Every finding on record at Harmony Health and Rehabilitation

Based on staff interviews, resident interviews, and record review, the facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency (SSA) within the required time frame for two of six sampled residents. The facility's failure to report the allegation timely had the potential to delay the identification and the prevention of abuse involving other residents.Findings include:1. Review of the admission Record for R4 documented diagnoses including schizoaffective bipolar disorder type, cognitive communication deficit, and behaviors involving wandering.Review of the Minimum Data Set (MDS) for R4 dated 06/25/2026, revealed that section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive deficit. Section GG (Functional Abilities and Goals) documented that R4 showed no impairment of extremities but partial to substantial assistance in activities of daily living (ADLs).Review of the care plan for R4, updated 06/30/2026, revealed a focus that R4 had a behavior problem of removing clothing and self ambulates into hall/common area naked or partially clothed and was difficult to redirect at times.Review of the Facility Reported Incident (FRI) indicates the incident occurred on 07/04/2026 but not reported until 07/06/2026. R4 and R5 were separated and R5 was redirected back to her room. It was found that R5 wandered into R4's room and R4 was positioned on top of R5. The Medical Doctor and families were notified on 07/04/2026 but police were not notified until 07/06/2026.2. Review of the admission Record for R5 revealed diagnoses including, but not limited to, Alzheimer's disease and cognitive communication deficit.Review of the MDS assessment for R5, dated 05/07/2026, documented, section C (Cognitive Patterns) a BIMS score of 3, indicating severe cognitive impairment. Section E (Behaviors) indicates wandering. Section GG (Functional Abilities indicates partial, severe, and dependent care needed for ADL's.Review of the care plan for R5, created on 05/13/2026 revealed focus areas for R5 including, but not limited to impaired cognitive function/dementia and lack of cognitive communication skills. Resident will wander at times.Interview with Registered Nurse (RN) AA on 07/21/2026 at 3:00 PM revealed she had received training on abuse prevention and reporting requirements. RN AA stated she understood the facility was required to report allegations of abuse or neglect within 2 hours when the alleged violation involved abuse.An interview on 07/21/2026 at 2:15 PM with the Director of Nursing (DON) confirmed the facility did not report the allegation to the State Survey Agency within the required 2-hour time frame. The DON further acknowledged she failed to report the incident timely and received disciplinary action for failing to report the allegation within the required time frame.An interview on 07/21/2026 at 4:05 PM with the Nurse Consultant revealed she was notified on 07/06/2026 about the incident between R4 and R5, by the Director of Nursing and the Administrator. The DON and Administrator advised her that the incident had taken place on 07/04/2026. Both employees were made aware that the incident should have been reported within a 2-hour window of the incident occurring on 07/04/2026. The Administrator and DON were educated on timely reporting of possible abuse.

Based on staff interviews, resident interviews, and record review, the facility failed to ensure residents were protected from resident to resident abuse for two of six sampled residents (R4 and R5). Specifically, resident R5 entered R4's bed, and R4 exposed his male genitalia to R5. This deficient practice placed R4 and R5 at risk for unwanted sexual contact and compromised the resident's right to be free from resident to resident abuse.Findings include:1. Review of admission Record for R4 documented diagnoses including schizoaffective disorder bipolar type, cognitive communication deficit, and behaviors involving wandering.Review of the Minimum Data Set (MDS) for R4 dated 06/25/2026, revealed that section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive deficit. Section GG (Functional Abilities and Goals) documented that R4 showed no impairment of extremities but partial to substantial assistance in activities of daily living (ADLs).Review of the care plan for R4, updated 06/30/2026, revealed R4 had behavior problem of removing clothing and wheels self into hall/common area naked or partially clothed and was difficult to redirect at times.2. Review of the admission Record for R5 revealed diagnoses including, but not limited to, Alzheimer's disease and cognitive communication deficit.Review of the MDS assessment for R5, dated 5/7/2026, revealed section C (Cognitive Patterns) documented a BIMS score of 3, indicating severe cognitive impairment. Section E (Behaviors) indicates wandering. Section GG (Functional Abilities) indicates partial, severe, and dependent care needed for ADL's.Review of R5's care plan, initiated on 05/13/2026, revealed focus areas that included, but were not limited to, impaired cognitive function related to dementia, impaired cognitive communication skills, and wandering behaviors. The care plan documented that the resident wandered at times.Review of the Facility Reported Incident (FRI) indicated the incident occurred on 07/04/2026 but was not reported until 07/06/2026. R4 and R5 were separated and R5 was redirected back to her room. It was found that R5 wandered into R4's room and R4 was positioned on top of R5. The Medical Doctor and families were notified on 07/04/2026 but police were not notified until 07/06/2026.Review of the facility's five-day investigation revealed that R4 was found lying on top of R5 while both residents were fully clothed. The investigation further documented that R4's penis was exposed outside the of his jeans at the time of the incident.An interview on 07/21/2026 at 2:15 PM with the Director of Nursing (DON) revealed she would not consider the incident that occurred between R4 and R5 as abuse.An interview on 07/21/2026 at 4:05 PM with the Nurse Consultant confirmed she was notified about the incident that happened between R4 and R5, by the DON and the Administrator. The Nurse Consultant revealed the facility did a thorough investigation and determined abuse did not occur due to both residents not having any recollection of the incident and both residents having a BIMS of 3 (severe cognitive impairment).

Based on record review, observations, staff interviews, and review of the facility's policy titled Hemodialysis, the facility failed to ensure safe and coordinated dialysis care for one of one sampled resident(R)(R87). Specifically, the facility did not complete required pre and post dialysis assessments, did not maintain effective communication with the contracted dialysis provider, and did not have a formal written contract or agreement with the dialysis agency responsible for providing services to the resident. These failures placed the R87 at risk for compromised health, safety, and continuity of care.Findings include:Review of the admission Record, located in the electronic medical record (EMR) under the Profile tab revealed that R87 was originally admitted to the facility on [DATE] with diagnoses of end stage renal disease and dependence on renal dialysis.Review of R87's Care Plan located in the EMR under the Care Plan tab revealed a Focus area revised 07/03/2025, [R87] needs dialysis type hemo r/t [related to] ESRD [end stage renal disease]. Residents had dialysis Tuesday, Thursday and Saturday. [name of dialysis center with address and phone number]. Interventions included, Do not draw blood or take B/P [blood pressure] in arm with graft, encourage resident to go for the scheduled dialysis appointments, monitor labs and report to doctor as needed, and monitor vital signs as indicated. Notify MD [doctor] of significant abnormalities.Review of R87's Orders tab in the EMR revealed the only orders related to dialysis were: staff to utilized Enhanced Barrier Precautions while providing direct patient care related to wounds and AV [arteriovenous] fistula [used for dialysis access] dated 10/08/2025 and Hemodialysis on Tuesday, Thursday, and Saturday at [name of dialysis center], dated 07/18/25. There were no orders regarding the assessment of the dialysis site or of the resident pre- or post-dialysis.Review of R87's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/2026 located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. R87 received dialysis.Review of R87's Dialysis Communication Forms located in a binder kept in a pocket on the back of R87's wheelchair from 01/01/2026 to 03/03/2026 revealed communication on 14 dates out of 16 dialysis treatments. The forms included three sections: Pre-Dialysis Information, Dialysis Center Information, and Post-Dialysis Information. The pre-dialysis portion included vital signs, medications administered prior to dialysis, shunt/catheter location/status, and additional information such as changes in condition, physician orders changes, and new labs. It was not filled out, or was partially filled out, on 12 of the 14 forms. The dialysis center information included pre- and post-weights, fluid removed, meal/snack intake, shunt/catheter location/status, additional information, vital signs, and new orders/recommendations. It was missing weights, fluid removed, and/or vital signs on nine dates. The post-dialysis information included assessment of the shunt/catheter as well as vital signs. When fully completed, on seven occasions, it was signed by the dialysis center.Interview on 03/04/2026 at 11:21 AM with Licensed Practical Nurse (LPN) 3 reported that the facility nurse filled out the top, pre-dialysis, section of the communication form. Sometimes R87 left for dialysis before nursing filled it out. When R87 returned from dialysis, nursing made a copy of the communication form to be scanned into the EMR and placed the original back in the binder which is kept on the back of R87's wheelchair. The dialysis center completed the post-dialysis assessment.Interview on 03/04/26 at 11:57 AM with Unit Manager (UM) 1 stated she tried to check the communication forms once or twice a week and tried to call to get post-weights. Often, she left messages which were not returned. UM1 verified the missing documentation on the communication forms from 01/01/26 to 03/03/26.Interview on 03/04/2026 at 2:46 PM with the Director of Nursing (DON) reported the expectation is that the facility's nurses fill out the pre-dialysis portion of the communication form and that the dialysis center fill out the dialysis portion. The DON stated she would need to check who was to fill out the post-assessment portion. The DON expected that there were orders to assess the dialysis site.Interview on 03/04/2026 at 2:47 PM with the Administrator stated that R87's dialysis center refused to provide a contract or a formal agreement with the facility. The dialysis center informed the Administrator that they do not offer agreements to any nursing facilities.Review of the facility's policy titled, Hemodialysis dated 09/01/2024 revealed, 3.The facility will coordinate and collaborate with the dialysis facility to assure that: . d. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff . 5. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Timely medication administration . d. Physician/treatment orders, laboratory values, and vital signs; . d. Nutritional/fluid management including documentation of weights, . dialysis treatment provided and resident's response, .f. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site; . 8. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications.

Based on record review, and staff interviews, the facility failed to complete a baseline care plan for two of 27 sampled residents (R) (R85 and R29). This failure had the potential to result in the residents' medical, nursing, mental, and psychosocial needs not being met, increasing the risk for adverse outcomes.1.Review of R85's Electronic Medical Record (EMR) located under the Minimum Data Set (MDS) tab revealed a revealed an admission date of 10/31/2025. Review of the EMR located under the Evaluation tab revealed no documentation that R85's base line care plan had been completed. Interview on 03/03/2026 at 4:05 PM the MDS Coordinator (MDSC) stated that it is the nurse's responsibility to complete the base line care plan at the time of admission. The MDSC also stated that it does not look like the baseline care plan for R85 was completed. Interview on 03/03/2026 at 4:15 PM with the Administrator stated that R85's base line care plan was not done. The Administrator confirmed that the baseline care plan would be located in the EMR under the Evaluation tab. The Administrator also stated that the care plan lets staff know how to care for a particular resident. The Administrator confirmed the facility did not have a policy for base line care plan. Interview on 03/04/2026 at 1:15PM with Licensed Practical Nurse (LPN)4 stated that she does not know about doing a base line care plan at the time of admission. LPN4 stated that all the charge nurse does when a resident is admitted is the Nursing Admission/readmission Evaluation document. 2. Review of R29's EMR admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, muscle weakness, dementia, major depressive disorder and hypertension. Review of R29's EMR Physician Orders under the Orders tab indicated Regular Diet, Mechanical soft with chopped meats texture regular/thin liquids consistency and full code status. Review of the EMR revealed no documentation that the baseline care plan was developed upon admission, or that the baseline care plan was generated, provided or reviewed with R29 or their representative. Interview on 03/04/2026 at 08:41 AM with the MDSC stated that the baseline care plan is conducted by the unit nurse. The MDSC further stated that the baseline care plan for R29 had not been completed. Interview on 03/04/2026 at 09:00 AM with the Director of Nursing (DON) revealed that when a resident was admitted the admission assessment was completed by the nurse, and an initial baseline care plan was generated. The DON further stated there was miscommunication and the baseline care plan for R29 was not completed. Interview on 03/04/2026 at 3:00 PM, Unit Manager 2 (UM2) confirmed that R29's baseline care plan had not been completed.

Based on record review, staff interviews, and review of the facility policy titled Bed Hold Notice Upon Transfer the facility failed to notify the ombudsman and to provide a resident and their representative with the required written transfer and bed-hold notices following an emergency hospital transfer for one of two sampled residents (R) (R87). This failure limited the residents' and representative's ability to understand appeal rights and access ombudsman information, placing them at risk for potential denial of readmission.Findings include:Review of the admission Record located in the electronic medical record (EMR) under the Profile tab revealed that R87 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. R87 had diagnoses including osteomyelitis (bone infection) and acquired absence of the left foot (amputation).Review of R87's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/26, located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.Review of Alert Notes dated 02/02/2026 and located in the EMR under the Prog Notes tab revealed, I received a call from [name and place] Vascular, she stated . to let them know he was hospitalized .Resident admitted to [hospital].Review of a Health Status Note dated 02/02/2026 and located in the EMR under the Prog [Progress] Notes tab revealed, Resident out of facility to an appointment with Vascular . Review of an admission Note dated 02/13/2026 and located in the EMR under the Prog Notes tab revealed, Resident arrived at facility via stretcher . Interview on 03/05/2026 at 10:10 AM with the Social Services Director (SSD) reported that he had no role in providing bed hold or written transfer notices to residents or their representatives.Interview on 03/05/2026 at 10:12 AM with the Business Office Manager (BOM) reported the nurses completed the bed hold forms when residents sent out to the hospital and provided the bed hold form to her by sliding them under her door. The BOM was unaware of any written notice of transfer and did not notify the ombudsman of any transfers or discharges.Interview on 03/05/2026 at 10:15 AM with Licensed Practical Nurse 3 (LPN) confirmed when a resident was transferred to the hospital, she sent information with them to include a bed hold notice. LPN3 made a copy of the bed hold notice and put it under the door of the BOM.Interview on 03/05/2026 at 10:10 AM with the BOM revealed that since R87 went directly from an appointment to the hospital, she did not have a bed hold form for his hospitalization.Interview on 03/05/2026 at 10:25 AM with the Administrator revealed that residents were provided with a bed hold policy at the point of leaving. The Administrator was unsure about any written notice of transfer that included appeal rights and the ombudsman's contact information and did not have a policy. The Administrator notified the ombudsman when residents transferred to other facilities, discharged home, or if a 30-day notice was issued, but she did not notify the ombudsman of hospital transfers.Interview on 03/05/2026 at 11:00 AM with the Administrator provided the Notice of Transfer/Discharge form from corporate and confirmed the facility had not been using it.Review of the facility's policy titled, Bed Hold Notice Upon Transfer, dated 07/01/2024, revealed, Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide the resident and/or the residents' representative with written information that specified: a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility, b. The reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed-hold period to include allowing a resident to return to the next available bed . In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies .

Based on staff interviews and record review, the facility failed to provide Form CMS 10055, Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), in a timely manner to two of three sampled residents(R) (R13 and R73) reviewed for liability notices. This failure prevented the residents or their responsible parties from having the ability to make an informed decision regarding the cost of continued therapy services.Findings include:1. Review of R13's electronic medical record (EMR) admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE].Review of R13's document provided by the facility titled, Notice of Medicare Non-Coverage indicated R13's skilled therapy services would end on 12/10/2025.Review of R13's SNF/ABN, provided by the facility indicated that R13 signed the SNF ABN on 12/22/2025. The form indicated that the resident's signature acknowledged receipt of and understanding of the notice eleven days after therapy services ended.Review of R13's EMR indicated the resident remained in the facility after the end of their skilled therapy services.Interview on 03/04/2026 at 3:45 PM, the Administrator stated that R13 still had skilled benefit days remaining.2. Review of R73's EMR admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE].Review of R73's document provided by the facility titled, Notice of Medicare Non-Coverage, indicated R73's skilled services ended on 12/18/2025.Review of R73's SNF/ ABN provided by the facility indicated that the resident signed the SNF ABN on 12/22/2025. The form indicated that the resident's signature acknowledged receipt of and understanding of the notice four days after their therapy services ended.Review of R73's EMR indicated the resident remained in the facility after the end of their skilled therapy services. Interview on 03/04/2026 at 3:45PM, the Administrator stated that R73 still had skilled benefit days remaining.Interview on 03/05/2026 at 01:35 PM the Social Services Director (SSD) stated that she completed the SNFABN documents but was not aware of a specific time frame as to when the documents should have been completed. When asked if they had a policy and procedure for the NOMC/ABN, the SSD stated he did not have one and knew if the facility had a policy.Interview on 03/05/2026 at 1:50 PM with the Therapy Director stated that she lets the team know during morning meetings as to when a resident will be coming off therapy services. The Therapy Director further stated that the SSD completes the SNFABN forms.Follow up interview on 03/05/2026 at 2:17 PM with the Therapy Director confirmed that she completes the facility form Last Day of Therapy Notification with the information as to when the resident will receive their last day of skilled therapy services. She further stated that the Social Worker was given the information three days prior to the resident's therapy services ending.Interview on 03/04/2024 at 3:30 PM with the Administrator confirmed that during morning meetings the team discusses whose skilled services will end. The Administrator stated that the SSD was to notify the residents or representatives.

Based on observations, interviews, record review and review of the facility's policy titled Incident and Accidents, the facility failed to provide adequate supervision to prevent accidents for one of four residents (R) (R1) reviewed for falls. Actual harm occurred on 10/2/2025 when R1 who required two person assist with Activities of Daily Living (ADL) care rolled out of bed onto the floor during incontinent care that was being provided by one Certified Nursing Assistant (CNA). As a result of the fall, R1 sustained a distal fracture of left femur and a fracture of the lower end of the right tibia.Findings include:A review of the facility's policy titled Incidents and Accidents dated 4/1/2025 under Policy revealed, It is the policy of this facility for staff to utilize the Risk Management porta [sic] to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involved a resident. Under the Compliance Guidelines section revealed, .6. In the event of an accident, immediate assistance will be provided or securement of the area will be initiated, unless it places one at risk of harm. A review of the electronic medical record (EMR) under the Medical Diag tab revealed R1 was admitted to the facility with a diagnosis that included but was not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture to right and left knee, transient alteration of awareness, other seizures, cerebral infarction due to embolism of left posterior cerebral artery, alcohol dependence with withdrawal, other epilepsy, intractable, without status epilepticus, unspecified, memory deficit following cerebral infarction, anxiety disorder, unspecified dementia, with other behavioral disturbance. Further review of the list of diagnoses revealed, other fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing was added on10/3/2025 and unspecified fracture of lower end of right tibia, subsequent encounter for closed fracture with routine healing was added on 10/6/2025.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R1 under Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score indicated the resident was rarely/never understood; Section GG (Functional Abilities) revealed that R1 was dependent on staff for all activities of daily living (ADL) care and for chair/bed-to chair transfer that indicated assistance of two or more staff was required for the resident to complete the activity.A review of R1's undated care plan revealed, a focus that indicated Mr. [R1's Name] is at risk for Falls R/T(related to) CVA (cerebral vascular accidents) with right side weakness. Needs extensive assistance with bed mobility and transfers and has Seizure d/o (disorder) and altered mental status at times. Confusion and incontinent of bowel and bladder. He has h/o (history of) having delusions that he can walk, trying to scoot out of bed to get up. He has contracture of bilateral knees. Interventions included but not limited to: Two person assist with ADL care as needed.A review of R1's nurse's note dated 10/2/2025 at 7:15 am revealed, Writer was alerted to resident's room by staff. Staff reported that during incontinent care, resident rolled out of bed onto the floor. Resident was assessed for injury with no visible injuries noted. Resident was two person assist with use of Hoyer lift off of the floor and back into the bed. Incontinent care was provided by staff. Director of Nursing (DON), Administrator, Nurse Practitioner (NP), and RP was notified. Will continue to observe.A review of R1's progress note titled eINTERACT Situation, Background, Assessment, and Recommendation (SBAR) Summary for Providers dated 10/2/2025 at 7:38 am revealed Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Fall at the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 138/78 - 10/2/2025 7:39 Position: Lying left/arm - Pulse: P 83 - 10/2/2025 7:40 Pulse Type: Regular - RR: R 19 - 10/2/2025 7:40 - Temp: T 98.2 - 10/2/2025 7:40 Route: Forehead (non-contact) - Weight: W 201.2 lb (pound) - 9/5/2025 12:52 Scale: Mechanical Lift - Pulse Oximetry: O2 97 % - 10/2/2025 7:41 Method: Room Air; Skin Status Evaluation: No changes observed - Pain Status Evaluation: Does the resident/patient have pain? No - Neurological Status Evaluation: No changes observed; Nursing observations, evaluation, and recommendations are: Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: initiate neuro checks observe for any c/o (complaints of) pain or discomfort, B. New Testing Orders: C. New Intervention Orders:A review of R1's progress note dated 10/2/2025 6:45 pm revealed, a late entry that indicated Resident resting in bed throughout shift. Noted requesting bed repositioning several times after lunch to time of shift. Verbally denies pains, but voices overall being uncomfortable. Voices appreciation with repositioning and bed adjustment. No falls noted this shift. Will observe for any changes.A review of R1's progress note dated 10/2/2025 at 6:45 pm revealed, a late entry dated 10/3/2025 at 12:12 am that indicated, Writer alerted to resident's room by CNA staff during incontinent care. Resident noted to have discoloration to left thigh area and resident noted to have facial grimacing when being turned and repositioned in bed. new order placed with mobile images for x-ray of left hip and femur to be done later today. DON notified.A review of R1's progress note dated 10/3/2025 at 5:16 pm revealed, a Transfer to Hospital Summary Late Entry that indicated: The resident was sent out to TRMC (Name of Hospital) regarding left femur fracture evaluation per NP (4:08 pm) orders. The DON (4:05 pm), Administrator (4:11 pm), and NP (4:30 pm) were all notified. (Emergency Medical Services) EMS was called at 4:33 pm and arrived at 4:42 pm. Report to be called by floor nurse to TRMC ER (Emergency Room).A review of R1's progress note dated 10/3/2025 at 10:20 pm revealed, Resident return to facility. TRMC paperwork states consultation made with DR. (Name). TX (treatment) for distal left femur fx (fracture) is recommended as an immobilizer/splint to left knee/nonoperative tx. Staff to follow up with Dr. (Name) office on Monday for any further instructions or questions. Resident noted no new orders on ER D/C (discharge) paperwork. Resident resting in bed, bed in low position, verbally denies needs or concerns at this time.A review of R1's progress not dated 10/5/2025 at 7:15 pm revealed, Resident lying in bed resting at this time and no distress at this time. Extra strength 500 mg (milligram) given for left hip pain when repositioning. Resident right outer foot has noted redness, bruising and swelling. Notified (Name of NP) about ordering an in-house x-ray. Notified resident sister of this problem.A review of R1's progress note dated 10/5/2025 at 8:34 pm revealed, Writer called and scheduled x-ray for right foot and ankle d/t (due to) swelling and discoloration post fall at this time. A review of R1's progress note dated 10/6/2025 at 8:53 am revealed, Mobile images present to do right foot/ankle x-ray. Resident cooperative with testing. Noted discomfort during x-rays. Standing order Tylenol 650 mg provided, tolerates well. Will observe for any changes.Observations on 10/27/2025 at 1:15 pm, on 10/28/2025 at 10:15 am and on 10/29/2025 at 3:15 pm revealed, R1 lying in bed watching television and he did not appear to be in any discomfort. The bed was in a low-locked position.Interview on 10/27/2025 at 10:15 am with the Administrator confirmed that R1 was a two person assist with ADLs and transfers however, the Certified Nursing Assistant (CNA) went in by herself to provide ADL care for R1. The Administrator revealed that when the CNA rolled him on his side he continued to roll and rolled off the bed. Interview on 10/29/2025 at 11:28 am with CNA DD revealed that if a resident was one person or two persons assist with ADLs and transfers, she would check in Point Click Care (PCC). Interview on 10/29/2025 at 11:31 am with Licensed Practical Nurse (LPN) BB revealed that staff should communicate if there had been a change in the residents' condition from a one person to a two person assist during shift change. Interview on 10/29/2025 at 11:48 am with LPN CC revealed that he was able to look at the Minimum Data Set (MDS) in PCC to verify if a resident was a one person to two persons assist for ADL's. LPN CC also revealed that the CNA's documentation in Kardex indicated if the residents were one person or two persons assist.Interview on 10/30/2025 at 10:02 am with CNA FF revealed that there were three residents on South Hall B that were two person assist but since the incident occurred on 10/2/2025, it had been implemented that all residents receive two person assist with ADL's. CNA advised that it was also documented in PCC if a resident was two persons assist and changes in the residents' care were verbalized during shift change.Interview on 10/30/2025 at 12:42 pm with CNA EE revealed she participated in trainings provided by the facility in reference to transfers, hygiene, resident abuse and two persons assist. She revealed that since the recent fall incident with R1, it was revealed that the CNA that went in to provide R1 with ADL care left something that she needed in the hall, then went to go get it, and left R1 and on his side and when she came back in the room he was on the floor. So since then, staff have been advised that all residents were to be two persons assisted with ADL's until further notice. Interview on 10/30/2025 at 2:30 pm with the Administrator revealed that she expects staff to follow the residents care plan when providing care.[Cross Reference - F656]

