of the resident on the front porch. A receptionist was observed entering the facility at 9:05 a.m. An interview was conducted on 05/23/22 at 9:32 a.m. with the Director of Maintenance (DOM). The DOM stated he had not participated in any elopement drills at this facility and had recently begun working at the facility (date of hire 4/26/22). The DOM said, I do not know how they conduct the elopement drills. The DOM stated he was aware a resident had eloped on 05/16/22 because he received a call and did not know how the resident left the facility. The DOM stated the following day (05/17/22) they checked all the doors and checked all ankle monitors to make sure they were working. The DOM said no problems were found with the doors. All alarms were working. The DOM was aware residents sit in the front patio area with and without staff supervision and the two gates in the patio area were supposed to remain open. The DOM stated he checks the doors twice daily and logs his entries in their system. A tour of the front door area was conducted with the DOM. The DOM stated staff must enter a keypad pin to unlock the door. If a resident who has a wander guard approaches the door, the alarm will sound. During the tour, a resident was observed sitting in her wheelchair in the front patio/porch area with no staff supervision. The DOM stated if the residents want to come back inside from the patio, they push the wheelchair accessibility button and let themselves back in. The DOM did not know if that would stop other residents from exiting out the front door without staff knowledge. The DOM stated visitors must be let in and out by a staff member. The surveyor proceeded to hit the wheelchair accessibility button located in the exterior front patio area. This immediately opened the front entrance doors without staff inside having to enter a code to allow entry. The DOM did not comment on this security flaw, which could allow a resident to exit the building without staff knowledge. Random observations of the front porch area on 5/23/22 at 11:45 a.m. and 12:11 p.m. revealed residents re-entered the facility by pushing the wheelchair accessibility button which opened the front entry doors. No staff assistance was used to gain entry to the facility. On 5/23/22 at 12:11 p.m., Resident #7 was observed in the front porch area without staff supervision. He stated he was new to the facility. He stated he just started to come out to the patio a couple of days ago. He stated the staff let him out and nobody sits with him while he is on the porch. When asked how he re-enters the facility, he stated, Push the blue box pointing to a wheel chair accessibility button by the door. When this button was pressed, it opened the doors without staff inside typing in a code to allow entry. A review of Resident #1's Admission Record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's Hospital Discharge Summary dated 3/30/22 (just prior to her admission to the facility) indicated patient has a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She was at home per EMS and had a fall and hit her head, the family called EMS as the patient is weak and having trouble ambulating, unknown what the actual time of onset is. The patient is a very difficult historian. Denied any pain, shortness of breath, nausea vomiting, black or bloody stools. Capacity attestation was placed in the chart and proxy assigned. CT scan head reported as no acute intracranial abnormalities, atrophy greater than expected for patient's age. Patient was admitted for stroke workup and neurology consultation obtained. MRI brain revealed small area of acute [CONDITION(S)] in the left basal ganglia region consistent with subacute or acute lacunar infarction. Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] ., Fall at home ., Generalized weakness, right sided weakness, History of alcohol . Procedures performed during the hospital stay: insert peg tube on 3/22/22. A review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, reflecting severe cognitive impairment. The resident exhibited no wandering behaviors or risks and required extensive assistance by one person for activities of daily living (ADL's). The resident's balance during transitions and walking was not steady and she could only stabilize with staff assistance. The resident had not walked during the assessment observation period from 3/30/22 to 4/5/22. No additional MDS assessments had been initiated or completed during Resident #1's stay at the facility. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Diet NPO (nothing by mouth). -Enteral (intestinal) feed orders every 4 hours flush enteral tube with 150 ml (milliliters) H20 (water) -Enteral feed orders every shift [MEDICATION(S)] 1.5 via peg-tube at a rate of 60 ml/hr. (hour) for a total volume of 1200 ml to be infused in 24 hours. May turn off for care/services. Start at 2 p.m. Verify infusion every shift. Clear the pump only when the total volume has been infused. -Cleanse G-tube site with soap and water daily as well as PRN (as needed) every night shift. -Flush feeding tube with 5 ml of water between meds every shift for patency and hydration. -Flush tube with 30 ml water before or after medication administration and feeding every shift for patency and hydration. -May go on LOA (leave of absence) with escort for physical assistance. On 05/24/22 at 10:50 a.m. an interview was conducted with Resident #1's assigned RN at the hospital. The Hospital RN stated Resident #1 was her patient on this day (5/24/22). She stated the resident was alert and was able to understand simple communication. She stated the resident was currently under direct observation meaning she has a staff member in the room with her because the resident attempted to elope from the hospital on Sunday, 5/22/22. She had told the nurse she was going to the taco truck. The Hospital RN stated the resident was being treated with IV fluids and total nutrition and hydration was being provided by tube feeding. She stated the resident would remain in the hospital until a locked facility could be secured for her transfer. On 05/24/22 at 11:15 a.m., an interview was conducted with Resident #1 in the hospital. The door to Resident #1's hospital room had a sign stating NPO (nothing by mouth). Resident #1 was asked about her elopement from the skilled nursing facility on 05/16/22. She stated, I wanted to go home, and I told them I wanted to go home several times. The resident stated she did not tell anyone that she was going to leave because she was afraid they would try to stop me and call my sister who would then not let me go. The resident pointed to a bag on the floor and stated she packed up her stuff and walked out. The resident indicated she was not using a walker or any assistive device when she left the facility. She was not able to state who opened the door for her to leave the facility. The resident stated she started to walk down the street because I was going to hitchhike home to Sarasota She stated she fell , someone she did not know called for help, and the ambulance took her to the hospital. Her voice raised as she explained, there is nothing wrong with me, my brain and my health are just fine. I want to get out of here and away from my sister. She stated she was not receiving a tube feeding with nutrition and hydration, I eat regular food. A review of a nursing progress note dated 5/16/22 at 21:48 (9:48 p.m.) showed The hospital notified this writer that the resident who is alert and oriented x4 with a BIMS of 13 experienced a fall while LOA [on leave of absence] and was transported to [name] hospital for evaluation. The resident is her own responsible party and stated that she was going to her home when she fell and bumped her head. Facility MD notified of admission to the hospital while LOA. On 5/23/22 at 1:41 p.m., an interview was conducted with the DON and the Nursing Home Administrator (NHA). The DON stated Resident #1 came to the facility after a hospital stay and on admission showed slight confusion. She progressed well. Her deficits were not limiting, and the resident was known to sit on the front porch at different times. After her improvement, she would move about the whole facility. The DON stated if a resident has a BIMS score below 10, they would not be capable of being outside. The DON stated if they were exit-seeking, I would be concerned. The DON stated an elopement assessment should have been done, under the initial admission assessment on 3/30/22. The DON stated an elopement assessment should be conducted if a resident has triggers, such as alcohol dependence diagnosis. The DON stated Resident #1 did not elope. The DON stated Resident #1 was on a leave of absence, but she did not sign out. The DON stated Resident #1 had said she wanted to go home. The DON stated that was why they did not report her as an elopement. We investigated her as a missing person. The DON stated the day nurse had provided enteral feeding and medications were administered at 11:45 a.m. The DON stated the tube feeding should have been reconnected at 2:00 p.m., per orders. The DON stated she was called on 05/16/22 at 5:52 p.m. by a supervisor (Staff A) for the 3:00 p.m. to 11:00 p.m. shift. The D [TRUNCATED]