Based on observation, interviews, record review and review of the facility's policy titled Comprehensive Care Plans, the facility failed to follow the care plan interventions related to falls for one of four Residents (R) (R1) Actual harm occurred on 10/2/2025 when R1 who required two person assist with Activities of Daily Living (ADL) care rolled out of bed onto the floor during incontinent care that was being provided by one Certified Nursing Assistant (CNA). As a result of the fall, R1 sustained a distal fracture of left femur and a fracture of the lower end of the right tibia Findings include:A review of the facility's policy titled Comprehensive Care Plan dated 6/2/2025 under Policy revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Under the section titled Policy Explanation and Compliance Guidelines revealed, 3.(f) Resident specific interventions that reflect the resident's and preferences .A review of the electronic medical record (EMR) under the Medical Diag tab revealed R1 was admitted to the facility with a diagnosis that included but was not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture to right and left knee, transient alteration of awareness, other seizures, cerebral infarction due to embolism of left posterior cerebral artery, alcohol dependence with withdrawal, other epilepsy, intractable, without status epilepticus, unspecified, memory deficit following cerebral infarction, anxiety disorder, unspecified dementia, with other behavioral disturbance. Further review of the list of diagnoses revealed, other fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing was added on10/3/2025 and unspecified fracture of lower end of right tibia, subsequent encounter for closed fracture with routine healing was added on 10/6/2025.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R1 under Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score indicated the resident was rarely/never understood; Section GG (Functional Abilities) revealed that R1 was dependent on staff for all activities of daily living (ADL) care and for chair/bed-to chair transfer that indicated assistance of two or more staff was required for the resident to complete the activity. A review of R1's care plan revealed, a focus that indicated Mr. [R1's Name] is at risk for Falls R/T(related to) CVA (cerebral vascular accidents) with right side weakness. Needs extensive assistance with bed mobility and transfers and has Seizure d/o (disorder) and altered mental status at times. Confusion and incontinent of bowel and bladder. He has h/o (history of) having delusions that he can walk, trying to scoot out of bed to get up. He has contracture of bilateral knees. Interventions included but not limited to: Two person assist with ADL care as needed.A review of R1's nurse's note dated 10/2/2025 at 7:15 am revealed, Writer was alerted to resident's room by staff. Staff reported that during incontinent care, resident rolled out of bed onto the floor. Resident was assessed for injury with no visible injuries noted. Resident was two person assist with use of Hoyer lift off of the floor and back into the bed. Incontinent care was provided by staff. Director of Nursing (DON), Administrator, Nurse Practitioner (NP), and RP was notified. Will continue to observe.Interview on 10/30/2025 at 1:05 pm with the Corporate MDS nurse revealed that the nursing staff do not update the Care Plans for the residents. She stated that during the Interdisciplinary Team (IDT) meetings they talk about if there needs to be changes/updates to residents' care plans. She revealed that she was currently working to get all of the care plans corrected.Interview on 10/30/2025 at 2:30 pm with the Administrator revealed that she expects staff to follow the residents' care plan when providing care. She also revealed that she expect the residents needs be reflected in the care plan interventions and for all staff to follow the care plan. [Cross Reference - F689]

Based on record review, staff interview, and review of the facility's policy titled Documentation of Wound Treatments, the facility failed to ensure the medical record documentation was completed and/or accurate for three of three residents (R) (R1, R3 and R4) reviewed for pressure ulcers from a total sample of nine residents. Findings include: Review of the facility's policy titled Documentation of Wound Treatments dated 9/1/2024 under Policy revealed, The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition and changes in treatment. Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact). 1. Review of clinical records revealed R1 was admitted to the facility with the following diagnoses but not limited to: congestive heart failure, chronic obstructive pulmonary disease, hypertension, atherosclerosis, morbid obesity, and peripheral vascular disease. Review of R1's physician's order dated 5/11/2025 revealed, to clean the right leg with normal saline, pat dry, apply absorbent dressing and wrap with Kerlix every other day and as needed. Review of the May 2025 Treatment Administration Record (TAR) revealed there was lack of documentation to indicate if the treatment was provided on 5/11/2025, 5/13/2025, 5/19/2025, 5/21/2025, 5/23/2025, 5/25/2025 and 5/27/2025. 2. Review of clinical records revealed, R3 was admitted to the facility with the following diagnoses but not limited to: diabetes, mild protein calorie malnutrition, peripheral vascular disease, chronic venous hypertension with ulcer of the left lower extremity, and hyperlipidemia. Review of R3's physician's order dated 4/1/2025 revealed, to clean wound to coccyx with normal saline, apply calcium alginate to wound bed and cover with foam and or bordered gauze dressing every Tuesday, Thursday and Saturday. Review of the May 2025 TAR revealed there was lack of documentation to indicate if the treatment was provided 5/6/2025, 5/8/2025, 5/13/2025, 5/22/2025 and 5/27/2025. Review of the June 2025 revealed there was lack of documentation to indicate if the treatment was provided on 6/5/2025, 6/10/2025, 6/19/2025, 6/26/2025 and 6/28/2025. 3. Review of clinical records revealed, R4 was admitted to the facility with the following diagnoses but not limited to: congestive heart failure, chronic obstructive pulmonary disease, diabetes, atherosclerotic heart disease, chronic peripheral venous insufficiency, cerebral infarction, and history of diabetic foot ulcer. Review of R3's physician's order dated 5/8/2025 revealed, to cleanse wound to coccyx with normal saline, apply Mesalt to wound bed and cover with bordered gauze every Tuesday, Thursday and Saturday and as needed. Review of the June 2025 TAR revealed there was lack of documentation to indicate if the treatment was provided on 6/1/2025, 6/4/2025, 6/10/2025, 6/13/2025 and 6/19/2025. During an interview with the Director of Nursing (DON) on 7/2/2025 at 12:20 pm, she stated the previous treatment nurse resigned 5/9/2025. The DON revealed nurses were told they were responsible for doing treatments. She stated in June 2025 she was reviewing documentation and realized how bad the documentation on the TAR's was. She stated although the nurses were doing the treatments they were not documenting on the TAR. They educated the staff in June 2025 regarding completing skin assessments and treatments as ordered. The DON provided a copy of a Performance Improvement Plan Worksheet dated 6/5/2025 regarding wound care and lack of appropriate documentation. One of the measurements indicated nursing management will conduct daily checks for one week of wound care documentation, followed by five times weekly for two weeks, followed by three times weekly for one week. However, the DON could not provide documentation this had been done.

Based on observations, staff interviews, and review of the facility's policy titled, Cleaning Instructions: Ice Machine and Equipment, the facility failed to ensure the ice machine was maintained in a clean and sanitary condition and failed to ensure staff wore appropriate head covering in the food service area. This deficient practice had the potential to affect 82 of the 85 residents receiving an oral diet. Findings include: Review of the facility's undated policy titled, Cleaning Instructions: Ice Machine and Equipment revealed the purpose was, to ensure that ice machine and equipment (scoops and receptacles that are used to hold or transport ice) will be cleaned and sanitized on a regular basis. Procedures explained: 2. Wash the interior thoroughly using a detergent solution. Rinse and drain the interior with clean hot tap water. 6. Clean the exterior of the machine with detergent solution daily. Rinse and allow to air dry. Clean the area underneath and around the machine. Observation on 1/7/2025 at 11:45 am with the Dietary Manager upon inspection of ice machine in the main kitchen, a black substance was visible on the upper inside of the ice machine. A white napkin was used to wipe the upper level of the ice machine. Black substance was noted on the napkin. Observation on 1/7/2025 at 11:50 am in the kitchen with revealed dietary staff/Dishwasher AA and Dishwasher BB did not have on hairnets. Interview on 1/7/2025 11:55 am with [NAME] CC revealed the ice machine was to be cleaned weekly by the maintenance department. She also revealed that all kitchen staff know they are supposed to wear hair nets upon entering the kitchen. Interview on 1/7/2025 at 12:00 pm with Dishwasher AA confirmed that she knew to have a hairnet upon entering the kitchen. She stated she had just come on shift and confirmed she had not put on a hairnet at this time. Interview on 1/7/2025 at 12:05 pm with Dishwasher BB confirmed she came in and started working and forgot to put on a hairnet. She also revealed she was aware of having to place the hairnet upon entering the kitchen. Interview on 1/1/2025 at 1:00 pm with the Dietary Manager revealed that her staff inspects the ice machine daily for cleanliness, and staff have been in-serviced about always wearing hairnets while in the kitchen, and hairnets are available in a bin outside the kitchen before entering.

Based on staff interviews, record review, and review of the facility's policy titled, Annual Inservice Education for Long Term Care 2024, the facility failed to establish, implement, and sustain a comprehensive training program for all staff that would include education on standards, policies, and procedures for infection prevention. This deficient practice had a potential to increase the risk of healthcare-associated infections and compromise the quality of care provided to the residents of the facility. Findings include: Review of the facility's undated policy titled, Annual Inservice Education for Long Term Care 2024, revealed that the annual education calendar is to be implemented each year as scheduled, along with any additional educational needs that are identified. The calendar provides a monthly education schedule for 2024, covering a variety of topics, including infection control and prevention, among others. The facility was unable to provide the survey team with documentation of in-service training provided to staff. Interview on 1/6/ 2025, at 4:50 pm with the Director of Nursing (DON) revealed that she could not locate any in-service education provided to the staff by the previous DON. Observation and interview on 1/6/2024 at 10:30 am, during the tour of the facility, there was signage on one of the resident's doors that indicated that the resident was on Enhanced Barrier Precautions (EBP). The surveyor interviewed Licensed Practical Nurse (LPN) FF, who was taking care of the resident, about why the resident was on EBP, what it meant to the facility staff, and the difference between EBP and Transmission-Based Precautions (TBP). LPN FF revealed that if there is signage on a door for EBP, staff are always required to wear PPE. LPN FF expressed confusion about Enhanced Barrier Precautions, questioning why PPE is required when entering the room if the resident is allowed to walk in the hallways without PPE. He was unable to explain the difference between Enhanced Barrier Precautions and Transmission-Based Precautions to the surveyor. He also revealed that he did not know where this information would be documented in the chart.

Based on observations, staff interview, and record review, the facility failed to properly administer respiratory inhalant medications for one of 15 residents (R) (R24) receiving inhaled respiratory medication. Specifically, the facility failed to ensure that the Licensed Practical Nurse (LPN) properly administered inhaled medications by having the resident rinse their mouth after receiving inhaled respiratory medication. Findings include: A facility policy for administrating inhaled medications was requested. There was no policy provided by the facility. Observation on 1/7/2025 at 9:32am to 9:40 am revealed Registered Nurse (RN) EE preparing medications for R24 that included but not limited to Trelegy inhaler. RN EE performed hand hygiene, entered room of R24, and handed the inhaler to the resident. RN EE instructed R24 to take in one puff, hold her breath for as long as she could before removing the inhaler and exhaling. LPN EE then had the resident take her pills. She performed hand hygiene before leaving the room. During an interview on 1/7/2024 at 9:47am with RN EE, she was asked if a resident's mouth should be rinsed after receiving the inhaler. She revealed that some staff do, but not her. Review of the electronic medical record revealed that R24 admitted to the facility with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD) and pneumonia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section I, revealed that R24's primary medical condition was COPD. Review of the care plan, dated 12/7/2024, revealed R24 had a focus for diagnosis of COPD. She requires supplemental oxygen. She has a history of lobar pneumonia. Intervention included administer aerosol or bronchodilators as ordered, monitor and document any side effects and effectiveness. Review of the physician orders for R24 revealed that R24 was to receive Trelegy inhaler, one puff inhaled, once daily. An interview on 1/7/2024 at 1:56 pm with the Director of Nurses (DON), revealed that it was her expectation that when a resident receives an inhaler, that the mouth would need to be rinsed after it was administered. Interview further revealed that she expects instructions for the nasal sprays to be followed, that includes blow nose prior, and then rinsing mouth after.

Based on observations, interviews, and review of the facility's policy titled, Resident Rights and Dignity Management, the facility failed to ensure one of 13 residents (R) (R17) was able to exercise their right to smoke. Findings include: Review of facility's policy titled, Resident Rights and Dignity Management, dated October 2023, in section self-determination and participation standard revealed, our facility respects and promotes the right of each resident to exercise his/her autonomy regarding what the resident considers to be important facets of his/her life . 3. The resident shall be encouraged to make choices about aspects of his/her life in the facility including: roommates, smoking. Review of the clinical record revealed that R17 was admitted to the facility with the diagnoses of but not limited to, intracranial injury without loss of consciousness, schizoaffective disorder bipolar, chronic obstructive pulmonary disease, and emphysema. Further record review revealed completed smoking and safety assessments dated 11/11/2024, 10/16/2024, 8/16/2024, and 5/5/2024 which confirmed R17 uses tobacco, follows the facility's policy on location and smoking times, and no clinical suggestions. In addition, smoking and safety assessments dated 8/16/2024, 10/16/2024, and 11/11/2024 safety note revealed R17 had no issues and needed reminders of smoking times. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Section GG: Functional Abilities and Goals Status revealed no impairment. Review of the care plan for R17, completed date 12/4/2024, revealed care area Focus: Risk for potential injuries and health complications related to, has preference of smoking. Goal: Will be free from injuries related to smoking. Interventions included cigarettes and lighters to be kept at nurses' station and to be given to resident at scheduled and supervised smoke breaks. Complete smoking assessment quarterly to access safety of smoking outside. Provide resident with proper clothing protector when smoking to prevent potential injuries. Observation on 1/7/2025 at 1:30 pm of designated smoking area confirmed R17 did not attend smoke break nor have anything to smoke. Interview on 1/7/2025 at 1:39 pm with the Interim Director of Nursing (DON) revealed she was the med-cart charge nurse at the time, she revealed she made a judgement call that R17 was not allowed to smoke based on pneumonia, coughing, and lips turning blue. The Interim DON confirmed that there was no physician order, the care plan was not updated, and there was no smoking assessment completed that would indicate R17 was not eligible to smoke at the facility. Interview on 1/7/2025 at 1:52 pm with the Nurse Practitioner revealed the nurse should have documented and educated R17 that it could not be beneficial to smoke while having medical challenges, but still give R17 the right to choose. Interview on 1/8/2025 at 9:12 am with R17 confirmed he had not attended the smoke break during the designated times. During the interview R17 revealed that he had been a pack a day smoker for 50 plus years, and that the facility reduced him to smoking three to four cigarettes a per day to not smoking at all, and by not being able to smoke is causing him more harm than good.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Respiratory System Management, the facility failed to ensure that one of 15 residents (R) (R24) receiving oxygen (O2) therapy was administered the therapy in accordance with the physician's orders. This deficient practice had the potential to put R24 at risk for medical complications. Findings include: Review of the facility's policy titled, Respiratory System Management, revised in August 2021, under the section Oxygen Therapy Protocol, outlines the following procedures: 1) Verify the physician's order in the resident's clinical record . Review of the electronic record revealed R24 admitted to the facility with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD) and pneumonia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment. Section I, Active Diagnoses, lists R24's primary medical condition as COPD. Review of Section O, Special Treatments, Procedures, and Programs does not include that R24 is on oxygen therapy. Review of the care plan for R24, dated 12/7/2024, revealed a focus on diagnosis of COPD. R24 required supplemental oxygen and had a history of lobar pneumonia. Goal: The resident will display optimal breathing patterns daily through the review date. Interventions included but not limited to, monitor for and document signs and symptoms of acute respiratory insufficiency, including anxiety, confusion, restlessness, shortness of breath (SOB) at rest, cyanosis, and somnolence and ensure oxygen settings are as ordered. Review of the physician orders for R24 dated 6/23/2023 revealed an order for oxygen, administer O2 at 2L (2/liters per minute) NC (through/by nasal cannula) as needed for shortness of breath (SOB). Observations on 1/5/2025 at 3:05 pm, and at 5:00 pm, on 1/6/2025 at 10:30 am, revealed R24 was receiving O2 at three liters via NC. Observation and interview on 1/6/2025 at 10:30 am, inside R24's room, Licensed Practical Nurse (LPN) FF confirmed that the oxygen concentrator was set to deliver 3 liters per minute via NC. After review of R24's chart, LPN FF confirmed that the provider had ordered 2 liters of oxygen per minute via nasal cannula. Continued interview also revealed that it is the responsibility of the nurse to ensure that the residents are receiving oxygen as ordered by the physician and in accordance with the resident's care plan. Interview on 1/8/2024 at 2:50 pm with the Unit Manager (UM) confirmed that nurses are responsible for ensuring that orders and care plans are followed.

Based on observations, staff interviews, record review, and review of the facility's policies titled Hand Hygiene, Indwelling Catheters, Two-Tier Transmission Based Precautions, and Infection Control Manual, the facility failed to ensure infection control practices were followed for two of seven Residents (R) (R435 and R7). Specifically, the facility failed to ensure hand hygiene was performed during medication administration, failed to ensure residents with an indwelling catheter drainage bag was secured properly, and failed to ensure that the infection control policy and procedures were reviewed annually. Findings include: Review of the facility's policy titled, Hand Hygiene, with a revision date of 9/2023, revealed that the facility will follow the Center for Disease Control guidelines for hand hygiene. Hand Hygiene is the single most important procedure for preventing nosocomial infections. The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient microorganisms. Hand Hygiene is mandated between resident contact to prevent the spread of infection. Alcohol gel may be utilized for hand hygiene. Hands must be washed after the following, including, but not limited to contact with residents, removal of gloves, contact with contaminated items or surfaces. Review of the facility's' undated policy titled, Two-Tier Transmission Based Precautions policy, revealed that Enhanced Barrier Precautions expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multi drug resistant organisms (MDROs) to staff hands and clothing. The use of gown and gloves for high contact resident care activities is indicated when contact precautions do not otherwise apply, for nursing home residents with wounds and or indwelling devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Review of the electronic medical record revealed R435 was admitted to the facility with diagnoses of but were not limited to acute and chronic respiratory failure with hypoxia, and neuromuscular dysfunction of bladder. 1. Medication (med) administration observation on 1/7/2024 at 8:39 am, with Licensed Practical Nurse LPN DD, observed during med administration for R435 revealed that during the observation LPN DD did not wash or sanitize her hands before preparing medications for administration. After all medications were prepared, LPN DD knocked on the door and then entered the room. There was no observation of LPN DD washing or sanitizing her hands before or after medication administration. Interview on 1/7/2024 at 9:17 am, LPN DD was asked when hand hygiene should be performed LPN DD stated before I go in and then before coming out. She stated, I am not going to deny it, I did not do it. 2. Medication administration observation on 1/7/2024 at 10:05 am, revealed LPN NN was observed pushing a capsule out of the foiled card, and picked it up with her bare hand and then placed it in the medicine cup. Interview on 1/7/2024 at 10:07 am, with LPN NN revealed she was not supposed to handle the pill bare handed. Still at the cart, she then performed hand hygiene, donned gloves, proceeded with administering the medication to R435. She then returned to the cart, and then with the same gloves on, she opened the cart, doffed the gloves, and then donned a new pair of gloves to remove a straw for the resident without performing hand hygiene after removing the gloves. Interview on 1/7/2024 at 10:14 am, LPN NN was asked when hand hygiene is to be performed. She stated that she is to perform hand hygiene when she is finished with the medication pass for each resident. She was then asked if she should have performed hand hygiene in between glove use, and she then stated that she thought she did. 3. Review of the electronic medical record for R7 revealed that she was admitted to the facility with diagnoses that included, but were not limited to neuromuscular dysfunction of bladder, colostomy malfunction, absence of kidney, and chronic viral hepatitis C. Review of the care plan for R7 revealed that she is at risk for complications of ostomy that is used for excretion of waste products related to Bowel Obstruction, and urostomy. Interventions in place for this risk include but are not limited to colostomy care as ordered, Enhanced Barrier Precautions. Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Basic Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment. Section H revealed that R7 had an indwelling catheter and an ostomy. Observation on 1/5/2025 at 4:56 pm of R7 revealed R7's catheter bag was observed laying on the floor. Observation on 1/7/2025 at 1:23 pm revealed the catheter bag for R7 was laying on the floor. Observation on 1/7/2025 at 1:27 pm, revealed LPN DD verified that the catheter bag was laying on the floor. She stated that they have tried everything to get the bag to drain, and laying on the floor is the only way. She stated that it be a good idea if there was a barrier underneath the catheter bag. Interview on 1/7/2024 at 1:56 pm, with Director of Nurses (DON) revealed that hand hygiene should be performed before and after preparing medications. She then stated that a nurse would need to have PPE on when entering an EBP room, especially when administering a nebulizer treatment. She completed the interview by stating that a catheter bag should never by laying on the floor. She stated that if it needed not be on the floor for any reason, that it needed not be on a barrier, and that it needs not be added on the care plan. 50940 Interview on 1/6/2025, at 4:50 pm with the DON confirmed that the facility has an Infection Control Manual containing their policies and procedures, which is reviewed annually. However, upon reviewing the manual, it was noted that the last revision date was September 20, 2023, indicating that it has been a year and three months since the last update. She further stated that they will now begin working on updating the policies and procedures.

Based on observations, staff interviews, record reviews, and review of the facility's policies titled, Resident Assessment Instrument (RAI)/Care Planning Management, and Process for Completing the MDS, CAAs and Care plans, the facility failed to ensure that the care plan was followed for three of 15 residents (R) (R24, R7, and R54). Specifically, the facility failed to ensure the care plan was followed for R24 for receiving oxygen therapy, for R7 related to positioning of an indwelling catheter, and for R54 for behaviors related to oxygen use. This deficient practice had the potential for R24, R7, and R54 to not have the care provided to them according to their individual care needs. Findings included: Review of the undated facility's policy titled, Resident Assessment Instrument (RAI)/ Care Planning Management, revealed that the Comprehensive Care Plan is completed within seven (7) days after the care area assessments (CAAs) are completed and reviewed quarterly thereafter. If modifications, deletions, additions are necessary, changes should be made at the time of occurrence. Modifications are made by resolving the item in the electronic medical record and adding the new information. Care plans are to be accessible for clinical staff to facilitate care plan interventions or to update as indicated due to resident condition change. Review of the facility's policy titled, Process for Completing the MDS, CAAs and Care plans, revised in August 2021 reads .the resident assessments and documentations accurately reflect .resident's medical, physical, cognitive, emotional, and functional status . Director of Nursing .is to ensure that the documentation accurately describes the clinical condition of each resident. Review of the Respiratory System Management, revised in August 2021, under the section Oxygen Therapy Protocol, outlines the following procedures: 1) Verify the physician's order in the resident's clinical record . 1. Review of the electronic record revealed R24 was admitted to the facility with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD) and pneumonia. Review of the physician orders for R24 dated 6/23/2023 revealed an order for oxygen ()2), administer O2 at 2 liters (L) (liters) via nasal cannula (NC) as needed for shortness of breath (SOB). Review of R24's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment. Section I, Active Diagnoses, reported R24's primary medical condition as chronic obstructive pulmonary disease (COPD). Section O, Special Treatments, Procedures, and Programs did not include that R24 was on oxygen therapy. Review of the care plan for R24 revealed a focus on diagnosis of COPD. R24 required supplemental oxygen and had a history of lobar pneumonia. Goal: The resident will display optimal breathing patterns daily through the review date. Interventions included, oxygen settings as ordered, administer aerosol or bronchodilators as ordered, monitor for and document signs and symptoms of acute respiratory insufficiency, including anxiety, confusion, restlessness, shortness of breath (SOB) at rest, cyanosis, and somnolence. Observation on 1/5/2025 at 3:05 pm and 5:00 pm, and on 1/6/2025 at 10:30 am, revealed oxygen being delivered to R24 via NC, the oxygen flow rate was set on 3 liters. Observation and interview on 1/6/2025 at 10:30 am, inside R24's room, Licensed Practical Nurse (LPN) FF confirmed that the oxygen concentrator was set to deliver 3 liters per minute via nasal cannula. After review of R24's chart, LPN FF confirmed that the provider had ordered 2 liters of oxygen per minute via nasal cannula. Further interview also revealed the nurses are supposed to check the orders and care plans to ensure they are being followed. Interview on 1/8/2025 at 2:50 pm with the Unit Manager (UM) confirmed that nurses are responsible for ensuring that orders and care plans are followed as written by the physician. 46579 2. Review of the electronic medical record revealed that R7 was admitted to the facility with diagnoses of but not limited to neuromuscular dysfunction of bladder, colostomy malfunction, absence of kidney, and chronic viral hepatitis C. Review of the physician orders for R7 revealed that stoma sites were to be monitored, routine colostomy care, and routine urostomy care were to be provided. Review of the Annual MDS assessment dated [DATE], for R7 assessed a BIMS score of 15, indicating little to no cognitive impairment. Section H revealed that she had an indwelling catheter and an ostomy. Review of the care plan for R7 revealed a risk for urinary complications including UTI (urinary tract infection) related to having a urostomy. She (R7) places urostomy bag on floor when staff attempts to place in correct place, she declines stating it does not drain as good. She will disturb colostomy and urostomy at times causing leakage and drainage. She has history of UTI. Observation on 1/5/2025 at 4:39 pm revealed that R7 was laying in her bed talking with visitors. The catheter drainage bag was laying on the bare floor. Observation on 1/7/2025 at 1:23 pm, revealed that R7 was awake, laying in her bed. The catheter drainage bag was laying on the floor next to her bed. Observation and interview on 1/7/2025 at 1:27 pm with LPN DD confirmed that R7's catheter bag was laying on the floor. LPN DD revealed that they have tried everything to get the bag to drain, and laying on the floor is the only way. She then confirmed that any situation like that would need to be care planned but was not sure if it is or not. Interview on 1/7/2025 at 1:56 pm with the Director of Nursing (DON), when asked about the catheter drainage bag needing to be on the floor to drain, the DON confirmed it had not been care planned. She revealed she would need to add to the care plan that staff are placing the bag on the floor and that it needs to be placed on a barrier. 3. Review of the electronic medical record revealed R54 was admitted to the facility with diagnoses that included but were not limited to chronic pain, COPD, chronic respiratory failure with hypoxia, dementia with behavioral disturbance, and pneumonia. Review of the 5-day Admission MDS assessment dated [DATE] for R54 assessed a Basic Interview for Mental Status (BIMS) score of 14, indicating little to no cognitive impairment, and there were no behaviors noted during the look back period. Section O-Special treatments included oxygen was coded. Review of the care plan for R54 revealed a diagnosis of COPD related to smoking. He [R54] has a diagnosis of chronic respiratory failure with hypoxia. Oxygen at 3 liters as needed. Resident refuses to keep oxygen tubing in bag at times. Resident places oxygen tubing on the floor. An intervention for this problem is to administer oxygen O2 as ordered. An observation and interview on 1/5/2025 at 3:19 pm with R54 revealed he was receiving oxygen via a nasal cannula (NC), at a rate of 4 liters per minute. R7 revealed when asked what his oxygen flow rate should be set at, R54 stated it should be on 4 liters, because I have emphysema (late stages), and I need it to breathe. An observation on 1/6/2025 at 2:40 pm, revealed R54 was laying in bed receiving oxygen via NC with the concentrator flow rate set on 4 liters per minute. An interview on 1/8/2025 at 10:30 am with LPN KK revealed that R54's oxygen was supposed to be set on 2 liters, but he (R54) would adjust the flow rate himself. LPN KK revealed that R54 had been educated that having the oxygen set higher than ordered could cause him problems related to his COPD. An interview on 1/8/2025 at 12:13 pm with the MDS Coordinator, revealed that R54 behaviors should have been care planned related to him adjusting the oxygen himself. Interview on 1/7/2024 at 1:56 pm with the Director of Nursing revealed that R54's behaviors should be care planned and interventions added.

Based on staff interviews, record review, and review of the facility's Elopement Standard and Task List titled, Elopement Management, the facility failed to ensure the care plan was revised for one of 24 sampled residents (R) (R1). Specifically, the facility failed to revise and update R1's care plan following an elopement on 10/17/2024. This deficient practice had the potential to place R1 at risk of not receiving treatment and/or care according to their needs. Findings included: Review of the facility's Elopement Standard and Task List titled, Elopement Management, dated 2023, defined elopement, Elopement occurs when a resident leaves the facility or a safe area without authorization. If a resident is off facility property, then an elopement has occurred. If a resident is on facility property but not under supervision as need identifies; then an elopement has occurred. The standard and task list also included that post elopement, the care plan was to be updated. Review of the clinical record revealed R1 was admitted to the facility with diagnoses including, but not limited to, schizoaffective disorder, traumatic brain injury, post-traumatic stress disorder, and unsteadiness on feet. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R1 was assessed as exhibiting wandering behavior and being independent for mobility and ambulation. Review of R1's care plan, initiated on 9/20/2023, revealed R1 was at risk for elopement with a history of elopement and wandering behavior. The care plan included that R1 resided on a secure unit. Further review revealed no evidence that the care plan had been revised to include R1's elopement on 10/17/2024. Review of a Maintenance Request form dated 10/17/2024, completed by the Maintenance Director, revealed that R1 got out of the side door exit on the North Hall (which was not the secured unit R1 resided on at the time). Interview on 12/4/2024 at 11:50 am with Licensed Practical Nurse (LPN) EE revealed that she found R1 outside of the facility several weeks prior but could not recall the exact date. Interview on 12/9/2024 at 11:29 am with Certified Nursing Assistant (CNA) FF revealed she thought R1 got out of the facility on 10/17/2024. Interview on 12/9/2024 at 1:30 pm with LPN GG confirmed that she was working on the North Hall secure unit when LPN EE brought R1 back to the North Hall but could not recall the date. Interview on 12/17/2024 at 12:30 pm with the MDS Coordinator confirmed that she was unaware R1 had eloped from the facility when it occurred in October, which was why his care plan was not updated. Cross-Reference F689

Based on staff interviews, record review, and review of the facility's Elopement Standard and Task List titled, Elopement Management, the facility failed to ensure one of 24 sampled residents (R) (R1) was adequately supervised to prevent elopement. In addition, the facility failed to ensure a door leading to the outside was secured to prevent elopement by residents. This deficient practice had the potential to place R1 at risk of avoidable injury and a diminished quality of life. Findings included: Review of the facility's Elopement Standard and Task List titled, Elopement Management, dated 2023, defined elopement, Elopement occurs when a resident leaves the facility or a safe area without authorization. If a resident is off facility property, then an elopement has occurred. If a resident is on facility property but not under supervision as need identifies; then an elopement has occurred. The standard and task list also included that post elopement, a progress note (in the clinical record) was to be completed at the time of the elopement with an accurate timeline of events. Review of the clinical record revealed R1 was admitted to the facility with diagnoses including, but not limited to, schizoaffective disorder, traumatic brain injury, post-traumatic stress disorder, and unsteadiness on feet. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] assessed R1 with a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. R1 was also assessed as exhibiting wandering behavior and being independent in mobility and ambulation. Review of R1's care plan, initiated on 9/20/2023, revealed R1 was at risk for elopement with a history of elopement and wandering behavior. The care plan included that R1 resided on a secure unit. Review of R1's physician's orders revealed an order dated 9/20/2023 to admit to secure unit for diagnosis of schizophrenia. Review of an Elopement Evaluation completed on 9/19/2024 documented that R1 wandered aimlessly. Review of census information revealed R1 resided on the [NAME] Hall secure unit from 9/20/2023 until he was transferred to the North Hall secure unit on 10/28/2024. Review of a Maintenance Request form dated 10/17/2024, completed by the Maintenance Director, revealed that R1 got out of the side door exit on the North Hall (which was not the secured unit R1 resided on at the time). The form further documented that the Maintenance Director was called in at 6:10 pm because a resident had gotten out of the North Hall side exit door. When the Maintenance Director arrived at the facility, staff had already gotten R1 back to his room, and the side door was closed and locked. Review of Logbook Documentation, completed by the Maintenance Director, revealed that prior to 10/17/2024, the North side exit door was checked on 10/16/2024 and 10/17/2024 and documented as passed. Observation on 12/5/2024 at 10:30 am revealed there was a locked door at the end of North Hall secure unit, that when unlocked (by staff), opened up into the [NAME] Hall secured unit activity area. Interview on 12/4/2024 at 11:50 am with Licensed Practical Nurse (LPN) EE indicated that she found R1 outside of the facility several weeks prior but could not recall the exact date. LPN EE said she was on-call that day, returned to the facility after 4:00 pm to do something, and R1 was sitting on the bench outside of the front door entrance. She stated she did not know how he got there. She further stated R1 walked inside the building with her, and she returned him to North Hall secured unit and let LPN GG know. LPN EE also revealed she notified the Director of Nursing (DON) BB. LPN EE revealed she returned R1 to the North Hall secured unit because that was the hall he resided on. Interview on 12/4/2024 at 1:00 pm with the Maintenance Director revealed he checked the doors and keypads daily to make sure they were working and locked. He revealed that he was called and came back to the facility (on 10/17/2024). He was informed that R1 got out of the side door on the North Hall, which exits out the front of the building. He revealed the door was closed and locked when he checked it, and he changed the keypad code on the outside and inside of the door. Interview on 12/9/2024 at 11:29 am with Certified Nursing Assistant (CNA) FF (who worked on the North Hall secured unit during the 3:00 pm to 11:00 pm shift on 10/17/2024) revealed she thought R1 got out of the facility on 10/17/2024. CNA FF recalled that R1 was at the back door lined up with other residents, waiting to go out to smoke. She stated R1 did not smoke, so he went back up the hallway, and she went out with the residents for smoke break. CNA FF stated she took the residents who smoke outside at 6:10 pm, and while she was still outside with them, the DON BB called her on the phone and informed her that R1 got out the side door. She further revealed that R1 resided on North Hall when this occurred, which conflicted with the census information that documented R1 resided on the [NAME] Hall secure unit on 10/17/2024. Interview on 12/9/2024 at 1:30 pm with LPN GG confirmed that she was working on the North Hall secure unit when LPN EE brought R1 back to the North Hall but could not recall the date. LPN GG revealed she was getting ready to go on break and she saw LPN EE bring R1 back to the North Hall unit and asked LPN GG if she was missing a resident. LPN GG revealed she could not recall the last time she had seen R1 prior to LPN EE bringing him back, but it did not seem like he was missing. LPN GG confirmed that CNA FF worked with her that shift and was out on smoke break when R1 was brought back to the unit. She confirmed that R1 resided on the North Hall when the incident occurred.

Based on staff interviews, record review, and review of the facility's Standard and Task List titled, Elopement Management, the facility failed to ensure that the physician and responsible party were notified of an elopement of one resident (R) (R1) from a total sample of 24 residents. This deficient practice had the potential to place R1 at risk of unmet needs and a diminished quality of life. Findings included: Review of the facility's Elopement Standard and Task List titled, Elopement Management, dated 2023, defined elopement, Elopement occurs when a resident leaves the facility or a safe area without authorization. If a resident is off facility property, then an elopement has occurred. If a resident is on facility property but not under supervision as need identifies; then an elopement has occurred. The standard and task list also included that post elopement, a progress note (in the clinical record) was to be completed at the time of the elopement with an accurate timeline of events, and MD/RP (Medical Doctor/Responsible Party) notification with documentation. Review of the clinical record revealed R1 was admitted to the facility with diagnoses of but not limited to schizoaffective disorder, traumatic brain injury, post-traumatic stress disorder, and unsteadiness on feet. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R1 was assessed as exhibiting wandering behavior and being independent for mobility and ambulation. Review of R1's care plan, initiated on 9/20/2023, revealed R1 was at risk for elopement with a history of elopement and wandering behavior. The care plan included that R1 resided on a secure unit. Review of R1's physician's orders revealed an order dated 9/20/2023 to admit to secure unit for diagnosis of schizophrenia. Review of R1's clinical record revealed no documented evidence that R1's responsible party or physician was notified of an elopement occurrence. Review of a Maintenance Request form dated 10/17/2024, completed by the Maintenance Director, revealed that R1 got out of the side door exit on the North Hall. Interview on 12/4/2024 at 11:50 am with Licensed Practical Nurse (LPN) EE revealed that she found R1 outside of the facility several weeks prior but could not recall the exact date. LPN EE revealed she returned R1 to the North Hall secure unit because that was the hall he resided on. Interview on 12/9/2024 at 11:29 am, with Certified Nursing Assistant (CNA) FF revealed she thought R1 got out of the facility on 10/17/2024. Interview on 12/9/2024 at 1:30 pm with LPN GG confirmed that she was working on the North Hall secure unit when LPN EE brought R1 back to the North Hall but could not recall the date. Interview further revealed that when asked if she notified R1's responsible party or the physician after R1 eloped, LPN GG responded that she was on a break and unaware of what happened.

Based on resident and staff interviews, record review, review of the facility's resident admission agreement in the admission packet, and review of the facility's policy titled, Advance Directives, the facility failed to ensure one of three residents (R) (R49) wishes were correctly entered into orders to reflect the residents preferred code status and failed to ensure a copy of the resident's advance directives were obtained and filed in the medical record. Findings include: Review of the facility's Resident Admission Agreement included in the Residents Admission Packed revealed under the Refusal of Treatment and Issuance of Advance Directive section that the resident may also issue an Advance Directive in accordance with state law that describes the residents' wishes with respect to treatments that may be administered or withheld in the event the resident becomes unable to make health care decisions for him or herself. Review of the facility's policy titled, Advance Directives with an effective date of [DATE] revealed: under Purpose - The facility must inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. Under Process: The Social Services Director will assist the resident/ Power of Attorney (POA) in updating preferences for care and treatment at all quarterly care plan meetings, and anytime there is a re-admit. During the care plan reviews, the social worker will review with the resident, and or POA the advanced directive to ensure instructions are still resident wishes or will assist in changes as per resident, or POA request. A POLST (Physician Orders for Life Sustaining Treatment) or IPOLST (Iowa Physician Orders for Life Sustaining Treatment). Like a DNR, the form is completed with the resident's doctor and based on end-of-life decisions. Once signed, doctors and other medical professional must honor the instructions on the POLST/IPOLST. Review of R49's Profile in the Electronic Medical Record (EMR) under the Profile tab revealed R49 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R49 signed a Physician Orders for Life-Sustaining Treatment (POLST) document on [DATE] that acknowledged R49 wanted an attempt resuscitation; Full treatment - use intubation, mechanical ventilation, and cardioversion as indicated; use antibiotics if life can be prolonged, long-term artificial nutrition by tube, and long-term intravenous (IV) fluids. Review of R49's quarterly MDS with an ARD of [DATE] revealed a BIMS score of 12 out of 15, indicating the resident was cognitively intact. Review of R49's current physician orders revealed an order for Full Code-Attempt Resuscitation. Review of R49's care plan initiated [DATE] revealed that resident requested CPR. The interventions listed included to communicate resident's choice and if cardiac arrests do resuscitate and offer support and reassurance. Record review revealed a care conference noted dated [DATE] that reads a Care plan meeting was held with Interdisciplinary Team (IDT) and resident. Resident's wife was in attendance via telephone. Discussed resident current care plan, diagnosis, medications, diet, behaviors, and activities. Resident wishes to become a DNR. SSD will get a new POLST to resident for signature. During an interview with R49 on [DATE] at 12:02 PM, it was revealed that the resident was lying in bed. R49 stated he remembers talking to the social worker about not wanting CPR if he is not breathing and his heart stops. R49 further stated he still does not want to be resuscitated but no one had asked him about signing a paper for that. During an interview [DATE] at 1:08 PM with Licensed Practical Nurse (LPN) DD revealed that she is provided with a list of residents code status. LPN DD further stated that the list is posted at the nurses station. LPN DD further stated each residents code status is also listed in the electronic record and she relies on this this data to be accurate in an emergency situation. During an interview [DATE] at 1:33 PM with Social Service Director (SSD) revealed she did remember the conversation with R49 and him requesting to be a DNR during the care plan conference. SSD stated she thought she had given him the form to sign. SSD reviewed R49's record and verified resident was still a Full code and there was not a new POLST form uploaded into the medical record. SSD also looked through a folder and verified that there was not a new POLST form in the folder. SSD stated that his request must have just slipped her mind. During an interview [DATE] at 1:52 PM with DON revealed R49 is able to make his own decisions regarding his care. DON stated that process of residents requesting DNR included having the resident sign the form, physician signing the form and changing the orders to DNR. DON further stated that the process should take ,d+[DATE] days but definitely not a month. DON further stated that normally there is a nurse in the care plan meetings, but the SSD is ultimately responsible for caring out Advanced Directive issues. During an interview on [DATE] at 10:34 AM with Administrator revealed that he was not aware of the issue with advance directives, but his expectations is for the SSD to have the POLST forms addressed by the resident and physician as soon as possible.

Based on observations, interviews, record reviews, and review of policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to maintain an environment free from verbal abuse for five residents (R#6, R#12, B, G, and H), mental abuse for two residents (R#9 and R#11), and physical abuse for one resident (R#1), all perpetuated by facility staff. The facility also failed to maintain an environment free from physical abuse for six residents (R#2, R#3, R#4, R#5, R#6, and R#11) and sexual abuse of one resident (R#22), all perpetuated by other residents. The sample size was 40. On 6/23/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator BBB and Assistant Director of Nursing (ADON) DDD were informed of the Immediate Jeopardy (IJ) on 6/23/22 at 12:19 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/26/22. At the time of exit on June 29, 2022, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: The facility had a Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts Standard, with revision date of January 2021. The purpose of the Standard included that it was to outline the preventive and action steps taken to reduce the potential for abuse, mistreatment and neglect of residents and the misappropriation of resident property and to review practices and omissions which if allowed to go unchecked, could lead to abuse. The purpose statement also documented that the standard demonstrated a zero tolerance of abuse of any type or manner. The Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts Standard included Staff to Resident abuse and Resident to Resident Abuse. In regard to staff to resident abuse, the policy documented that the facility was responsible for the actions of its employees, including intentional acts by employees who are aware they are doing something wrong and are in conflict with the facility's policies and procedures. Contractors and volunteers are held to the same standard as employees. In addition, the policy notes that staff members are expected to be in control of their own behavior and understand how to work with the nursing home population. However, the facility failed to implement this Standard regarding staff to resident abuse effectively, resulting in abuse of eight residents (R#1, R#6, R#9, R#11, R#12, B, G, and H), by facility staff. In regard to Resident-to-Resident abuse, the policy documented that the facility would take all steps reasonable and necessary to protect the residents from harm at all times, including protection from any type of abuse from other residents. However, the facility failed to protect six residents (R#2, R#3, R#4, R#5, R#6, and R#11) from being physically abused by R#1 and failed to protect R#22 from being abused by R#11. In addition to the Freedom of Abuse, Neglect and Exploitation: Abuse Prevention: Fast Alerts Standard, the facility had a Social Media Policy with a revision date of August 2021. The policy included that employees would not post images of the company/facility or residents or staff or families on any social media site. However, videos of two residents, R#9 and R#11 were posted by an agency nurse on social media. 1.Review of the Admission Record revealed Resident #5 was admitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Date Set (MDS) Quarterly assessment dated [DATE] revealed Section G Functional Status revealed resident was independent to limited assist with one person. She did not have any impairment to upper extremities and her lower extremities. She uses a wheelchair for mobility. BIMS score of 14 indicating cognitively intact. During an interview on 4/21/22 at 11:26 a.m. R#5 stated that R#1 got in her face and said some words. She would not hit R#1 because she didn't want to go to jail for hitting a retard person. R#5 reported that she tried to tell the people, but they would not listen and told her that she was crazy and would not be getting out of the facility. R#5 continued to state that she feels unsafe at night because she thought someone would come in her room at night. She reported that she was not happy living in this facility. Review of the medical record for R #1, the nurses notes revealed an entry dated 3/5/22 that R #1 came across the hall from her room and was seen in the room of R#5 with her hands and arm around R#5's neck. R#5 was yelling for help. Review of the medical records and nurse's notes for R#5 dated 1/19/22 through 3/21/22 revealed no documented evidence of the incident where R#5 was being attacked by R#1. 2. Review of the Admission Record revealed R#3 was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Date Set (MDS) Annual assessment dated [DATE] revealed Section G Functional Status revealed resident required independent to supervision. She did not have any upper extremities or lower extremities impairment. Her BIMS score was 15 indicating intact cognition. Review of R#3s medical records showed no documented evidence of the incident on 3/8/22, where R#1 threw a cup at her face or that R#3 sustained a left eye laceration. Further review revealed there was no evidence that the left eye laceration was addressed. Review of R#1's medical records summarized the attack on R#3. A nurse's notes dated 3/8/22 at 4:00 p.m. revealed that R#1 was standing at the medication cart when another resident (R#3) came up the hall from the restroom. R#1 threw the cup in her hand at the other resident (R#3) and immediately attacked her, hitting, kicking and swinging at R#3. Both CNAs and the writer separated the two residents and walked the attacker (R#1) to her room. R#1 ran down the hall to attack R#3 again. The SBAR dated 3/8/22 noted that R#1 had total aggressive behaviors. She had out of control behaviors that could most likely lead to the death of another resident or staff. During an interview on 4/21/22 at 11:36 a.m. R#3 revealed she does not feel safe here, but it was alright. Resident had some confusion during this interview and the interview was stopped. The LPN that entered the note on 3/8/22 in R#1 medical record was not available for an interview. 3. Review of the Admission Record revealed Resident #4 was admitted to the facility on [DATE] with a readmitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Date Set (MDS) Quarterly assessment dated [DATE] revealed Section G Functional Status revealed resident required limited to extensive assistance with one or two persons assist. He did not have impairment to his upper extremities or lower extremities on either side. His BIMS score was 8 indicating moderate cognitive impairment. Review of an Incident/Accident Report dated 3/21/22 revealed that R #4 was sitting in the hallway by the nurse's station when another resident walked up to him and slapped this resident in the face. No apparent injuries noted Review of the nurse's note revealed an entry dated 3/29/22 that R #4 was sitting in his wheelchair at the nursing station requesting coffee and was returning to his room. On return to his room, a female resident (R#1) was noted to dart away from a 1:1 sitter, and slapped R #4 open handed, in the back of his head. R #4 voiced being upset because this was the second time the female resident (R#1) had slapped him in his head. There was no evidence that the 3/21/22 incident was documented in the medical record for R#4. During an interview on 4/21/22 at 11:54 a.m. R #4 revealed that he was sitting in his wheelchair and the lady (R #1) walked up to him and slapped him in the face. He thought it was a love tap initially, but he became mad when she came to his room and hit him in the back of the head the second time. 4. Review of the Admission Record revealed Resident #2 was admitted to the facility on [DATE] with a readmitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Date Set (MDS) Quarterly assessment dated [DATE] revealed Section G Functional Status revealed resident required extensive assistance to total dependent on one or two persons. She was noted to have impairment to upper extremities and her lower extremities on both sides. Her Brief Interview for Mental Status (BIMS) was 04 indicating severe cognitive impairment. Review of the Situation Background Assessment and Recommendation (SBAR) Communication Form dated 2/26/22 revealed R#2 was bitten by another resident (R#1). The Skin evaluation section revealed multiple teeth marks on forehead, and the skin was broken. The family was notified. The Nurse Practitioner (NP) HHHH give orders for [MEDICATION(S)] 500 milligram (mg) by mouth four times a day for seven days. Review of the nurse's note revealed entry dated 2/26/22 that the nurse was summoned to the room by the CNA who was reporting a physical altercation. When entering the room Resident #1 was on the floor and Resident #2 was in her chair with the CNA standing between them. Resident #2 had bite marks on the forehead with blood noted and Resident #1 had red marks on her hands. During an interview on 5/2/22 at 3:09 p.m. Licensed Practical Nurse (LPN) GGG revealed that Certified Nurse Aide (CNA) WWW and CNA VVV were the first two people that went in the room when R#1 bit R#2 on the forehead. R#2 was sitting in her Broda chair and had bite marks on her forehead. R#2 had R#1 by the hair with her left hand (non-dominant) and R#1 was sitting on the floor. The residents were separated, and R#1 was placed on 1:1 observation. During an interview on 5/9/22 at 12:24 p.m. CNA VVVV revealed that he heard a loud scream, and when he got to the room, he saw that it was R#1. R#2 had pinned R#1 down on the floor with her good arm. R#1 was trying to bite R#2 again. He reported that he separated the two residents. R#2 was bleeding from the forehead and had teeth marks that were visible. CNA WWW removed R#1 from the room. R#2 has a scar from the bite mark. During an interview on 5/10/22 at 11:00 a.m. CNA WWW revealed that she heard R #2 hollering and ran into her room. She saw R #1 lying on the floor and R#2 had R#1 by the hair. R#1 was screaming, and the bite mark area on R#2's forehead was swollen that evening. It was reported that on the following day you could see the teeth print on R #2's forehead. 5. R#1 resided at the facility from 2/21/22 through 3/29/22, on the West Hall secured unit, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 3/5/22 Admission Minimum Data Set (MDS) assessment revealed that R#1 was independently ambulatory without an assistive device. A review of facility reported incidents revealed a Facility Incident Report Form, dated 3/11/22, that documented an allegation of staff to resident abuse. The form included that the allegation involved R#1 and LPN GG and had occurred on the morning of 3/10/22. A further review of the form revealed that R#1 had an abrasion to the left inner bottom lip and that the police, responsible party and physician were notified. LPN GG was also suspended pending the final investigation. A review of the accompanying investigation that included a staff witness statement, police reports, and a follow up summary conclusion revealed evidence that the allegation was substantiated, and LPN GG was terminated on 3/15/22. The investigation revealed that while CNA II was assisting LPN GG and LPN HH to administer an injection to R#1 for combative behavior, LPN GG punched R#1 in the mouth, causing injury to R#1's lip. Corporate Senior [NAME] President (VP) FF and corporate Regional [NAME] President (RVP) CC, the staff who completed the initial reporting and investigation of the allegation of LPN GG physically abusing R#1, were interviewed on 5/2/22 at 11:15 a.m. During the interview, VP FF stated they became aware of the allegation when they conducted staff interviews (on a different incident) on 3/11/22. CNA II reported to VP FF, on 3/11/22, that she had witnessed LPN GG hit R#1 on 3/10/22. RVP CC stated that LPN GG was the night shift nurse going off shift and LPN HH was the day shift nurse coming on shift when the incident occurred (on the morning of 3/10/22). RVP CC stated that LPN GG and LPN HH were related to each other. During the interview with VP FF and RVP CC on 5/2/22 at 11:15 a.m., they stated that they had attempted to make contact with LPN GG or LPN HH via phone calls and letters sent via certified mail but had not heard from either one of them; both nurses had been terminated. During a subsequent interview on 5/2/22 at 1:35 p.m., RVP CC confirmed that warrants had been made for LPN GG and LPN HH. A review of the 3/10/22 police department incident report revealed that an officer responded to the facility at 8:01 a.m. for an altercation that occurred between R#1 and LPN GG. LPN GG alleged in the police report that R#1 physically attacked her, then R#1 punched herself in the mouth and said she was going to blame it on LPN GG. Further review of the police report revealed that R#1 alleged that a nurse had hit her in the mouth, and the officer observed bleeding from her mouth. R#1 was transported to the emergency room following the incident. A review of the 3/10/22 emergency room Physician Report revealed R#1 was noted with an injury to the lower lip and scratches on the face. R#1 returned to the facility on [DATE]. LPN HH documented in a 3/10/22 7:05 a.m. nurses note that R#1 exited her room to charge at LPN GG and attempted to hit the nurse. Her attempts were blocked with her hands held and R#1 dropped herself to the floor then began kicking LPN GG. LPN GG stepped back and R#1 asked for help to get up and as LPN GG assisted R#1 to get up, R#1 slapped LPN GG in the chest and bit her finger. The nurse's note further documents that R#1 then hit herself in the face and stated that she was going to say LPN GG did it so she would lose her job. Review of CNA II's written statement, dated 3/11/22, revealed that on 3/10/22 she witnessed physical abuse. The statement included that R#1 was acting out and LPN HH was going to give her an injection. LPN GG held R#1 down so LPN HH would give the injection and that CNA II held R#1's hands. Further review of the statement from CNA II revealed that LPN GG hit R#1 in the mouth with her fist, twice. During an interview on 5/11/22 at 11:25 a.m., CNA II confirmed the written statement that had been obtained from her on 3/11/22. She stated that on 3/10/22 R#1 was off the chain early that morning; LPN GG was still there from night shift and LPN HH had come in for the day shift. They were going to give R#1 an injection. The nurses were holding R#1 down, but R#1 was still swinging at the nurses, so CNA II held her hands. Then, LPN GG punched R#1 in the mouth twice and busted R#1's lip. CNA II stated the incident occurred in R#1's room. When CNA II was asked what LPN HH's reaction was to LPN GG hitting R#1, CNA II stated that LPN HH commented to CNA II that R#1 had hit LPN GG earlier in the chest and bit her finger. CNA II stated that she did notice redness to LPN GG's chest. When CNA II was asked during the interview if she had ever seen R#1 hit herself and say she was going to blame it on someone else, CNA II stated no, but that is what the nurses told the police had happened. CNA II stated that R#1 liked to hit everyone else, not herself. 3/10/22 Following CNA II's statement on 3/11/22, the police were notified. A review of the 3/11/22 police department incident report revealed that RVP CC reported that on 3/10/22 LPN GG and LPN HH held R#1 down to give her an injection. While holding R#1 down, LPN GG hit the resident two times in the mouth, busting her lip. The report included that CNA II was also present when the incident occurred and had reported it to RVP CC (on 3/11/22). The police report documented warrants would be taken out on LPN GG and LPN HH. 6. Review of facility reported incidents revealed a Facility Incident Report Form, dated 3/10/22, that documented an allegation of staff to resident verbal abuse. The form included that the allegation involved LPN AA and the residents on the West Hall secured unit, with an unknown date and time of occurrence. Further review of the form revealed that LPN AA was suspended pending the final investigation. A review of the accompanying investigation that included staff statements, resident interviews, police report, letter sent out to responsible parties, and a follow up summary conclusion revealed evidence that the allegations of verbal abuse were substantiated. LPN AA was terminated on 3/15/22. A review of the Separation Notice and timecard information for LPN AA revealed that 3/10/22 was the last date she worked at the facility. During an interview on 5/2/22 at 11:15 a.m. with corporate VP FF and corporate RVP of Operations CC, they stated that they received an email and a call on the evening of 3/9/22 from Regional Director of Business Development FFFF. Regional Director FFFF had visited the facility and in speaking with Admissions staff, had concerns of possible abuse at the facility. One of the specific allegations she reported to them was of verbal abuse of the residents on the West Hall secured unit by LPN AA. They confirmed initially suspending LPN AA and speaking to her at that time and again when they terminated her (via phone) and stated that she denied the allegations and said it was all lies. Continued interview with VP FF and RVP CC confirmed that they terminated LPN AA based on the information they obtained in the documented staff interviews for threatening to take away resident assistive devices and smoking privileges. During a subsequent interview with corporate VP FF on 5/5/22 at 2:00 p.m. she confirmed that she and RVP CC, following the allegations they received on the evening of 3/9/22, were at the facility on 3/10/22 and 3/11/22 and through that weekend conducting an investigation. A review of the staff statements, obtained by corporate staff on 3/10/22 and 3/11/22, revealed two specific residents named in the allegations of verbal abuse; R#6 and R#12, who both resided on the West Hall secured unit. A review of the 3/11/22 written statement for Activity Director LL revealed that LPN AA was very firm and had stated to residents that their smoking privileges were taken away. During an interview on 5/23/22 at 2:10 p.m., Activity Director LL stated that LPN AA would take R#12's walker and smoke breaks away from him and would say it was for behavior modification. Activity Director LL stated that R#12 would come out in the hall anyway and hold onto the railing to walk and they would tell him to go back to his room. A review of the of the 3/11/22 written statement from Admissions staff KK revealed that LPN AA would tell residents to get back in their rooms. One resident (unnamed) told LPN AA no and LPN AA responded that she would take their walker away. A review of the 3/11/22 written statement from LPN JJ revealed that she witnessed verbal abuse of more than one resident by LPN AA. LPN JJ's statement included that R#12 asked LPN AA for pain medicine and LPN AA kept telling him to get to his room; that she did not want to hear his complaints. The statement also included that LPN AA took R#6's wheelchair away from her because the resident kept coming out of her room, and that LPN AA threatened to take residents smoking breaks away if they did not stay in their rooms. LPN JJ's statement documented that she reported the verbal abuse to Administrator BB. During an interview on 5/24/22 at 1:57 p.m., LPN JJ confirmed her documented statement from 3/11/22. She stated that the abusive behavior she witnessed from LPN AA on the West Hall secured unit occurred in December 2021 and January 2022 and that she reported it to the Administrator each time because she did not think it was right. LPN JJ stated that after LPN AA took R#6's wheelchair away, she (LPN JJ) took the wheelchair back to the resident and reported it to the Administrator. LPN JJ included that what she witnessed occurred during a COVID-19 outbreak at the facility (in December 2021 and January 2022) and residents on other halls were encouraged to stay in their rooms, but if they came out, they were allowed to. Review of State Agency Facility Reportable Incidents revealed no evidence that these incidents were reported by the facility in December 2021 and January 2022. 7. Review of the Admission Record revealed Resident #6 was admitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Date Set (MDS) Quarterly assessment dated [DATE] revealed Section G Functional Status revealed R #6 was independent to limited assist. She did not have any impairment to her upper extremities or her lower extremities on either side. Her BIMS score was a 11 indicating moderate cognitive impairment. On 3/26/22, R#6 was slapped by another resident (R#11). The medical records noted that R#6 was mocking the sound of R#11 and that R#11 slapped R#6 on the left cheek. There were no injuries. Review of the nurse's note dated 12/15/21 through 4/12/22 revealed that there was no evidence of the incident that occurred on 3/11/22, when R#6 had a bruised upper right lip because of R#1. A written statement obtained on 3/11/22 revealed that R#6 was noted to have a bruise on her right upper lip. The corporate RVP CC and corporate VP FF wrote that R#6 stated that the girl (referring to R#1) did that to her the other day. There was no evidence that the two corporate staff investigated R#6's statement. During an interview on 5/2/22 at 11:18 a.m. the corporate RVP CC and corporate VP FF revealed that all the interviews in the investigation package was done on 3/11/22 by them. During an interview on 5/26/22 at 3:28 p.m. Licensed Practical Nurse (LPN) DDDD unit manager revealed that she witnessed on 3/26/22 R#6 was standing near the nursing station. The medication cart was separating the two residents (R#6 and R#11). R#6 had come up to her to ask her for something. R#11 started making that noise and R#6 started making the same sound with body gestures. R#11 slapped R#6 on the cheek. LPN DDDD reported that to her knowledge, this was the first time R#11 had slapped another resident. 8. Record review revealed that Resident (R) #9 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#11's clinical record revealed that she was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Both R#9 and R#11 resided on the West Hall secured unit. A review of facility reported incidents revealed a Facility Incident Report Form, dated 4/21/22, that documented an allegation of staff to resident abuse. The form included that the allegation involved agency LPN VV and resident information being posted on social media. Further review of the form indicated that the incident occurred on 4/15/22. The police were notified, and LPN VV was suspended and placed on a do not use list while an investigation continued. A review of the accompanying investigation documentation that included a police report and summary conclusion of the investigation revealed evidence that LPN VV mentally abused R#9 and R#11 by posting videos of the residents on social media. A review of the 4/21/22 police department incident report documented that an officer was initially dispatched to the facility on [DATE] at 12:53 p.m. in reference to a report of videos of R#9 and another resident being posted on social media. The report included that RVP CC reported to the officer that the videos included LPN VV making sexual comments to R#9 and of R#11 screaming as they went to hunt Easter eggs outside. The report documented that the officer made a second trip to the facility that same day, on 4/21/22, after RVP CC was able to obtain the videos. The report detailed that the officer recorded the videos on his body camera. The officer's documented observations of the videos included LPN VV recording R#9. LPN VV repeated sexual comments R#9 was saying. R#9's back was visible in the video. The report also included that a female resident's face was visible. The videos LPN VV posted to social media were viewed on 5/3/22 at 2:50 p.m. There was a total of five short videos. The first video included LPN VV looking at and speaking directly into the camera with R#9 visible behind her. The back of R#9's head and back are in the frame and his voice was audible. LPN VV prompted R#9 to repeat sexual comments that he had previously made to her. LPN VV then repeated what R#9 said to her, which was that he wanted to make love to her. The name and location of the facility are also printed across the screen. The second video included LPN VV looking at and speaking directly into the camera. No residents are visible in the frame, but R#9's voice is audible as LPN VV prompted him to again repeat sexual comments, he had previously made to her. LPN VV then also repeated the sexual comments which included that R#9 wanted to put his penis in LPN VV's vagina. The third video was of a small, cracked window within a door. LPN VV was not visible, but her voice was audible. R#11's face was visible on the other side of the cracked window. The fourth video included R#11 and LPN VV. An electronic/phone generated cartoon emoji smiley face was partially covering R#11's face. In the video, LPN VV talked to R#11. R#11 responded to LPN VV with repeated loud distinctive sounds as a form of communication. The words all day were printed across the screen. The fifth video included LPN VV looking at and speaking directly into the camera while walking outside. R#11 was visible behind her. R#11 made repeated loud distinctive sounds as LPN VV spoke to her. During an interview on 5/5/22 at 2:36 p.m. with corporate VP FF and corporate RVP CC, RVP CC stated that the videos that were posted on a social media platform (by LPN VV) occurred on 4/15/22. She stated that a staff person from a home health agency phoned the facility on 4/21/22 to report the videos to the Administrator, and RVP CC took the call. RVP CC stated that she reported LPN VV to the staffing agency she worked for and worked with their information technology department to obtain a copy of the videos. She stated that she reviewed the videos, and they were disturbing. RVP CC confirmed that the police were also notified. Continued interview with RVP CC, she stated that she interviewed staff and residents, and no one else saw LPN VV make the videos. RVP CC stated that LPN VV only worked at the facility on 4/14/22 and 4/15/22 and there was no indication that videos were made on 4/14/22. 9. Record review revealed that Resident (R)B was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RB resided on the South Hall. A review of facility reported incidents revealed a Facility Incident Report, dated 3/18/22, that documented an allegation of staff to resident abuse. The form included that the allegation involved RB and CNA UU. Further review of the form revealed that RB had no injuries noted, and the physician and responsible party were notified. CNA UU was also suspended with an investigation in progress. A review of the accompanying investigation that included a grievance report, witness statement, resident interviews, and conclusion summary of the investigation revealed that there was evidence that CNA UU verbally abused RB. Social Service Director EEEE documented on a 3/18/22 Resident Grievance/Concern/Complaint Report form that RB reported that the day shift CNAs were mean to him when assisting him with changing soiled briefs or clothing and fussed at him for needing help. The grievance form specifically named CNA UU and included that she threatened to move RB to the West Hall secured unit of the facility if he complained. Social Service Director EEEE included on the grievance report that RB was tearful throughout the interview. Social Service Director EEEE documented an interview with RB's roommate (RC) on a 3/24/22 Written Statement-Detailed Account of Events form. The form included that RC stated that CNA UU did not know how to treat people. CNA UU fussed, did not encourage, and always threatened him with moving to the West Hall secured unit. The form also documented that CNA UU talked roughly to RB. During an interview on 5/23/22 at 10:10 a.m. with RB and RC, RB was immediately tearful. He stated that he had reported CNA UU and that she had been mean to him. RC confirmed RB's statement of CNA UU being mean. Following the facility's investigation, CNA UU was terminated. A review of the Separation Notice, dated 3/31/22, revealed that CNA UU's period of employment ended on 3/28/22. The reason for separation was listed as violation of company policy. 10. Review of the Admission Record revealed that R#11 was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Date Set (MDS) Quarterly assessment dated [DATE] revealed Section G Functional Status revealed R#11 was independent to limited assist. She did not have any impairment to her upper extremities or her lower extremities on either side. Her BIMS score was a 00 which indicated severe cognitive impairment. R#11 care plan dated 3/1/22 revealed that the Resident is at risk for sexual behaviors with other residents. Per Physician, the resident cannot consent to sexual activities due to BIMS score. An entry dated 5/9/22 revealed that R#11 was in bed with another resident, fully dressed, on top of cover. Another entry dated 5/22/22 revealed that R#11was noted in inappropriate sexual activity with another resident. R#11 entered his room. The Interventions/Tasks for 5/9/22 revealed that the crisis nurse was to come to exam resident, but (did not show). She was to be redirected when she attempts to go into another residents room; a police report was filed; reported to state, and to the administrator. On 5/16/22, there was an intervention for medication to be added to manage sexual impulses. On 5/2[TRUNCATED]

Based on interviews, record reviews, and review of the job summaries for Nursing Home Administrator and Director of Nursing (DON), facility Administration failed to effectively oversee an abuse prevention program to promote, foster and maintain an abuse free environment. The facility census was 99. On 6/23/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator BBB and Assistant Director of Nursing (ADON) DDD were informed of the Immediate Jeopardy (IJ) on 6/23/22 at 12:19 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/26/22. At the time of exit on June 29, 2022, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: The facility had a Job Summary for the Licensed Nursing Home Administrator. The primary purpose of the Nursing Home Administrator was to oversee the day-to-day operation of the facility and to review organizational performance. The description included job duties and responsibilities for the categories of resident care and quality of life, human resources, finance, leadership and management, and physical environment and safety. The category of Resident Care and Quality of Life included a job duty to oversee that residents received care in a manner and in an environment that maintained and enhanced their quality of life without abridging the safety of other residents. The category of Leadership and Management included a responsibility to ensure that policies and procedures were developed, implemented, monitored, and evaluated in order to maintain compliance with federal, state, and local rules and regulations. The facility had a Job Summary for the Director of Nursing. The job summary included that the primary purpose of the DON position was to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care was maintained at all times. The job duties and responsibilities included administrative functions, committee meeting functions, personnel functions, nursing care functions, safety and sanitation, equipment and supply functions, care plan and assessment functions, budgeting and planning functions, residents' rights responsibilities, and staff development functions. A review of the list of management changes at the facility revealed that the facility had seven different Administrators since June 2021, six of them since March 2022. The facility's Administrators with their dates of service were as follows: Administrator BB (6/28/21-3/18/22), Administrator OO (3/14/22-3/20/22), Administrator DD (3/21/22-5/4/22), corporate Senior [NAME] President (VP) FF (5/4/2-5/9/22), corporate Regional [NAME] President (RVP) of Operations (5/9/22-5/23/22), Administrator AAA (5/23/22-5/30/22), and Administrator BBB as of 5/31/22. Further review of the list of management changes at the facility revealed that the facility had six different DONs since November 2021. The facility's DONs with their dates of service were as follows: DON FFF (11/19/21-1/19/22), DON PP (11/10/21-3/17/22), DON EE (3/18/22-5/12/22), Regional Nurse Consultant (RNC) BBBB (5/13/22-6/22/22), ADON DDD (6/23/22-6/26/22) and DON ZZZ as of 6/27/22. Facility Administration failed to consistently and effectively oversee areas of the facility that were included in their job descriptions. 1. Administration failed to maintain an environment free from verbal abuse for five residents (R#6, R#12, RB, RG, and RH), mental abuse for two residents (R#9 and R#11), and physical abuse for one resident (R#1), all perpetuated by facility staff. Cross refer to F600 2. Administration failed to maintain an environment free from physical abuse for six residents (R#2, R#3, R#4, R#5, R#6, and R#11) and sexual abuse for one resident (R#22). The physical abuse and the sexual abuse were caused by other residents. Cross refer to F600 3. Administration failed to ensure that one resident (R#1) was free from involuntary seclusion. Administrator BB initiated the involuntary seclusion of R#1 on 2/26/22 by directing maintenance staff to put slide bolt type locks on her room and bathroom doors. Cross refer to F603 4. Administration failed to implement multiple abuse policy components (reporting, investigation, protection) for two physical altercations that occurred on 3/8/22 and 3/9/22 between R#1 and CNA YY. Cross refer to F607 5. Administration failed to ensure that abuse allegations were reported in a timely manner for six residents (R#1, R#4, R#5, R#6, RG and RH). Cross refer to F609 6. Administration failed to ensure that an allegation of verbal abuse of two residents (RG and RH) was thoroughly investigated, and corrective actions implemented, including protection of the residents, in a timely manner. Cross refer to F610 7. Administration failed to ensure that care plans were revised to include physical altercations that occurred with another resident and additional interventions implemented, to prevent recurrence, for four residents (R#3, R#5, R#6, and R#11). Cross refer to F657 8. Administration failed to ensure concerns were identified and QAPI plans implemented, in a timely manner related to the abuse prevention system, including staff to resident abuse allegations, resident to resident abuse, and implementing all components of the abuse polices. Cross refer to F867 During an interview on 5/2/22 at 11:15 a.m. with corporate Senior [NAME] President (VP) FF and corporate Regional [NAME] President (RVP) of Operations CC, they stated that they received an email and a call on the evening of 3/9/22 from Regional Director of Business Development FFFF. Regional Director FFFF had visited the facility and in speaking with Admissions staff, had concerns of possible abuse at the facility. One of the specific allegations she reported to them was of Administrator BB putting a lock on R#1's door. They determined through staff interviews that Administrator BB had a lock installed on R#1's room door and bathroom door and the locks were used at times to confine R#1 to her room. Administrator BB was suspended and subsequently terminated. Continued interview revealed that another allegation that was initially reported to VP FF and RVP CC, by Regional Director FFFF, was of verbal abuse of the West Hall secured unit residents by LPN AA. They suspended and subsequently terminated LPN AA based on the statements obtained from staff interviews. A review of the documented staff statements revealed that Administrator BB was made aware of the allegations of verbal abuse by staff but with no evidence that the allegations were addressed. During the interview, RVP CC also stated that DON PP (DON from 1/10/22-3/17/22) had been out a lot and she had been in the process of progressive discipline of her.

Based on interviews, record reviews, and policy review, the facility failed to identify concerns and effectively implement QAPI plans related to abuse. The facility census was 99 residents. On 6/23/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator BBB and Assistant Director of Nursing (ADON) DDD were informed of the Immediate Jeopardy (IJ) on 6/23/22 at 12:19 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/26/22. At the time of exit on June 29, 2022, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: The facility had a Quality Assurance Performance Improvement Management program, with revision date of August 2021. The program overview documented that the Quality Assurance Performance Improvement (QAPI) program provided an opportunity for the facility to assess current practices and procedures in order to determine a plan for improvement in the quality of care. The program policy specified that the Administrator shall be responsible for the management of the program in the administration of the facility. The policy also included that QAPI committee members should meet at least monthly and more often as needed to identify issues with respect to which QAPI activities were necessary. 1. During an interview with corporate VP FF on 5/5/22 at 2:00 p.m. she confirmed that she and RVP CC, following the allegations they received on the evening of 3/9/22, they were at the facility on 3/10/22 and 3/11/22 and through that weekend, conducting an investigation. Administrator BB was suspended and subsequently terminated. In addition, VP FF stated that they conducted and Ad Hoc QAPI meeting. Following corporate staff entering the building on 3/10/22, an Ad Hoc QAPI meeting was held on 3/11/22. Review of the meeting documentation revealed that the identified concern addressed in the meeting was: inappropriate management of abuse reporting and investigations. Allegations of abuse on the secured unit were not being identified and reported as required. Review of an Inservice Sign In Sheet revealed that the 3/11/22 Ad Hoc QAPI meeting plan was also reviewed on 3/18/22. A review of QAPI performance plans revealed that the following problems were identified and QAPI plans had been developed: 1. Staff were not following abuse policy regarding resident potential identified abuse or allegations of abuse; investigations of abuse; lack of administrative oversight by the abuse coordinator. The start date was listed as 3/9/22 with a completion date of ongoing. 2. Facility leadership was not producing positive resident outcomes nor regulatory compliance; policies regarding Freedom of Abuse were not followed and resident rights were violated. The start date was listed as 3/9/22 with a completed date of ongoing. 3. Violation of resident rights regarding freedom of abuse and the manner in which care and services were provided. The start date was listed as 3/15/22 with a completion date of ongoing. 4. Staff education regarding following abuse policy; investigations of abuse and timely reporting. The start date was listed as 3/15/22 with a completion date of ongoing. Further review of the facility identified problems and plans revealed that the plans shared root cause of lack of leadership/oversight, lack of competent leadership, lack of Administrator and/or DON oversight. As part of the QAPI committee, facility administration failed to identify areas of concern for resident abuse, in a timely manner, and effectively implement interventions to prevent recurrence. During an interview on 6/9/22 at 3:45 p.m., Administrator BBB stated that she could not locate any QAPI plans (from the previous Administration) on abuse prior to March 2022 (when corporate staff entered the facility to investigate abuse allegations). 2. A review of facility QAPI documentation revealed that the QAPI committee met monthly on 8/24/21, 9/21/21, 10/19/21, 11/30/21, and 12/28/21. There was no evidence of an further QAPI meetings until 3/11/22. During an interview on 6/29/22 at 2:10 p.m., Administrator BBB, who had been at the facility since 5/31/22, stated that the Administrator was in charge of QA. She stated that the facility's policy stated they (QAPI committee) would meet monthly. A review of the list of management changes at the facility revealed that the facility had seven different Administrators since June 2021. The facility's Administrators with their dates of service were as follows: Administrator BB (6/28/21-3/18/22), Administrator OO (3/14/22-3/20/22), Administrator DD (3/21/22-5/4/22), corporate Senior [NAME] President (VP) FF (5/4/2-5/9/22), corporate Regional [NAME] President (RVP) of Operations (5/9/22-5/23/22), Administrator AAA (5/23/22-5/30/22), and Administrator BBB as of 5/31/22. The facility had six different DONs since November 2021. The facility's DONs with their dates of service were as follows: DON FFF (11/19/21-1/19/22), DON PP (11/10/21-3/17/22), DON EE (3/18/22-5/12/22), Regional Nurse Consultant (RNC) BBBB (5/13/22-6/22/22), ADON DDD (6/23/22-6/26/22) and DON ZZZ as of 6/27/22.

Based on interviews, record reviews and review of policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts the facility failed to ensure that abuse allegations, including staff to resident and resident to resident altercations were reported in a timely manner for six residents (#1, #4, #5, #6, G, and H). On 6/23/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator BBB and Assistant Director of Nursing (ADON) DDD were informed of the Immediate Jeopardy (IJ) on 6/23/22 at 12:19 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/26/22. At the time of exit on June 29, 2022, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: The facility had a Freedom of Abuse, Neglect And Exploitation; Abuse Prevention: Fast Alerts Standard, with revision date of January 2021. The Reporting/Investigation/Response Policy section of the standard included that any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect is to be thoroughly reported. The policy further documented that all employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly. However, the facility failed to report the involuntary seclusion of R#1 to the State Survey Agency. In addition, the verbal abuse of RG and RH and the resident-to-resident physical altercations involving R#1 and R#4, R#5, and R#6 were not reported in a timely manner to the State Survey Agency. Furthermore, witnessed physical abuse of R#1 by LPN GG was not immediately reported to facility Administration. 1. R#1 resided at the facility from 2/21/22 through 3/29/22, on the West Hall secured unit, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 3/5/22 Admission Minimum Data Set (MDS) assessment revealed that R#1 was independently ambulatory without an assistive device and was continent of bowel and bladder. During an interview on 5/2/22 at 11:15 a.m. with corporate Senior [NAME] President (VP) FF and corporate Regional [NAME] President (RVP) of Operations CC, they stated that they received an email and a call on the evening of 3/9/22 from Regional Director of Business Development FFFF. Regional Director FFFF had visited the facility and in speaking with Admissions staff, had concerns of possible abuse at the facility. One of the specific allegations she reported to them was of Administrator BB putting a lock on R#1's door. They determined through staff interviews that Administrator BB had a lock installed on R#1's room door and bathroom door and the locks were used at times to confine R#1 to her room. RVP CC and VP FF indicated during the interview that they questioned Administrator BB as to why he had the locks installed on R#1's doors and he said it was to protect other residents because he did not know what else to do with R#1. During a subsequent interview with corporate VP FF on 5/5/22 at 2:00 p.m. she confirmed that she and RVP CC, following the allegations they received on the evening of 3/9/22, were at the facility on 3/10/22 and 3/11/22 and through that weekend, conducted an investigation. She stated that Administrator BB was at the facility on 3/10/22 and they suspended him and sent him home that day. Following the suspension of Administrator BB on 3/10/22 and initiation of an investigation, by corporate staff, into the allegations of involuntary seclusion of R#1, Administrator BB was terminated. A review of the Separation Notice and Worksite Employee Termination/Separation forms revealed that he was terminated on 3/14/22, with his last date worked as 3/10/22. The reason for separation was listed as violation of company policy. Corporate RVP CC also reported Administrator BB to local law enforcement on 3/11/22. Facility corporate staff investigated the allegation of involuntary seclusion of R#1, notified the police, and suspended and subsequently terminated Administrator BB. However, there was no evidence that the allegation was reported to the state survey agency. The facility did submit an allegation involving Administrator BB to the State Survey Agency, but it was for a different occurrence. A review of facility reported incidents revealed a Facility Incident Report Form, dated 3/11/22, that alleged potential inappropriate management of abuse reported by Administrator BB. The form documented that abuse investigations did not follow policy and Administrator BB was suspended pending investigation. A summary of the completed investigation, dated 3/17/22, referenced Administrator BB's failure to address a separate matter; allegations of verbal abuse that were reported to him. Neither the initial Facility Incident Report Form nor the follow-up summary included any information concerning the involuntary seclusion of R#1, that was initiated by Administrator BB. During the interview on 5/2/22 at 11:15 a.m., RVP CC stated that the initial report (to the state survey agency) from 3/11/22, about Administrator BB, was meant to be all inclusive, including the involuntary seclusion allegations. They did not do a separate report. Cross refer to F603 2. A review of facility reported incidents revealed a Facility Incident Report Form, dated 3/11/22, that documented an allegation of staff to resident abuse. The form included that the allegation involved R#1 and LPN GG and had occurred on the morning of 3/10/22. A further review of the form revealed that R#1 had an abrasion to the left inner bottom lip and that the police, responsible party and physician were notified. LPN GG was also suspended pending the final investigation. A review of the accompanying investigation that included a staff witness statement, police reports, and a follow up summary conclusion revealed evidence that the allegation was substantiated, and LPN GG was terminated on 3/15/22. The investigation revealed that while CNA II was assisting LPN GG and LPN HH to administer an injection to R#1 for combative behavior, LPN GG punched R#1 in the mouth, causing injury to R#1's lip. LPN HH documented in a 3/10/22 7:05 a.m. nurses note that R#1 exited her room to charge at LPN GG and attempted to hit the nurse. Her attempts were blocked, and her hands held, and R#1 dropped herself to the floor then began kicking LPN GG. LPN GG stepped back, and R#1 asked for help to get up and as LPN GG assisted R#1 to get up, R#1 slapped LPN GG in the chest and bit her finger. The nurse's note further documented that R#1 then hit herself in the face and stated that she was going to say LPN GG did it so she would lose her job. Review of CNA II's written statement, dated 3/11/22, revealed that on 3/10/22 she witnessed physical abuse. The statement included that R#1 was acting out and LPN HH was going to give her an injection. LPN GG held R#1 down so LPN HH would give the injection and that CNA II held R#1's hands. Further review of the statement from CNA II revealed that LPN GG hit R#1 in the mouth with her fist, twice. Corporate VP FF and corporate RVP CC, the staff who completed the initial reporting and investigation of the allegation of LPN GG physically abusing R#1, were interviewed on 5/2/22 at 11:15 a.m. During the interview, VP FF stated they became aware of the allegation when they conducted staff interviews (on a different incident) on 3/11/22. She stated that CNA II sought her out and told her the next day about the incident, VP FF stated that after CNA II spoke to her, VP FF did observe R#1 and saw her busted lip and R#1 told her at that time that the nurse had hit her. RVP CC stated that LPN GG was the night shift nurse going off shift and LPN HH was the day shift nurse coming on shift when the incident occurred (on the morning of 3/10/22). RVP CC stated that LPN GG and LPN HH were related to each other. Continued interview with VP FF and RVP CC on 5/2/22, they stated that they had attempted to make contact with LPN GG and LPN HH via phone calls and letters sent via certified mail but had not heard from either one of them, and both nurses had been terminated. During an interview on 5/11/22 at 11:25 a.m., CNA II confirmed the written statement that had been obtained from her on 3/11/22, that she reported it to VP FF the next day, on 3/11/22. She further revealed that LPN GG punched R#1 in the mouth twice and busted R#1's lip. When CNA II was questioned as to why she waited to report the physical abuse until the following day, CNA II responded that the facility did not have an Administrator, and she did not know who to talk to, and she was in shock. Following CNA II's statement on 3/11/22, the police were notified. The altercation between R#1 and LPN GG occurred on 3/10/22 and was witnessed by CNA II and LPN HH. However, it was not reported to the facility corporate administrative staff until the following day, on 3/11/22, by CNA II. There was no evidence that LPN HH reported the altercation to anyone. Cross refer to F600 3. Review of the Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, revision January 2022. Reporting/Investigation/Response Policy. Any complaint, allegation, observation or suspicion of resident abuse, mistreatment, or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be communicated to the Abuse Coordinator, thoroughly reported, investigated, and documented in a uniform manner as detailed below. The intent of the regulation is that as soon as the facility is aware of a situation that meets the reporting requirements, they must immediately notify the administrator, and other officials in accordance with State Law, including the State Survey Agency. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the Admission Record revealed R#4 was admitted to the facility on [DATE] with a readmitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Incident Report Form dated 3/21/22 revealed that Resident #4 was sitting in the hallway by the nurse's station, when R#1 walked up to R#4 and slapped him in the face. There was no evidence of a final report submitted to the State Survey Agency until 5/26/22. 4. Review of Admission Records revealed R#5 was admitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medical records of R#5 revealed no evidence of documentation of the incident that occurred on 3/5/22. However, the medical records of R#1 revealed that on 3/5/22, R#1 was seen in R#5 room with her hands and arm around R#5's neck. R#5 was yelling for help. Review of the Facility Incident Report Form dated 4/28/22 revealed resident to resident abuse that occurred on 3/5/22. R#1 was choking R#5. There was no evidence that the facility reported the resident-to-resident abuse (between R#1 and R#5) on 3/5/22 to the State Survey Agency. 5.Review of the Admission Record revealed R#6 was admitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a written statement on 3/11/22 per VP FF, that during the initial investigation of R#1, R#6 had reported that R#1 had bruised her lip. There was no evidence of an investigation until 4/28/22. Review of the Facility Incident Report Form dated 4/28/22 revealed R#6 was not investigated during the initial abuse investigation on 3/10/22 and 3/11/22 by RVP CC and VP FF. There was no evidence that the facility reported the abuse on 3/10/22 or 3/11/22 during the initial abuse investigation in March 2022 to the State Survey Agency. 6. Review of the Admission Record revealed that Resident G was admitted to the facility with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Record revealed that Resident H was admitted to the facility with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Incident Report Form dated 6/8/22 revealed that the State Survey Agency did not receive the staff to resident abuse report, that occurred on 4/24/22, until 6/8/22 at 3:51 p.m. for R G and R H. On 5/31/22 at 3:54 p.m. the RVP CC was unable to provide evidence that the state reportable had been filed, or that the investigation had been conducted on the alleged verbal abuse. During this brief meeting, she stated that she had delegated the task to RNC BBBB and that she would oversee that the reportable was done and the incident investigated. There was no evidence that the state reportable was filed nor the investigation initiated until 6/8/22 for verbal abuse by LPN ZZ towards R G and R H. Cross Reference F600

Based on interview, record review, and policy review titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to implement multiple abuse policy interventions (reporting, investigation, and protection) for two staff to resident physical altercations that occurred on 3/8/22 and 3/9/22 and involved R#1. The sample size was 40. On 6/23/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator BBB and Assistant Director of Nursing (ADON) DDD were informed of the Immediate Jeopardy (IJ) on 6/23/22 at 12:19 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/26/22. At the time of exit on June 29, 2022, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: The facility had a Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts Standard, with a revision date of January 2021. The abuse standard included the required components of screening, training, prevention, identification, investigation, protection, and reporting. However, the components of investigation, protection and reporting were not implemented for two altercations that occurred involving R#1 and CNA YY. Record review revealed that R#1 resided at the facility from 2/21/22 through 3/29/22 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She resided on the West Hall secured unit. A review of R#1's clinical record revealed nurses notes entries from 3/8/22. A 3/8/22 4:00 p.m. nurse's note entry documented that R#1 threw a cup at another resident then attacked the resident. Staff responded and separated the residents. R#1 then ran down the hall to attack the resident again. Once again staff separated the residents, and R#1 calmed down. At 5:10 p.m., a nurse's note entry documented that R#1 was standing at the medication cart and instantly walked over to a staff person and started choking her without provocation. Other staff separated R#1 from the attacked staff person. R#1 is documented as attacking the staff member again. When R#1 was held to stop her, she got loose and attacked again. Additional staff attempted to redirect R#1 to her room, but R#1 fell on the floor instead, and refused to get up. At that time four police officers were on the unit after R#1 called 911. Review of the 3/8/22 police report revealed that an officer was dispatched to the facility at 5:31 p.m. because a resident complained that a nurse hit her in the face. Emergency Medical Services (EMS) also responded. The officer included that he observed R#1 sitting on the floor and that she would only moan and attempt to put a shirt on that she had in her hands. EMS personnel was also present and assisted R#1 to her room, while the officer spoke with the staff member involved. The police report referenced staff member YY as a nurse, however, staff member YY was a CNA. CNA YY reported that R#1 attacked her. The report included that R#1 approached CNA YY like she was going to hug her, but then attacked instead. The report documented that CNA YY stated she defended herself, striking R#1 in the face. Following the altercation on 3/8/22, R#1 was sent to the emergency room . A review of the hospital emergency room documentation revealed documentation of a reddened area around R#1's neck. The documentation included that R#1 was evaluated by a mobile crisis team and was noted to be stable and not meeting criteria for a 1013 and would be discharged back to the nursing home. The following day, a 3/9/22 nurse's note entry in R#1's clinical record documented that she returned to the facility at 12:00 p.m. Further review of the clinical record revealed that after returning to the facility on [DATE] at 12:00 p.m., a 3/9/22 12:10 p.m. nurse's note entry revealed that licensed nursing staff administered an injection of [MEDICATION(S)], Benadryl and [MEDICATION(S)] due to increased aggression and R#1 attempting to fight staff. There were no further nurses' notes for 3/9/22 after the 12:10 p.m. entry. However, a Form 1013- Certificate Authorizing Transport to Emergency Receiving Facility and Report at Transportation form was completed by Nurse Practitioner HHHH on 3/9/22 as having examined R#1 at 2:18 p.m. The 1013 form documented that R#1 was combative and violent; that she endorsed command hallucinations, destroyed property and attempted to assault staff and residents. A One on One Documentation for Resident Supervision/24 Hours form, dated 3/9/22 documented one on one supervision with hourly comments from 3/9/22 at 11:00 a.m. through 3/10/22 at 6:00 a.m. The form included an entry on 3/9/22 at 2:45 p.m. that documented R#1 attempted to attack a CNA again. Review of a 3/9/22 police department incident report revealed that officers were again dispatched to the facility at 2:54 p.m. for a report of a resident attacking a nurse. EMS also responded. The officer documented that he made contact with Administrator BB upon arrival at the facility. The report documented that Administrator BB reported that R#1 had just attacked CNA YY. The police report noted that no aggressive activity was observed at that time. Staff reported to the officer that R#1 heard voices and that the voices told R#1 to do things. R#1 would try to give someone a hug, but then attack when she got close. EMS personnel transported R#1 to the emergency room to be evaluated. The police report documented that CNA YY stated that she had just come in for her shift and was putting things in her bag when R#1 came up behind her and pulled CNA YY's hair and began attacking her. Administrator BB witnessed the attack and pulled R#1 off CNA YY. The report included that Administrator BB commented on charging R#1 for attacking CNA YY. However, the officer declined to pursue charges due to R#1's altered mental state. Further review of the police report revealed that the officer went and spoke with R#1 at the hospital. R#1 alleged that CNA YY abused her and had attacked her. The police report documented injuries on R#1 that included scratches on the left side of her face along with bruising and swelling under the left eye. There was a scratch on the front left side of the neck and bruising and swelling on the top and bottom of the left hand. There was a scratch and small bruises on the left arm, near the elbow. Pictures of R#1's injuries accompanied the report. Following the altercation on 3/9/22, R#1 was transported to the emergency room . A review of the hospital emergency room documentation revealed documentation of a fresh scratch to the left arm. The documentation included that R#1 did not demonstrate any aggressive behavior in the emergency department and would be discharged back to the nursing home. Despite the documented evidence of physical altercations with injuries occurring between R#1 and CNA YY on 3/8/22 and 3/9/22, there was no evidence that the altercations were reported to the State Survey Agency in a timely manner. In addition, there was no evidence that an investigation of events was conducted, and the CNA involved in the altercations suspended pending the completed investigation. Administrator BB, who was documented in the 3/9/22 police report as being present at the time of the 3/9/22 altercation and being aware of the 3/8/22 altercation, was suspended by corporate staff on 3/10/22 and subsequently terminated for a separate matter. A review of CNA YY's personnel file revealed that she continued to work at the facility without suspension until she was terminated. During an interview on 5/2/22 at 1:35 p.m., RVP CC stated that CNA YY was terminated for being a no call/no show. A review of the Worksite Employee Termination/Separation form revealed that CNA YY's separation was effective 3/30/22, with her last date worked as 3/17/22. Continued interview on 5/2/22, RVP CC also stated that she was not previously aware of the altercations that occurred on 3/8/22 and 3/9/22. Following surveyor inquiry, the facility completed and submitted a Facility Incident Report Form on 5/11/22 to the State Survey Agency for the altercation that occurred on 3/8/22.

Based on record review, staff interview, the facility failed to ensure that care plans were revised to include physical altercations that occurred with another resident (R#1) and additional interventions implemented, to prevent reoccurrence for four residents (R#3, R#5, R#6, and R#11). On 6/23/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator BBB and Assistant Director of Nursing (ADON) DDD were informed of the Immediate Jeopardy (IJ) on 6/23/22 at 12:19 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/26/22. At the time of exit on June 29, 2022, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: 1. Review of the Admission Record revealed Resident #3 was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 5/28/21 revealed that there was no evidence, that on 3/8/22 the care plan was revised to reflect that R #1 had thrown a cup in R#3's face which resulted in a small laceration to the left eye of R#3. 2. Review of the Admission Record revealed R#5 was admitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 8/5/21 revealed that there was no evidence, that on 3/5/22, that R#5 care plan was revised to include the 3/5/22 incident when R#1 had her hand and arm around R#5's neck. Review of the nurses' notes dated 1/19/22 through 3/21/22 revealed that there was no evidence of the neck incident from 3/5/22 when R#1 had her hand and arm around R#5's neck. 3. Review of the Admission Record revealed R#6 was admitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 3/5/20 revealed that there was no evidence, that R#6's care plan was updated to reflect incidents between R#1 and R#6 on 3/10/22 and 3/11/22 which resulted in R#6 receiving a bruised upper lip. 4. Review of the Admission Record revealed R#11 was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 3/1/3/22 revealed that there was no evidence that the care plan had been revised to include an incident or resident to resident abuse which resulted in R#1 choking R#11 on 3/15/22. During an interview on 5/26/22 at 2:48 p.m. Licensed Practical Nurse (LPN) JJ Minimum Data Set (MDS) Coordinator revealed that she was not aware of the 3/8/22 of R#3 incident with R#1. She explained that she was not aware of the incident on 3/5/22 with R#5 and R#1; she was not aware of the 3/11/22 incident involving R#6 and R#1; she was not aware of the 3/15/22 incident of R#11 being choked by R#1. She stated that the care plans had not been revised because she was not aware of the incidents. She stated that normally she would get the incident report. When she gets the incident reports, she would update care plan at that time. She stated she always get copies of the telephone orders every morning (Monday through Friday) and would update the care plan. And had she known, she would have revised the care plan with interventions. Cross refer F600

Based on resident interviews, staff interviews and facility policy Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to ensure that an allegation of verbal abuse of two residents R G and R H was thoroughly investigated, and corrective actions implemented (including protection of resident) in a timely manner. The facility census is 99 residents. On 6/23/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator BBB and Assistant Director of Nursing (ADON) DDD were informed of the Immediate Jeopardy (IJ) on 6/23/22 at 12:19 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/26/22. At the time of exit on June 29, 2022, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Review of the facility abuse policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, revision January 2021. Overview Staff to Resident Abuse. The facility is responsible for the actions of its employees, including intentional acts by employees who are aware they are doing something wrong and are in conflict with the facility 's policies and procedures. Contractors and volunteers are held to the same standard as employees. If a staff is accused of abuse by a resident/family member or another staff person, that staff member is suspended pending investigation. If it is determined the allegation is unsubstantiated through investigation, then the staff member is brought back to work; educated as to preventions, identification, reporting of abuse and allowed to continue to work. Staff observation and monitoring for this staff member will occur through the licensed nurse on duty for a time determine by the Administrator to ensure alleged staff follows Freedom of Abuse policies. If through investigation the staff member is found to be guilty of abuse, then the progressive discipline process will be initiated. Review of a Grievance dated 4/24/22 revealed that on the East Hall two Residents (R G and R H) had reported to the Registered Nurse (RN) XXX that the License Practical Nurse (LPN) ZZ had cursed at them several times when he would give them their medications on the 11-7 shift. The two residents had revealed that they both had dropped their medications on the floor when LPN ZZ started cursing at them. They reported that this has happened on more than one occasion. There was no evidence that this grievance was thoroughly investigated for the alleged allegation of verbal abuse. Review of timesheet for LPN ZZ dated 4/11/22 through 6/8/22 revealed that LPN ZZ continued to work and provide services to the two residents. The timesheet revealed that he worked on 4/24 (day of occurrence), 4/25/22, 4/26/22, 4/27/22, 4/28/22, 4/29/22, 5/1/22, 5/29/22, 5/31/22, 6/1/22, 6/2/22, 6/3/22, 6/4/22, 6/5/22, 6/6/22, and 6/7/22. He also was scheduled to work on 6/8/22. There was no evidence that LPN ZZ was suspended pending the outcome of an investigation. LPN ZZ was suspended pending alleged allegations of verbal abuse for the two residents. A state reportable was filed on 6/8/22 for the 4/24/22 incident involving the two residents. Both residents (R G, R H) had expressed fear of LPN ZZ finding out they had reported him. Further investigation revealed that on 4/9/21, LPN ZZ had another incident of verbal abuse with another resident on South Hall. LPN ZZ was suspended pending outcome of the investigation. He returned to work, and he was educated on Freedom form Abuse, Counterproductive Behavior. During an interview on 5/31/22 at 3:54 p.m. Regional [NAME] President (RVP) CC revealed that she did not have a state reportable on LPN ZZ for cursing and yelling at the two residents. She stated that she had delegated Interim DON/Corporate Regional Nurse Consultant (RNC) BBBB to submit the report. During an interview on 6/2/22 at 10:28 a.m. Resident H revealed LPN ZZ had yelled at her for dropping her medication cup and told her that he was going to have a hard time finding her pills that she had dropped. She stated that the pills did not fall on the floor but on her. She explained that her hands shake a lot and sometimes the shaking was hard to control. She further stated that this was not the first time he had done this. She stated that she was not afraid of being in the facility and felt safe. But, that she did not want him to know that she had said something about him yelling at her. She stated that she was afraid he would find out, she then stated she should have not told anyone. During an interview on 6/2/22 at 10:51 a.m. Resident G revealed that she had dropped her pain medication on the floor. and LPN ZZ told her Got damn it you won't get another one. The pill had dropped on the floor, and he couldn't find the pill. She continued to state that LPN ZZ will get mad at her for telling. She stated that she did not know who to talk to when she is afraid but thinks she can talk to the Business Office Manager (BOM) GGGG but was not sure. An interview on 6/8/22 at 2:50 p.m. RVP CC revealed that she spoke with the interim DON/RNC BBBB and directed her to speak with LPN ZZ. LPN ZZ never got reported to the state agency and that she will do a late state reportable today. Cross Reference F600

Based on interviews, record review, and review of policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to ensure that one resident (R#1) was free from involuntary seclusion when locks were placed on her room and bathroom door and used intermittently by facility staff. Total resident sample was 40. On 6/23/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator BBB and Assistant Director of Nursing (ADON) DDD were informed of the Immediate Jeopardy (IJ) on 6/23/22 at 12:19 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/26/22. At the time of exit on June 29, 2022, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: The facility had a Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts Standard with a revision date of January 2021. The standard defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. The purpose statement of the abuse standard indicated a zero tolerance of abuse of any type or manner. However, R#1 was subjected to unreasonable confinement in her room, intermittently between 2/26/22 and 3/10/22 at the instruction of Administrator BB. R#1 resided at the facility from 2/21/22 through 3/29/22, on the West Hall secured unit, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 3/5/22 Admission Minimum Data Set (MDS) assessment revealed that R#1 was independently ambulatory without an assistive device and was continent of bowel and bladder. Review of a written statement, that was obtained by corporate staff on 3/11/22, revealed that Business Office Manager (BOM) GGGG documented that a CNA on the 3:00 p.m. to 11:00 p.m. shift had complained to her about urine and feces being in R#1's room and that the bathroom door was locked. The written statement also documented that BOM GGGG reported this complaint to Administrator BB. Review of a written statement, dated 3/11/22, revealed that Admissions staff person LL documented that Restorative CNA SS expressed to her the previous Tuesday (3/1/22) about being uncomfortable with a situation on West Hall; that R#1 was being treated poorly, and CNA SS was not comfortable about a lock being put on R#1's door. The written statement documented that Admissions staff LL reported the concern to Administrator BB, and Administrator BB responded that he was aware and was the person who had maintenance staff install the lock (on R#1's door) and that he was protecting other residents. During an interview on 4/26/22 at 2:17 p.m. Housekeeper TT, who provided housekeeping services on the West Hall secured unit, revealed that R#1 was urinating on the floor (in her room) and that she would have to mop the floor two to three times per day. She stated that the lock was on R#1's door for a week, then it was removed. She stated that she only saw two nurses that would let R#1 out of her room, but when R#1 began acting up, they would put her back in her room and slide the bar to lock her back in her room. Review of a 5/2/22 email from Maintenance Director QQ to RVP CC revealed that Administrator BB phoned Maintenance Director QQ on 2/26/22 and asked him to install two draw bolt locks on R#1's room door and bathroom door and did not give any details as to why the locks needed to be installed. The email further documented that Maintenance Director QQ arrived at the facility and met with LPN AA, who directed him where to install the locks. LPN AA indicated to the maintenance director that R#1 had tried to attack a couple of residents during the late night and early morning hours. Maintenance Director QQ documented in the email that he installed the locks on both doors (W5 room door and bathroom door) and left the facility. Further review of the email revealed that when the Maintenance Director returned to the facility on [DATE], he was instructed by Administrator BB to remove the draw bolt lock from R#1's bathroom door and reinstall it on the other bathroom door of the adjoining resident room (W3) that shared that bathroom. He documented in the email that he did as he was asked to do. The email then detailed that Maintenance Director QQ was on vacation from 3/6/22 through 3/14/22. During an interview on 5/2/22 at 11:15 a.m. with corporate Senior [NAME] President (VP) FF and corporate Regional [NAME] President (RVP) of Operations CC, they stated that they received an email and a call on the evening of 3/9/22 from Regional Director of Business Development FFFF. Regional Director FFFF had visited the facility and in speaking with Admissions staff, had concerns of possible abuse at the facility. One of the specific allegations she reported to them was of Administrator BB putting a lock on R#1's door. They determined through staff interviews that Administrator BB had a lock installed on R#1's room door and bathroom door and the locks were used at times to confine R#1 to her room. RVP CC and VP FF indicated during the interview that they questioned Administrator BB as to why he had the locks installed on R#1's doors and he said it was to protect other residents because he did not know what else to do with R#1. During an interview on 5/5/22 at 11:17 a.m., Maintenance Director QQ confirmed what he documented in the 5/2/22 email and that he had installed the locks on the room and bathroom of W5 (R#1's room) on 2/26/22. He stated they were slide bolt type locks. He installed one on the outside of the room door and one on the bathroom side of the bathroom door, confirming that R#1 would not have had access to her bathroom from her room, if the bathroom lock was in use. He confirmed that two days later, on 2/28/22, he removed the bathroom lock from the inside of R#1's door to the bathroom and put it on the outside of the adjoining room's bathroom door (W3), thus giving R#1 access to the bathroom. The Maintenance Director stated that he returned from vacation on 3/14/22 and the locks were not on the doors anymore, but he did not know when they were removed. He stated that he did not see the locks in use. Immediately following the 5/5/22 11:17 a.m. interview, an observation was made with Maintenance Director QQ of room W5 on the secured unit. The Maintenance Director confirmed that the set of holes on the side of W5's bathroom door that was facing the bathroom was from where he installed the slide bolt lock on 2/26/22. He confirmed that a set of holes on the door jamb and exterior part of W5's room door was from where he installed the slide bolt lock. When Maintenance Director QQ was questioned if a person on the other side of the locked slide bolt would be able to get out and he confirmed that they would not be able to get out. During a subsequent interview with corporate VP FF on 5/5/22 at 2:00 p.m. she confirmed that she and RVP CC, following the allegations they received on the evening of 3/9/22, were at the facility on 3/10/22 and 3/11/22 and through that weekend conducted an investigation. She stated that Administrator BB was at the facility on 3/10/22 and they suspended him and sent him home that day. Corporate VP FF stated she went and looked at the West Hall secured unit and the locks were no longer on R#1's doors. During an interview on 5/24/22 at 1:50 p.m., Restorative CNA SS confirmed that she had been uncomfortable with the way R#1 was being treated. She stated that she saw the lock on R#1's door but never saw her locked inside the room. She further stated that she saw the lock one time and that is why she went and told Admissions staff LL. She did not recall the day she saw the lock on R#1's door but stated it was not on there the next day, it had been removed.

Based on resident observation, clinical record review and staff interviews it was determined the facility failed to revise care plans for 11 Residents (R) (R#1, R#3, R#5, R#7, R#13, R#17, R#19, R#23, R#25, R#26 and R#27) out of 27 sampled residents, when the residents had a change of condition/status. Resident #5 and R#7 were harmed when they sustained fractures from unsupervised falls in the facility, which required hospitalization . Their care plans were not revised when they returned from the hospital. The facility's failure to revise care plans and individualize interventions to prevent further elopements, after the elopements of R#3, R#13 and R#17, and to develop interventions for the care plans for R#23, R#25, R#26, and R#27 who had been assessed to be at high risk for elopement was determined likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 3/15/17 at 10:15 a.m. and determined to first exist on 5/5/16 at 7:20 a.m. when R#13 eloped from the facility. The facility implemented 15 minute monitoring of R13. Approximately 12 hours later on 5/5/16 at 7:50 p.m., R#13 eloped the second time. Documentation indicated that the facility continued with 15 minute monitoring of R#13 and that there were no further interventions implemented. R#13 eloped from the facility again on 5/9/16 at 7:00 a.m. Resident #19 was assessed at moderate risk for elopement and the care plan did not address elopement risk. In addition, the care plans for R#5 and R#7, who had sustained injuries following unsupervised falls, were not revised to include new interventions after the residents returned from the hospital. Actual harm was identified for R#5 and R#7 during the 12/12/16 - 12/16/16 Abbreviated Survey at 42 C.F.R. 483.25 Quality of Care, F323. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 3/15/17 at 10:15 a.m. The Immediate Jeopardy was not removed at time of exit on 3/17/17 at 4:00 p.m. Findings include: 1. Record review of R#13's Admission Minimum Data Set (MDS) assessment (a federally mandated comprehensive assessment tool used for development of an individualized care plan), dated 3/29/16, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment of 3/29/16, the resident's Brief Interview for Mental Status (BIMS) score, (a tool used to assess cognitive status), was three out of 15 which indicated severe cognitive impairment. According to R#13's care plan for At risk for elopement initiated 5/5/16, it stated .place on secure unit and monitor need for placement . R#13 was not moved to the secure unit until 5/9/16 at 8:30 p.m. after his third elopement. The care plan also stated .check resident for whereabouts at least every 15 minutes, document . No timeframe was noted for the 15 minute checks and they were discontinued on 5/6/16 at 7:00 a.m. Furthermore, the care plan did not reflect R#13's initial Elopement Risk Assessment, dated 3/29/16, which was scored at 18 and the updated Elopement Risk Assessment dated 5/9/16, which was scored at 30. Both assessments indicated high risk for elopement. 2. According to the R#17's Admission Record, the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the R#17's MDS dated 1/28/17, the resident had a BIMS score of eight out of 15, which indicated the resident was moderately cognitively impaired. During review of the facility's 2017 Incident/Accident Reports during the investigation from 3/14/17 through 3/17/17, it revealed that R#17 had an elopement on 1/28/17 at 10:15 a.m. According to R#17's care plan for At risk for elopement, initiated 1/28/17, it stated .place on secure unit and monitor need for placement . R#17 was not currently, nor had he been on the secure unit. Additionally, the care plan did not reflect R#17's initial Elopement Risk Assessment dated 5/25/16 which was scored at 12 or the Elopement Risk Assessment, reviews on 8/25/16 which was scored at 12 and 12/1/16 which was scored at 12. A new Elopement Risk Tool dated 1/17/17 stated R#17 scored a 5, which indicated he was at high risk for elopement. The Elopement Risk Tool stated .develop resident specific care plan for scores of 3 or higher . 3. R#3 was admitted to the facility on [DATE] per the Admission Record with the [DIAGNOSES REDACTED]. Review of R#3's Nurse's Note dated 9/25/16 revealed that R#3 eloped from the secured unit of the facility. R#3 indicated in his statement that he exited the secure unit and went out through an unlocked gate. Cross reference F323 incident report dated 9/25/16 and staff interviews. Review of R#3's Elopement Risk Assessment dated 7/1/16 revealed a score of 22. Refer to F323 for complete details regarding the Elopement Risk Assessment. Refer to the interview with Director of Nursing (DON) on 3/15/17 at 3:35 p.m. in which the DON confirmed that the facility failed to develop an elopement care plan for R#3 until after he eloped on 9/25/16. Review of R#3's undated Elopement Risk Tool, revealed a score of 6. Located on the assessment was a legend that indicated, Conclusion Score 5 or above high risk of elopement. Refer to F323 for complete details regarding the undated Elopement Risk Tool. The care plan was updated on 9/25/16 with the problem, Eloped from facility . The interventions included in the care plan included, notify MD (medical doctor), Administrator, guardian and DON/ADON (Assistant Director of Nursing), place resident on 15 min (minute) checks, investigate reason he eloped. During interview on 3/15/17 at 10:00 a.m., the DON confirmed that R#3's care plan for elopement was not developed until 9/25/16 after his elopement from the facility's secure unit. Further, the DON confirmed that R#3's care plan was not revised with appropriate interventions when R#3 was assessed per the facility's Elopement Risk Tool as a score of 6 (high risk) then as a score of 9 (still high risk.) 4. According to R#27's Admission Record, the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Clinical record review revealed R#27 was admitted to the West unit (secure unit) on initial admission. According to the Elopement Risk Tool dated 10/6/16, R#27 scored an 8 which indicated she was at high risk for elopement. On 12/29/16, R#27 was moved off the secure unit, onto the East unit, which is a general, unsecured unit. A revised Elopement Risk Tool was completed on 1/12/17, where R#27 scored a 6, which indicated she remained at high risk for elopement. According to R#27's care plan for At risk for elopement, initiated 1/18/17, it stated .place on secure unit and monitor need for placement . No changes were noted to the care plan to indicate that R#27 was moved off the secure unit on 12/29/16. During interview with the Administrator on 3/16/17 at 9:30 a.m., the Administrator confirmed R#3, R#13, and R#17's care plan had not been revised. Cross reference F323. 5. Review of R#23, R#25, R#26 and R#27's Elopement Risk Tool revealed the care plans were not individualized based on this assessment tool: Review of R#23's Elopement Risk Tool dated 1/17/17 revealed a score of 5. Refer to F520 for complete details of the document. Review of R#25's Elopement Risk Tool dated 2/1/17 revealed a score of 5. Refer to F520 for complete details of the document. Review of R#26's Elopement Risk Tool dated 1/18/17 revealed a score of 5. Refer to F520 for complete details of the document. Review of R#23, R#25, R#26 and R#27's care plans revealed the same interventions. Refer to F520 for the interventions. Refer to interview with the DON on 3/15/17 at 10:00 a.m. in which the DON confirmed that R#23, F#25, R#26 and R#27's care plans were not individualized to reflect current interventions, especially if the resident no longer resided on the secure unit. 6. According to R#19's Electronic Medical Record (EMR) profile, the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#19's most recent MDS assessment, dated 1/24/17, revealed the resident had a BIMS of 15 out of 15, which indicated he was cognitively intact. The MDS further revealed the resident exhibited no wandering behavior during the 7-day assessment period. A review of R#19's Elopement Risk Tool dated 1/17/17 indicated the resident had a score of 4 for elopement. According to the Conclusion: noted at the bottom of the tool, a score of 4 indicated the resident had a moderate risk for elopement. The tool indicated the resident had the ability to make his own decisions and wanted to go to a personal care home, however it did not include information that would indicate the resident would leave without notifying staff. The resident's Care Area Assessment (CAA) worksheet, which contained further investigation into the MDS information, related to R#19's cognitive issues, revealed that due to the resident's history of mental illness, he required supervision and oversight. The same analysis indicated the resident was able to . make informed decisions concerning his care. R#19's care plan for the focus care area of elopement, which was related to the resident's .score on elopement risk assessment ., initiated 1/17/17, revealed no limitations on the resident's movement in and out of the facility. The interventions included: - Distract from wandering by offering pleasurable diversions, such as food, conversations, television, books, music - Redirect if resident attempts to elope - Attempt to make resident feel secure and safe within facility. On 3/14/17 at 5:20 p.m. R#19 was observed outside at the front of the facility building clipping roses from a rose bush. There was no staff observed outside, nor could staff see the resident at the rose bush by looking out from inside the facility. 7. R#1, per the clinical record, was admitted with [DIAGNOSES REDACTED]. R#1's care plan, dated 8/31/16, with a focus on the resident's risk for falls, related to her use of a [MEDICAL CONDITION] drug ([MEDICATION NAME]) and history of threatening to throw herself onto the floor, indicated the resident had followed through on her threat by lowering her bed and sliding her body onto .the floor when getting upset with staff. Cross reference F319 psychosocial difficulty. A Nurse's Note dated 12/13/16, revealed R#1 was found on the floor, talking on her cell phone, by the Certified Nursing Assistant (CNA). R#1 lowered her bed and rolled herself onto the floor. R#1 was observed later that day, at 11:30 a.m. lying in her bed. The bed was raised several inches from the floor. During the observation, the resident confirmed she had her cell phone with her on the floor. She said did not know how she got on the floor. She said other than back pain, she had no other injuries. Despite the care plan focusing on the resident's risk for falls and the resident's threats and follow through with her behavior of lowering her bed and rolling to the floor, the care plan interventions did not address ways to attempt to prevent the resident from injuring herself from rolling onto the floor. An interview with the MDS coordinator, Licensed Practical Nurse (LPN) BB and the ADON, on 12/14/16 at 10:25 a.m. confirmed the facility was aware of the R#1's behavior of lowering her bed and rolling onto the floor. LPN BB indicated the behavior began directly after the resident was admitted to the facility in 2013. LPN BB said the staff had tried to change the behavior. She confirmed the resident had not had any injuries related to the behavior. When asked, what intervention was in place to prevent the resident from injuring herself, LPN BB, nor the ADON could share interventions to keep the resident safe from injuries. LPN BB confirmed there was no mat used on the floor. While visiting with R#1 on 12/15/16 at 9:10 a.m., the resident was able to utilize her bed remote to change the height position of her bed with the controls. Her bed was observed in the high position at that time. Observations of R#1 the same day at 10:10 a.m., during incontinent care, revealed the resident could roll herself over onto her left side. 8. R#5 was readmitted to the facility on [DATE], after a hospital stay for a fall on 9/19/16 that resulted in a subdural hematoma. Review of R#5's care plan showed the care plan had been updated on 9/12/16 for a fall to include. 1) Keep bed in low position. 2) Bedside mat to floor. The care plan did not address the fall of 9/19/16 or R#5's subdural hematoma or the fact that R#5 was now on comfort care. During an interview on 12/13/16 at 2:30 p.m., MDS Coordinator LPN BB stated the care plan had not been updated when R#5 returned from the hospital. 9. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/21/16 quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated R#7 had severe cognitive impairment, and had not had any recent falls. The resident's balance at G300, Balance during transfers and walking documented the resident was unsteady but was able to stabilize himself with staff assistance. The resident's fall assessments dated, 5/19/16, 8/11/16, and 11/10/16 documented a score of 20 with greater than 10 being rated at a high risk for falls. The resident's care plan dated 5/21/16 documented, a Focus of: Mr.(Name) is at risk for falls d/t (due to) balance disturbance, Gait disturbance and [MEDICAL CONDITION] disorder. Prefers to have bed to be up against wall. At times, will start urinating when he gets up from bed, refuses to use brief or pull up. 10/09/15 Fall 4:45 p.m Resident got up to clean up a spill and lost his balance and fell obtaining Left 10th rib fracture. Bed alarm was in Place but battery compartment had been pried open and 2 batteries were missing. Last fall, 8/1/16 lost balance and was eased to floor by staff, no injury noted. The interventions on the care plan were: - Remind resident to call for assistance with all transfers. - Fall on 10/09/15 - 1.Therapy screen. 2. Encourage resident to leave equipment alone. 3. Encourage footwear. Intervention for 8/1/16, Encourage him to use walker when up walking. Therapy screen. May use SR (side rail) while in bed to enable the resident to assist with turning and repositioning and to enable resident freedom of movement while in bed. Needs assist of one to transfer (May need assist of two to transfer depending in resident's ability to participate at that time). Call light in reach. Keep environment free of obstacles. An Incident/Accident Report documented on 10/20/16 at 6:00 a.m. revealed the resident was found in his bathroom on the floor. The resident complained of rib and back pain at that time. The resident was transferred to the hospital where he was diagnosed with [REDACTED]. The resident was readmitted to the facility on [DATE] at 3:00 p.m. The care plan was not revised to include a need to increase supervision. An Incident/Accident Report documented a fall on 10/31/16 at 7:40 a.m. The report documented: Coming up hall heard alarm, went in room resident was leaning against door frame (Not able to read) Assisted the resident back to bed. The care plan at the time had interventions added of: 1) Encourage resident to call for assistance with transfers and ambulation, 2) Place bedside toilet in room. 3) Relocate refrigerator away from door going into bathroom. There were no changes on the care plan for supervision. The call light intervention was already on the resident's care plan. An Incident/Accident Report documented a fall on 11/8/16 at 10:00 a.m. The report documented, Resident trying to go to bathroom assistive devices not in use. ST (Skin Tear) to hand and elbow. Cleaned and bandage . There were no changes to the care plan for supervision of the resident after the fall. An Incident/Accident Report documented a fall on 11/19/16 at 5:30 p.m. The report documented, Resident noted on floor from fall. He was on buttocks, complains of severe pain. The resident was sent to the hospital and was diagnosed with [REDACTED]. The current care plan continued not to have any change in supervision of the resident added after the two falls with major injuries. Registered Nurse (RN) SS was interviewed on 12/15/16 at 9:50 a.m. about supervision of the resident to prevent him from having falls. She indicated the current care plan approaches, but confirmed there were not any additions to the care plan after the falls. On 12/15/16 at 10:45 a.m. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were interviewed as to why the supervision of the resident was not increased after the falls on 10/20/16, 11/8/16 and 11/19/16. They did not have a response.

Based on observations, interviews, review of clinical records and review of facility Incident/Accident Reports, it was determined the facility failed to provide supervision to ensure three Residents (R) (R#3, R#13 and R#17) of 7 sampled residents reviewed for elopement risks from a total of 27 sampled residents, were secure from unsafe departure from the safety and security of the facility. The facility failed to ensure two of 27 sampled Residents (R) (R#5 and R#7) were supervised to prevent falls. Resident #5 and R#7 were harmed when they sustained fractures from unsupervised falls in the facility, which required hospitalization . The facility's failure to provide supervision to keep residents safe from leaving the facility unsupervised was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified to have existed on 5/5/16 at 7:20 a.m. when R#13 first eloped from the facility unsupervised. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 3/15/17 at 10:15 a.m. The Immediate Jeopardy was not removed at the time of the exit on 3/17/17 at 4:00 p.m. Findings include: 1. Record review of R#13's Admission Minimum Data Set (MDS) assessment (a federally mandated comprehensive assessment tool used for development of an individualized care plan), dated 3/29/16, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment of 3/29/16, the resident's Brief Interview for Mental Status (BIMS) score, (a tool used to assess cognitive status), was three out of a possible 15. A score of three indicated severe cognitive impairment. A review of R#13's Incident/Accident Report, dated 5/5/16 at 7:20 a.m., revealed R#13 was observed walking in front of a church two blocks away from the facility. The facility's Activity Director (AD), who was on her way to work, observed the resident walking in front of the church. R#13's Nurse's Note, dated 5/5/16 at 7:20 a.m., revealed the resident reported to the nurse that he was not going anywhere, just walking. The Nurse's Note, dated 5/5/16 at 7:26 a.m., documented that every 15 minute checks were started on the resident and that staff would ambulate the resident every day. On 5/5/16, after implementing every 15 minute checks, according to R#13's Incident and Accident Report of 5/5/16 at 7:50 p.m., the resident was observed in the street in front of the building standing near the stop sign. According to the report, the resident said, I wanna walk. On 2/15/17 around 10:05 a.m., the Director of Nurses (DON) was asked for documentation of every 15 minute checks performed for R#13, which started on 5/5/16 after the 7:20 a.m. elopement. The DON found two Wandering Resident Monitor forms in the resident's closed record which were dated 5/5/16 and 5/9/16. The 5/5/16 Wandering Resident Monitor form, documented an X at 7:00 p.m. X was not included in the code legend noted on the form. An Incident/Accident Report for R#13, dated 5/5/16 at 7:00 p.m., revealed the resident was found walking in the street in front of the building. According to a Nurse's Note in R #13's closed record, dated 5/5/16 at 7:00 p.m., revealed the resident was redirected back to building after being found in the road in front of the building. Urine for lab testing was collected from the resident. An Incident/Accident Report for R#13, dated 5/9/16 at 7:50 p.m., revealed R#13 .wandered away from the facility and was found on another street. The resident's Wandering Resident Monitor form dated 5/9/16, revealed the resident was observed at 7:30 p.m. in the lobby of the facility. At 7:45 p.m. on 5/9/16, the form indicated the resident was OOF (out of facility), which was not explained on the form. R#13 was placed in the facility's secured unit on 5/9/16 at 8:30 p.m., according to a notation on the Wandering Resident Monitor form and on the resident's 5/5/16 care plan for his elopement risk. R#13 discharged from the facility on 1/16/17, according to a notation on the folder containing the resident's closed record. Further investigation conducted onsite on 3/14/17 through 3/17/17 included interviews with facility staff and additional clinical record reviews. During an interview on 3/15/17 at 5:30 p.m. with the Activity Director (AD), she stated when she drove by R#13 on 5/5/16 at approximately 7:15 a.m., she was .not completely sure who the person was and it was not fully daylight . The AD further stated she continued on to the facility, informed the Business Office Manager (BOM) what she saw, and it was the (BOM) who directed her that it was most likely R#13, and to go back and check. The AD also stated R#13 was approximately a quarter mile from the facility when she picked him up. According to the AD, R#13 made no comments about where he was going and was compliant with returning to the facility. During an interview on 3/15/17 at 5:55 p.m. with the BOM, she stated the AD informed her she .thought she saw R#13 walking on the road . and the BOM stated she informed the AD to go check. The BOM also stated after the AD left she called R#13's unit to inform them and was informed Certified Nursing Assistant (CNA) KK would go get him. The BOM further stated the AD returned with R#13 before CNA KK left the facility. During an interview on 3/16/17 at 11:15 a.m. with LPN AA, she stated the resident was in bed at 6:45 a.m. on 5/5/16 and CNA LLL walked the resident to the south dining room at approximately 7:00 a.m. LPN AA also stated at approximately 7:10 a.m. she checked the dining room, saw he was not in there and headed to the front lobby to look for him as .he liked to sit in the lobby . LPN AA was notified by the BOM that the AD had seen him out walking on the road and was bringing him back to the facility. LPN AA stated the resident was gone from the facility approximately 10 minutes and .most likely left through the front door . LPN AA further stated the resident had recently been admitted from a locked facility and was accustomed to walking around freely, with no assistive devices. He returned uninjured, alert but confused. During an interview on 3/16/17 at 11:25 a.m. with CNA LLL, she stated at approximately 6:45 a.m. on 5/5/16, she dressed the resident and walked him to the dining room. The food cart came at approximately 7:00 a.m. and when she noticed he was gone, she notified LPN AA. CNA LLL also stated .he was a fast walker and liked to sit in the front lobby . CNA LLL also stated the resident had been admitted from a locked facility. According to R13's Incident/Accident Report, the intervention put into place after the 5/5/16 elopement at 7:20 a.m. was .every 15 minute checks . The 15 minute checks were ongoing at the time of R#13's second elopement on 5/5/16 at 7:00 p.m. and, according to his care plan titled At risk for elopement initiated 5/5/16, the 15 minute checks were discontinued on 5/6/16 at 7:00 a.m. No documentation could be located in the clinical record which indicated why the 15 minute checks were stopped. An order was obtained on 5/5/16 at 7:40 a.m. to obtain a urine specimen for urinalysis. The specimen was obtained and the results on 5/8/16 were negative. Furthermore, no new interventions were put into place after the second elopement on 5/5/16 at 7:00 p.m. He returned to the facility uninjured, alert but confused. During an interview on 3/15/17 at 6:10 p.m. with LPN QQ, she stated .the resident (R13) liked to walk and walked all over the building . LPN QQ was not aware he was outside of the building the evening of 5/5/16. She also stated .he was supposed to be on 15 minute checks . Additionally, LPN QQ stated it was the responsibility of the nurses and the CNAs to document the 15 minute checks. During an interview with the DON on 3/15/17 at 11:00 a.m. she stated the elopements for R#13 on 5/5/16 at 7:20 a.m. and 5/5/16 at 7:00 p.m. were not reported to the state agency. The DON confirmed the elopement for R#13 on 5/9/16 at 7:50 p.m. was reported to the state agency. Additionally, the DON stated a resident was to be on 15 minute checks for 72 hours. The DON could not explain why R#13 had the 15 minute checks discontinued after 24 hours, as she was not the DON at the time. According to the facility policy and procedure, undated, under #11 - d, it stated . follow-up charting every shift (including behavioral problems) for 48 hours . Clinical record review revealed the facility had completed an Elopement Risk Assessment, for R#13 on 3/29/16. The assessment indicated a score of 18, which did not indicate high risk for elopement. Another assessment was conducted on 5/9/16 where R#13 scored a 30 which indicated he was at high risk. However, according to the Elopement Risk Assessment form, it stated .if a resident is not dependent in mobility and/or has a history of elopement than (sic) they are risk for elopement regardless of the score . According to R#13's Incident/Accident Report dated 5/9/16 at 7:50 p.m. the interventions utilized were to .transfer (R#13) to secure unit . During an interview with LPN QQ on 3/15/17 at 6:10 p.m. she stated .I thought he was still on 15 minute checks . when he eloped the evening of 5/9/16. LPN QQ also stated it was another employee who drove by the facility on 5/9/16 and noticed R#13 outside .approximately 100 feet from the building, by the stop sign . in front of the facility. Additionally, LPN QQ stated a resident would be placed on 15 minute checks for a .bit . LPN QQ stated a bit depended on what the 15 minute checks were for. R#13 was returned to facility uninjured, alert but confused. 2. R#3 was admitted to the facility on [DATE] per the Admission Record with [DIAGNOSES REDACTED]. R#3's Monthly Summary, dated August 2016, documented the resident continued to have hallucinations and delusions, but no wandering. Review of R#3's Care Plan Focus Summary, dated 8/15/16 indicated that the IDT (Interdisciplinary Team) determined the resident required residence on the secured unit related to his aggressive and threatening behavior toward others. According to this documentation, the resident had a history of [REDACTED]. Review of R#3's Care Plan, implemented 8/11/16, revealed a care focus area related to R#3's need to be housed on the secure unit. According to the care plan, the placement in the secure unit was related to R#3's aggressive behavior towards others, threatening behavior towards others, and actual physical altercations with other residents. The documented goal in the care plan, with a target date of 11/04/16, was Resident's quality of life will be maintained and will be safe and secure by next review. The interventions related to the focus care area of secure unit placement, dated 8/11/16, revealed: a. Explain to resident/Responsible Party the need to be housed on secured unit b. Monitor resident for necessity of living on secured unit c. Notify family/MD (Medical Doctor) as/if warrant d. Refer to SS (Social Services) as/if indicated e. Remove resident to unsecured unit as/if indicated. R#3's Minimum Data Set (MDS) assessment, dated 8/19/16, revealed the resident made no attempts at wandering during the assessment period. Review of R#3's Elopement Risk Assessment dated 7/1/16 revealed a score of 22. The legend at the bottom of the form revealed, a total score of 28 or more (symbol for greater than) is risk. However, the instructions at the top of the form indicated, Upon admission, quarterly and with a change of condition that directly relates to wandering and behaviors that would indicate a change in elopement risk .If a resident exhibits nonverbal desires .or voices a desire to go home and is NOT dependent in mobility and or has a hx (history) of elopement than (sic) they are at risk for elopement regardless of the score. The assessment dated [DATE] indicated that R#3 was fully ambulatory, alert and oriented x (times) 3 .History of elopement attempts, Voices but no action, Behavior Modification-Difficult to redirect . During interview with the Director of Nursing (DON) on 3/15/17 at 3:35 p.m., the DON confirmed that R#3 was at high risk for elopement and after review of R#3's care plan, confirmed that the potential for elopement was not identified on R#3's care plan until 9/25/16, the day R#3 eloped from the facility. Review of R#3's undated Elopement Risk Tool, revealed a score of 6. Located on the assessment was a legend that indicated, Conclusion Score 5 or above high risk of elopement. During interview on 3/15/17 at 3:35 p.m., the DON confirmed that R#3's clinical record did not contain another Elopement Risk Assessment from 7/1/16 to after R#3 eloped on 9/25/16. The DON stated that the undated Elopement Risk Tool had to have been completed sometime after 9/25/16, since the document indicated, Recent hx of elopement from (name of facility). According to R#3's Nurses' Notes, dated 9/19/16 to 9/25/16, the resident had displayed an increase in his usual behaviors, such reporting demons entering his room at night so he could not sleep, increased ambulation in the halls and increased agitation. According to a Nurse's Note dated 9/22/16, Resident (symbol for increased) agitated this shift, verbally aggressive (sic) towards writer, staff & other resident. PRN (as needed) Haldol 10 mg (milligrams) given-not effective. Resident noted crying, talking to self & constantly yelling, '(name of resident) is not my name.' Re-direction unsuccessful. (Symbol for increased) ambulatory hallway at this time. Will continue to monitor. The next Nurse's Note dated 9/22/16 late entry, no time documented, indicated, CNA (Certified Nursing Assistant) notified writer that she saw resident pick up a chair behind writer as if going to hit writer (symbol for with) chair. Resident denied doing so. Will continue to observe. According to R#3's Nurse's Note dated 9/23/16, at 4:20 p.m., Participating in scheduled smoke break. Verbally denies needs or c/o (complaint of) at present time. No BHV (behaviors) noted at this time. Will continue to monitor. According to R#3's Nurse's Note dated 9/24/16 at 7:30 p.m., Noted sitting against wall, crouched down. Resident hits head (back) multiple times against wall. When redirected to stop, resident rolls over onto floor & (and) acts as if he passed out. Redirect again & resident ignores staff & stay on floor. Will continue to monitor. According to R#3's Nurse's Note dated 9/25/16, Resident in bed resting. No distress noted. During interview with the DON on 3/15/17 at 3:35 p.m., the DON confirmed that there were no further nurses' notes until 9/25/16 at 0830 (8:30 a.m.) when the facility received the call from the other nursing home, in the same town, that the resident was in their facility looking for his room. According to the facility's Investigative Report, dated 9/25/16, R#3 left the facility before daylight on 9/25/16. Included in the investigation was a statement from the resident which indicated he left the facility through the west hall door to the outside smoke area. The report revealed the resident said the door and the gate, in the smoke area, were both open. According to Licensed Practical Nurse (LPN) PP, the 7-3 shift charge nurse's statement, dated 9/25/16, she received a call around 8:30 a.m. from a nurse at the other facility. The other facility nurse reported that R#3 was in their facility looking around for his room. After receiving the call, according to LPN PP's statement, 'After checking the hall .' a staff person was sent to retrieve R#3. The resident returned at 9:00 a.m. According to the charge nurse's statement, R#3 said he walked around town and a man in a pickup truck picked him up when he waved at him from the side of the road. He said the man asked where he was going and R#3 told him of the other nursing facility. The man in the pickup truck delivered the resident to the other facility. An interview with the 11-7 charge nurse, Licensed Practical Nurse (LPN) RR on 2/14/17 at 4:52 p.m., revealed R#3 was last seen by her between 5:35 a.m. and 5:45 a.m., when she gave his morning medications. She said, at that time, R#3 was in bed and she even had a difficult time waking him to take his medications. LPN RR said after R#3 took his medication, he laid back down. She said she continued to pass medications to the other residents in the unit and that was the last time she saw R#3 the morning of 9/25/16. On 2/15/17 at 9:12 a.m. a telephone interview was conducted with Certified Nursing Assistant (CNA) SS, who confirmed she worked on 9/25/16, the day R#3 eloped in the early morning. She said she left the facility at 6:00 a.m. According to CNA SS, the last time she saw R#3 that morning was around 5:45 a.m. sitting on the side of his bed. She said R#3 had never eloped before, but he was different that night. When asked to explain what she meant by different, she said he was usually out of his room walking and talking with her. CNA SS said, that night, R#3 was not walking much and mostly stayed in his room. Record review of the facility's undated Elopement Protocol - Missing Resident revealed, upon the resident's return to the facility, after an elopement, follow-up charting to include any behavioral problems, should be performed every shift for 48 hours. A review of R#3's clinical record revealed a Nurse's Note on 9/25/16 at 9:00 a.m. describing R#3's account of his elopement, and that the DON was notified at 9:10 a.m. on 9/25/16. And every 15-minute Wandering Resident Monitor checks on 9/25-29/16. An interview with the DON, on 2/14/17 at 11:00 a.m. indicated prior to R#3's elopement on 9/25/16, the 11-7 shift charge nurse's responsibility included a midnight census of the residents in the building. However, since R#3's elopement, she had initiated the Heads in Beds process. She explained this process required the charge nurses for each shift to do an eyes on check of all residents in the building to assure that they were present and accounted for. During an interview with the Maintenance Director (Maint.EE), on 2/14/17 at 1:35 p.m., it was revealed he received the report that R#3 said he eloped from the north hall smoke door and the gate in the smoke area on 9/26/16. He said he checked the door and the gate and found that both were working correctly. Maint. EE said the gate was difficult to open and could not be opened from inside smoke area. He said prior to the resident's elopement he had not received reports of problems with the doors and at that time he was checking the doors, locks, and alarms monthly. Maint. EE said the facility implemented a different system of checks, which collected computerized reports (TELS) of daily checks of all doors, locks, and alarms. A review of the TELS reports for December 2016, January 2017, and February 2017 revealed no identification of problems with the secure doors or alarms. According the facility's Charge Nurse/Supervisor's Investigation report, related to R#3's elopement to another facility on 9/25/16, once the resident was returned, 15 minute checks of his whereabouts was started and continued every shift through 9/30/16 at 6:45 a.m. The facility also started every 15 minute checks of the north hall smoke area gate to assure it was latched and locked. This continued through 9/29/16, at which time the checks became every shift through 12/21/16. Review of the 24-hour Report for the West hall, dated 9/25/16, revealed the following instructions: Do not, for any reason unlock gate outside or leave door to smoke area unlocked. Further instructions directed staff to perform Q (every) 15-minute wandering monitor started on (R#3 and 2 other un-sampled residents). Staff to also check gate to ensure it is locked q (every) 15 min (minutes). Walking rounds at change of shift, every shift for physical head count and document in 24 (hour) book. Use magnetic key only at smoke break. Do not unlock smoke door at nurse station and make sure door is locked and closed completely when ending smoke breaks! According to the DON, on 2/14/17 at 11:00 a.m., all department heads and staff were re-educated about checking the doors each shift. Observation on 3/15/17 at 9:00 a.m. revealed the distance from the facility's front door to the front door of the other nursing home facility, that R#3 was taken to on 9/25/16, was approximately 3 miles. The two lane road in front of the facility, from which R#3 eloped, did not have any sidewalks or shoulders along the road in which to walk. There were no streets lights. A large pond was located across the road. The traffic along this stretch of the road was fairly busy. Further observation revealed that this two lane road leads to (town's name) town center, and the streets were observed to be very busy. The neighborhood would be described as residential homes with many areas of undeveloped wooded areas. The road that leads from the center of town to the other nursing home required the traveler to cross a set of railroad tracks. This road was also observed to be very busy and without continuous sidewalks. During the interview on 3/15/17 at 3:35 p.m., the DON was asked to review the investigative documents and to review the nursing schedule for 9/24/16 and 9/25/16. The DON confirmed at this time that the investigative report regarding the elopement of R#3 on 9/25/16 did not contain interviews from all of the staff that were on duty on the night shift of 9/24/16 as well as the day shift on 9/25/16. The DON also confirmed that the investigative documents did not contain an investigation as to how R#3 exited the secure unit and then exited the building without staffs' knowledge. Interview with the Administrator was conducted on 3/16/17 at 9:30 a.m. regarding the Administrator's review of the R#3 investigative documents and report for the elopement of R#3 on 9/25/16. The Administrator confirmed that the investigation was incomplete and lacked information as to how R#3 exited the secure unit and then exited the building. Refer to F520 for complete interview. 3. According to the facility Admission Record, dated 1/21/17, R#17 was admitted to the facility on [DATE], which indicated he had [DIAGNOSES REDACTED]. According to the MDS dated 5/24/16, section G Functional Status, R#17 required supervision with ambulation. According to the MDS dated 1/28/17, R#17 had a Brief Interview for Mental Status (BIMS) of 8 out of 15, which indicated the resident was moderately cognitively impaired. During review of the facility's 2017 Incident/Accident Reports during the investigation from 3/14/17 through 3/17/17, it revealed that R#17 had an elopement on 1/28/17 at 10:15 a.m. According to the Incident/Accident Report, R#17 was .walking down road by nursing home, brought back by off duty employee, no injuries noted . Interventions noted for R#17 were 15 minute checks and to consider a room change further down the hall. Clinical record review revealed the facility had completed an Elopement Risk Assessment on 5/25/16, 8/25/16 and 12/1/16 where R#17 scored a 12, which did not indicate high risk for elopement. However, according to the Elopement Risk Assessment form, it stated .if a resident is not dependent in mobility and/or has a history of elopement than (sic) they are risk for elopement regardless of the score . Additional clinical record review revealed a different form titled Elopement Risk Tool, where R#17 scored a 5 on 1/17/17, which indicated he was at high risk for elopement. According to this tool R#17 was scored for .does the resident say that he/she wants to leave . and .eloped from home . According to R#17's care plan At risk for elopement, initiated 1/28/17, it stated .place on secure unit and monitor need for placement . R#17 was not currently, nor had he been on the secure unit. Additionally, the care plan did not reflect R#17's Elopement Risk Assessments. (Refer to F280) During an interview on 3/17/17 at 9:50 a.m. with the Food Service Supervisor (FSS), who was also R#17's niece, she was notified by a staff member that he had left the building on 1/28/17. The FSS stated the resident told her .I don't know where I was going . During an interview on 3/17/17 at 10:05 a.m. with Registered Nurse (RN) supervisor KKK, she received a call from another unit that R#17 had left the building and was approximately 1/8th of a mile from the facility. RN KKK stated she immediately took CNA JJJ with her to assist the resident back to the facility. RN KKK further stated the resident had his walker with him and was unsteady walking and that he was outside the facility approximately 10 minutes. He was placed on 15 minute checks at that point. During an interview on 3/17/17 at 10:15 a.m. with CNA HHH, she stated she had left the building on break and saw the resident walking down the road in front of the facility, .not too far from the facility, just past the mailbox . She also stated he had his walker. CNA HHH attempted to bring the resident back, but he was unable to get in her vehicle, so she called the facility and reported it. CNA HHH stated she stayed with him until CNA JJJ and RN KKK came to get him. During an interview on 3/17/17 at 11:05 a.m. with CNA JJJ, she stated she saw R#17 on the East unit and he stated to her he .was going for a walk . CNA JJJ further stated he often goes outside to sit, unsupervised, but always comes back in when ready. During an interview with the DON on 3/15/17 at 11:00 a.m. she stated the elopement for R#17 was reported to the state agency. 4. R#5 was admitted to the facility on [DATE] and readmitted [DATE], after a hospital stay for a fall on 9/19/16, which resulted in a subdural hematoma. R#5 had a fall on 9/12/16 at 3:45 a.m. that resulted in a hematoma to left eye and the resident was transported to the hospital. Review of the Post Fall assessment dated [DATE] showed the resident was confused and alert, lying in bed at the time of the fall. Review of the Charge Nurse/Supervisor's Investigation Report dated 9/12/16 revealed a thud was heard from resident's room and resident was found on the floor. A fall mat was to be placed at the bedside and the bed was put in the low position with a side rail to the open side of the bed and a pressure alarm was placed on the bed. Review of the care plan showed an update was completed on 9/12/16 for falls that included: 1) Keep bed in low position. 2) Bedside mat to floor. R#5 experienced a fall on 9/19/16 at 7:15 p.m. that resulted in bleeding from nose and mouth. R#5 was alert with confusion and transferred to the hospital. Review of the Post Fall Assessment form dated 9/19/16 showed the resident was found face down on the floor with blood on the nose and mouth. The form further showed the resident had a fall one time in the last three months, had poor cognition and a floor mat was in use. The side rail usage and alarm use was not documented on the form. The form did not identify if the bed was in low position. The Post Fall Assessment form revealed R#5 was sitting on the side of the bed eating supper, the CNA heard a thud and the resident was found lying on his face on the floor. Review of the Charge Nurse/Supervisor's Investigation Report dated 9/19/16 at 7:46 p.m. documented the resident needed a bed alarm. Review of the CNA Flow Sheets for 9/1/16 through 9/20/16 revealed R#5 required supervision with eating and limited assistance with bed mobility. After returning from the hospital on [DATE] the CNA Flow Sheets revealed R#5 required extensive assistance with bed mobility and was not eating/drinking. Review of the Fall Prevention and Management Policy, dated October 2012, revealed, B. Prevention; 2.b.vii; Utilizing bed alarms. During an interview on 12/13/16 at 2:30 p.m., MDS Coordinator BB stated the care plan had not been updated when R#5 returned from the hospital. 5. Resident #7 was admitted to the facility 1/4/05 with [DIAGNOSES REDACTED]. The 8/21/16 quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated R#7 had severe cognitive impairment, and had not had any recent falls. The resident's balance at G300, Balance during transfers and walking documented the resident was unsteady but was able to stabilize himself with staff assistance. The resident's fall assessments dated, 5/19/16, 8/11/16, and 11/10/16 documented a score of 20 with greater than 10 being rated at a high risk for falls. The resident's care plan dated 5/21/16 documented, a Focus of: Mr. (Name) is at risk for falls d/t (due to) balance disturbance, Gait disturbance and seizure disorder. Prefers to have bed to be up against wall. At times, will start urinating when he gets up from bed, refuses to use brief or pull up. 10/09/15 Fall 4:45 p.m. Resident got up to clean up a spill and lost his balance and fell obtaining Left 10th rib fracture. Bed alarm was in Place but battery compartment had been pried open and 2 batteries were missing. The interventions on the care plan were: - Remind resident to call for assistance with all transfers. - Fall on 10/09/15 - 1.Therapy screen. 2. Encourage resident to leave equipment alone. 3. Encourage footwear. Intervention for 8/1/16, Encourage him to use walker when up walking. Therapy screen. May use SR (side rail) while in bed to enable the resident to assist with turning and repositioning and to enable resident freedom of movement while in bed. Needs assist of one to transfer (May need assist of two to transfer depending in resident's ability to participate at that time). Call light in reach. Keep environment free of obstacles. An Incident/Accident Report documented on 10/20/16 at 6:00 a.m. revealed the resident was found in his bathroom on the floor. The resident complained of rib and back pain at that time. The resident was transferred to the hospital. The hospital History and Physical, dated 10/20/16 revealed Computed Tomography Scan (CT scan) reveals tiny pneumothorax and rib fractures, eight through eleventh right posterior ribs, mildly displaced. The resident was readmitted to the facility on [DATE] at 3:00 p.m. The care plan was not revised to include a need to increase supervision. An Incident/Accident Report documented a fall on 10/31/16 at 7:40 a.m. The report documented: Coming up hall heard alarm, went in room resident was leaning against door frame (Not able to read) Assisted the resident back to bed. The care plan at the time had interventions added of: 1) Encourage resident to call for assistance with transfers and ambulation, 2) Place bedside toilet in room. 3) Relocate refrigerator away from door going into bathroom. There were no changes on the care plan for supervision. The call light intervention was already on the resident's care plan. An Incident/Accident Report documented a fall on 11/8/16 at 10:00 a.m. The report documented, Resident trying to go to bathroom assistive devices not in use. ST (Skin Tear) to hand and elbow. Cleaned and bandage . There were no changes to the care plan for supervision of the resident aft

Based on observations, record review, review of the Administrator's job description, review of the facility's policies and staff interview, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to ensure new interventions to address Residents (R) #3, R#13 and R#17's elopements was communicated to all staff and a system was implemented to ensure the interventions were carried out to prevent further elopements and to maintain substantial compliance with Federal requirements at 42 Code of Federal Regulations (CFR) Part 483, Subpart B - Requirements for Long Term Care Facilities. The facility's failure to ensure interventions were communicated and implemented to safeguard R#3, R#13 and R#17 from further elopement was determined to likely cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 3/15/17 at 10:15 a.m. and determined to first exist on 5/5/16 at 7:20 a.m. when R#13 eloped from the facility. The facility implemented 15 minute monitoring of R13. Approximately 12 hours later on 5/5/16 at 7:50 p.m., R#13 eloped the second time. Documentation indicated that the facility continued with 15 minute monitoring of R#13 and that there were no further interventions implemented. R#13 eloped from the facility again on 5/9/16 at 7:00 a.m. Documentation indicated that R#3 eloped from the facility's secure unit on 9/25/16 between 5:15 a.m. and 5:45 a.m. When R#3 was returned to the facility, R#3 was placed again on the secure unit without any further interventions implemented. Documentation indicated that R#17 was assessed for elopement risk on 1/17/17 and determined to be at high risk for elopement. R#17 eloped from the facility on 1/28/17 at 10:15 a.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 3/15/17 at 10:15 a.m. The Immediate Jeopardy was not removed at the time of exit on 3/17/17 at 4:00 p.m. In addition, the facility's failures to protect residents from elopement (F323), review and revise the care plans addressing elopement risk (F280), ensure the responsibilities of the facility's administration was carried out effectively (F490), and implement effective quality assurance activities (F520) were all assigned a scope and severity of K, indicating a pattern of potential for serious injury, harm, impairment, or death to residents. The Immediate Jeopardy at F323 constituted Substandard Quality of Care at 42 CFR 483.25. Findings include: The facility's undated Administrator job description documented, Essential function of the Administrator position: 1. Implement procedures and controls necessary to provide quality resident care .5. Supervise and provide guidance and support to department heads .13. Maintain a clean, pest free and safe environment within the facility .18. Review and check competence of work force.19. Recognize and respond to changes in residents' conditions and report observation to nursing/medical staff .23. Develop, maintain and periodically update written policies and procedures which govern the day-to-day functions of the facility .27. Direct various committees of the facility, such as care plan, infection control .quality assessment and assurance .32. Maintain privacy and confidentiality of records, conditions, and other information relating to residents . The Administrator's job description was signed on 12/5/16. Cross-reference F323: Free of Accidents Hazards/supervision/devises - the facility failed to ensure that R#3, R#13 and R#17's elopements from the facility were thoroughly investigated to determine appropriate interventions were implemented to assure residents were safe from further potential harm. On 5/5/16 at 7:20 a.m. R#13 eloped from the facility. The facility implemented the intervention that facility staff was to monitor R13 whereabouts in the facility every 15 minutes. Approximately 12 hours later on 5/5/16 at 7:50 p.m., R#13 eloped the second time. Documentation indicated that the facility continued with 15 minute monitoring of R#13 and that there were no further interventions implemented. R#13 eloped from the facility again on 5/9/16 at 7:00 a.m. Documentation indicated that R#3 eloped from the facility's secure unit on 9/25/16 between 5:15 a.m. and 5:45 a.m. When R#3 was returned to the facility, R#3 was placed again on the secure unit without any further interventions implemented. Documentation indicated that R#17 eloped from the facility on 1/28/17 at 10:15 a.m. after being assessed as high risk for elopement on 1/17/17. Review of the investigations revealed that the facility did not interview all of the staff who would have knowledge regarding R#17's whereabouts prior to the elopement and the facility failed to determine how R#17 exited the building without staffs' knowledge. During interview on 3/15/17 at 5:30 p.m., the Administrator stated that she had reviewed the investigations for R#3, R#13 and R#17's elopements and could tell that the investigations were not thorough. During interview on 3/16/17 at 9:30 a.m., the Administrator confirmed that she was not aware that the care plans had not been revised with appropriate interventions to prevent future elopements for R#3, R#13, and R#17. On 3/14/17 at 11:25 a.m., in which the survey team observed and learned through interviews that the front entrance door and the employee entrance door were unlocked and that there was no system in place to assure that these doors were monitored so that residents did not exit the building without staffs' knowledge, was discussed with the Administrator. The Administrator was asked whether she was aware that the facility's policies address the use of wander guard bracelets and that facility doors were to be locked. The Administrator indicated that she was not aware of what the policies indicated until now. However, the Administrator confirmed that she was aware that the front entrance door and employee entrance door were left unlocked. The Administrator stated that the receptionist stayed until 5:00 p.m. and that she expected the staff to watch the doors as they were providing care. The Administrator stated that she became aware that the facility was not secure and that she requested funds in either December or January from Corporate to install key pads on these two doors so that the doors could be locked. The Administrator stated that she was approved by Corporate on 2/8/16 and that she requested the key pads for the doors on 2/14/17. The door key pads were installed 3/8/17. However, one of the key pads would not function and had to be reordered. The Administrator confirmed that the doors remained unsecured until 3/14/17 when the survey team brought the concern of the unlocked doors to the Administrator's and Director of Nursing's (DON) attention. Cross-reference F164: Personal Privacy- The facility failed to ensure personal privacy for two residents, R#9 and R#10, during the provision of wound and incontinence care. The facility's nursing staff failed to provide privacy during incontinence care. The facility failed to assure that R#10's privacy was maintained during incontinence care in that there was the lack of a privacy curtain between R#10 and her roommate's bed. Cross-reference F280: Care Plan Revision - R#3, R#13 and R#17's care plans were not revised to the residents' elopement from the facility. During interview on 3/16/17 at 9:30 a.m., the Administrator confirmed that she was not aware that the care plans had not been revised with appropriate interventions to prevent future elopements for R#3, R#13, and R#17. During interview on 3/16/17 at 9:30 a.m., the Administrator stated that she was not aware until now that R#23, R#25, R#26 and R#27's Elopement Risk Tool scored the residents' at high risk for elopement and that these residents' care plans had not been revised to reflect the current unit, either secure or unsecured unit, where the residents' resided. Further, the Administrator stated that she was not aware that R#25, R#26 and R#27's care plans indicated the same interventions and had not been individualized to meet the residents' needs, especially when the Elopement Risk Tool indicated that R#23 wandered towards the highway and R#26 and R#27 documents indicated both residents' had a history of [REDACTED]. Cross-reference F319: Treatment/Services for Mental/Psychosocial Difficulties -The facility failed to assist one resident, R#1, to receive professional care and services to address behaviors related to [DIAGNOSES REDACTED]. This failure placed R#1 at risk for harm related to continued threats and carrying out of self-injurious behaviors. Cross-reference F469: Maintain Effective Pest Control Program - The facility failed to ensure there was an effective pest control program as evidenced by observation of live and dead roaches throughout the facility in resident rooms, the dietary department and dietary dish room, food pantries located on the nursing units and the conference room. During an interview with the Administrator and Director of Nursing (DON), on 12/15/16 at 5:20 p.m., the DON confirmed that the facility's problems with roaches had been a topic of discussion in the committee meetings, however, there were no recommendations other than have more frequent visits from the contracted pest control company. During an interview with the Administrator on 3/16/17 at 9:30 a.m., the Administrator stated that she became the facility's Administrator the first week of December 2016. At that time she became aware of the roach problem. The Administrator stated that she terminated the contract with the existing pest control company and hired a new company after the survey team exited on 12/16/16. The Administrator stated that since then, the facility no longer had a problem with roaches. Cross-reference F498: Nurse Aide demonstrates Competency- The facility failed to ensure that Certified Nursing Assistants received performance evaluations yearly as indicated in the facility's policy as well received at least 12 hours of inservice hours per year. Interview with the Administrator on 3/17/17 at 10:10 a.m. revealed that the Administrator was not aware that employees that have been employed with the facility for greater than a year were not receiving a performance evaluation. The Administrator further confirmed that she was not aware that Certified Nursing Assistants were not receiving at least 12 hours of inservice training per year. Refer to F498 for complete interview with the Administrator. Cross-reference F514: Resident Records, Complete/Accurate/Accessible- The facility failed to ensure that residents' medical records were complete and accurate. R#2's progress notes were locked in an office and R#5's resident flow sheets lacked consistent documentation as to whether the resident was bathed three times a week. Cross-reference F520: Quality Assurance Activities - the facility failed to maintain an effective Quality Assurance program that systematically reviewed quality of care related to residents' elopement from the facility, failure to review and revise care plans, and the failure to provide a clean, pest free environment. Interview with the Administrator on 3/16/17 at 9:30 a.m. revealed that she confirmed that the QA minutes did not address the elopements of R#3 and R#13. Refer to F520 for the complete interview with the Administrator.

Based on interviews, record review, review of facility's policies, and review of the Risk Management/Quality Assurance Process -Improvement Program, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed quality of care related to residents' elopements and reviewed and revised care plans for residents identified as high risk for elopement. The facility's failure to maintain an effective QA program that implemented a plan to safeguard residents from further elopement by R#13, R#3 and R#17 was determined likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 3/15/17 at 10:15 a.m. and determined to first exist on 5/5/16, when R#13 first eloped from the facility at 7:20 a.m., then eloped from the facility the second time on 5/5/16 at 7:50 p.m. even though the facility's nursing staff had implemented 15 minute checks to monitor R#13's whereabouts. R#13 eloped four days later on 5/9/16 at 7 a.m. In addition, the facility failed to conduct a thorough investigation of R#3, R#13 and R#17 elopements to identify how R#3 eloped from one of the two secure units; how R#13 eloped two additional times, one the same day and again four days later, after the facility implemented the intervention of nursing staff monitoring R#13 every fifteen minutes and the elopement of R#17 on 1/28/17 at 10:15 a.m. after R#17 was assessed on the Elopement Risk Tool with a score of 5 which R#17 was at high risk for elopement. Review of R#17's care plan revealed that the only interventions were to monitor R#17 every 15 minutes for 72 hours and to move resident further down the unsecured hall way so that he had to walk past the nurses' station. After completion of the Elopement Risk Tool the QA program failed to review and revise care plans for residents (R#27, R#23, R#25 and R#26) who were identified as high risk, a score of 5 or more for elopement, to assure these residents' care plans addressed appropriate interventions to prevent elopement from the facility. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 3/15/17 at 10:15 a.m. In addition, the facility failed to seek assistance from the QA program regarding the following: - The facility failed to thoroughly investigate the frequent falls of R#5 and R#7 to assure that the residents' care plans were revised based on the results of the fall assessment which was completed after each fall. This failure resulted in harm for R#5 and R#7 who sustained fractures that required hospitalization . - The facility failed to seek assistance from the QA program regarding the continued concern of roaches throughout the facility to include residents' room, dietary department, conference rooms and food pantries. Findings include: 1.Cross-reference F323: Free of Accidents Hazards/supervision/devises - the facility failed to ensure that R#3, R#13 and R#17 elopements from the facility were thoroughly investigated to determine appropriate interventions were implemented to ensure residents were safe from further potential harm. On 5/5/16 at 7:20 a.m. R#13 eloped from the facility. The facility implemented the intervention that facility nursing staff was to monitor R13 whereabouts in the facility every 15 minutes. Approximately 12 hours later on 5/5/16 at 7:50 p.m., R#13 eloped the second time. Documentation that the facility continued with 15 minute monitoring of R#13 and that there was no further interventions implemented. R#13 eloped from the facility again on 5/9/16 at 7:00 a.m. Documentation that R#3 eloped from the facility's secure unit on 9/25/16 between 5:15 a.m. and 5:45 a.m. When R#3 was returned to the facility, R#3 was placed again on the secure unit without any further interventions implemented. Review of the nursing schedule for 9/25/16 revealed that all the nursing staff on duty had not been interviewed regarding their knowledge of R#3 whereabouts prior to his elopement from the facility. Review of R#3's Elopement assessment tool revealed that R#3 was not evaluated for elopement risk until after he returned to the facility on [DATE] and that R#3 did not have a care plan for elopement risk until after he returned to the facility on [DATE]. Documentation that R#17 eloped from the facility on 1/28/17 at 10:15 a.m. after being assessed as high risk for elopement on 1/17/17. Review of the investigations revealed that the facility did not interview all of the staff who would had knowledge regarding R#17's whereabouts prior to the elopement and the facility failed to determine how R#17 exited the building without staffs' knowledge. A review of the facility's policy on quality assurance, titled Risk Management/Quality Assurance Process -Improvement Program dated March 2016, the committee would focus on minimizing risk and improving resident/patient care by implementing a process for root cause analysis and the utilization of Quality Improvement Teams. In addition, the policy included specific quality indicators that would be reviewed and addressed. They included incident and accident trends and risk management concerns. Review of the facility's policy titled, Risk Management, Incident/Accident Management dated March 2016 indicted, 1. Gather all statements .obtained during the course of the investigations .Document and File Management, 1. Gather all statements, worksheets and any further information obtained during the course of the investigation . Interview with the Administrator on 3/16/17 at 9:30 a.m. revealed that she could only locate the August, September, and October 2016 QA minutes. The Administrator confirmed after reviewing these QA minutes that the elopements of R#13 in May 2016 and R#3 in September 2016 were not addressed in the QA minutes. The Administrator confirmed that these QA meetings did not address conducting a root cause analysis of the elopements, nor did the minutes identify trends or patterns for the QA committee to address. The Administrator stated that she assumed the position of facility Administrator the first week of December 2016. The Administrator stated that during the QA meeting dated 1/21/17 she instituted a formal QA procedure that incorporated a Performance Improvement Plan (PIP) to investigate future elopements. When asked why R#3's and R#13's elopements were not discussed at the January 2017 QA meeting, the Administrator stated that she was not around when these residents eloped. The Administrator stated that she wanted to guide the QA committee correctly and since the investigations into R#3 and R#13's elopements were incomplete, she could only move forward and gather information regarding future elopements that occurred at the facility. The Administrator stated that she was not aware until the survey team arrived on 3/14/17 how incomplete the investigations were regarding R#3 and R#13 elopements from the facility. The Administrator had some thoughts about how they eloped, but it was only hearsay, she had nothing in writing. The Administrator confirmed that the facility's policy did not give specific guidance regarding how to conduct an investigation. The Administrator stated when investigating an elopement, all staff should be interviewed, even the housekeeper may have information. Cross-reference F280: Care Plan Revision - R#3, R#13 and R#17's care plans were not revised with appropriate interventions to prevent future elopement from the facility. During interview on 3/15/17 at 10:00 a.m., the DON confirmed that R#3's care plan for elopement was not developed until 9/25/16 after his elopement from the facility's secure unit. Further, the DON confirmed that R#3's care plan was not revised with appropriate interventions when R#3 was assessed per the facility's elopement tool as a score of 6 (high risk) then as a score of 9 (still high risk.) During interview on 3/16/17 at 9:30 a.m., the Administrator confirmed that she was not aware that the care plans had not been revised with appropriate interventions to prevent future elopements for R#3, R#13, and R#17. In addition review of the facility's Elopement Risk Tool for R#23, R#25, R#26 and R#27 revealed the following information and the care plans were not individualized based on this assessment tool: Review of R#23's Elopement Risk Tool dated 1/17/17 revealed a score of 5 which according to the legend Score 5 or above high risk of elopement. In addition this document for item 8, wanders outside front doors heading toward hwy (highway). Review of R#25's Elopement Risk Tool dated 2/1/17 revealed a score of 5. The document , Item 6. States that she can live by herself .8. Are there relevant factors from the resident's history? Consider elopement from previous home or facility .If yes explain: Left this facility on previous admit . During interview on 3/15/17 at 9:00 a.m., the DON stated that she reviewed R#25's previous admission and that there was no documentation of an Elopement Risk Tool in the clinical record. Review of R#26's Elopement Risk Tool dated 1/18/17 revealed a score of 5. The document .8. History of leaving the premises unsupervised or without signing out was underlined. Review of R#25, R#26 and R#27's care plans revealed the same interventions of Attempt to make resident feel secure/safe within facility, distract from wandering by offering pleasant diversions such as food, conversations, television, books, music; follow elopement protocol if resident is missing and re-direct if resident attempts to elope. Interview with the DON at 9:00 a.m. revealed that R#26 was admitted on [DATE] to the secure unit, then transferred to the unsecured unit on 1/13/16, then transferred to the secure unit on 1/20/16 and then back to the unsecured unit on 7/1/16. The DON confirmed that R#25 and R26's care plans were not individualized and that R#26's care plan did not include residing on and off of the secure units. Review of R#27's Elopement Risk Tool dated 10/6/16 revealed a score of 8. R#27 was reevaluated on 1/12/17 and had a score of 6. Review of R#27's care plan revealed that R#27 was moved to the secure unit on 10/6/16 and then moved to the unsecured unit on 12/29/16. Review of R#27's care plan revealed that R#27 resided on the secure unit and the care plan had not been revised to reflect the resident was transferred to the unsecured unit on 12/29/16. During interview on 3/16/17 at 9:30 a.m., the Administrator stated that she was not aware until now that R#23, R#25, R#26 and R#27's Elopement Risk Tool scored the residents at high risk for elopement and that these residents' care plans had not been revised to reflect the current unit, either secure or unsecured unit, where the resident resided. Further, the Administrator stated that she was not aware that R#25, R#26 and R#27's care plan the same interventions and had not been individualized to meet the residents' needs, especially when the Elopement Risk Tool for R#23 wandered towards the highway and R#26 and R#27 documents both residents had a history of [REDACTED]. Cross reference F323: Accidents and Supervision regarding falls. R#5 fell two times within a seven-day period. The care plan was updated on 9/12/16 after the first fall; however the care plan was not updated to reflect the fall of 9/19/16 which resulted in a subdural hematoma. R#7's care plan reflected an update on 5/21/16 that read, bed alarm in place but battery compartment had been pried open and batteries were missing. Incident and Accident report 10/20/16, fall resulting in fractured ribs and pneumothorax. Incident and Accident report dated 11/8/16, fall resulting in skin tear to hand and elbow. Another fall 11/19/16 resulting in a fractured left hip. During an interview with the Administrator and Director of Nursing (DON) on 12/15/16 at 5:20 p.m., the DON revealed the facility did not calculate the facility's fall rate. She said the QA committee did not address the frequent falls of R#5 and R#7. Cross reference F469: Effective Pest control, observations of roaches on 12/12/16 at 8:45 a.m. and 11:00 a.m. on the South wing; on 12/13/16 at 9:15 a.m. and 9:40 a.m. on the West wing and on 12/14/16 at 10:45 a.m. on the South Wing. Interview with Registered Nurse Supervisor 12/13/16 at 2:30 p.m. regarding observation of roaches on the floors, the walls, and night stands. Interview with the cook on 12/14/16 at 10:25 a.m. about seeing roaches in the kitchen. Interview with R#12 on 12/14/16 at 10:30 a.m. regarding seeing roaches in her room and on her bed. During an interview with the Administrator and Director of Nursing (DON), on 12/15/16 at 5:20 p.m., the DON confirmed that the facility's problems with roaches had been a topic of discussion in the committee meetings, however, there was no recommendations from the QA committee.