Every finding on record at Heritage Manor of Baton Rouge II

Based on observations, interviews, and record review, the facility failed to ensure controlled drugs were accurately reconciled for 2 of 2 (Medication Cart A and Medication Cart B) medication carts observed for controlled drug reconciliation. Review of the facility's policy titled, Drug-Controlled Substances with a revision date of 09/2025 revealed the following:Controlled medications are to be signed out on Individual Resident Narcotics Record(Form NS-618) at the time they are to be administered. An observation of Medication Cart A on 03/03/2026 at 10:30 a.m. with S3LPN revealed Resident #46's Alprazolam 0.5 mg medication packet contained 55 tablets. Review of the Individual Resident Narcotics Record showed on 03/03/2026 at 7:00 a.m., S3LPN documented administration of one tablet with a remaining balance of 54 tablets. On 03/03/2026 at 10:31 a.m., an interview was conducted with S3LPN. S3LPN confirmed Resident #46's narcotic record showed 54 tablets remaining while the medication packet contained 55 tablets. S3LPN stated she signed out the medication during morning medication pass but forgot to administer it. S3LPN stated controlled medications should be prepared and administered at the time they are signed out. An observation of Medication Cart B on 03/03/2026 at 10:54 a.m. with S4LPN revealed Resident #86's Lorazepam 0.5 mg medication packet contained 47 tablets while the Individual Resident Narcotics Record indicated a remaining balance of 48 tablets. Further observation revealed Resident #117's Tramadol 50 mg medication packet contained 24 tablets while the Individual Resident Narcotics Record indicated a remaining balance of 25 tablets. On 03/03/2026 at 10:55 a.m., an interview was conducted with S4LPN. S4LPN confirmed the narcotic counts for Residents #86 and #117 were discrepant between the narcotic record and the medication packets. S4LPN stated she forgot to sign the medications out at the time of administration during morning medication pass and acknowledged controlled medications should be signed out when prepared for administration, stating, I should know better. On 03/04/2026 at 2:35 p.m., an interview was conducted with S2DON. S2DON stated the Individual Narcotic Record should accurately display the quantity of controlled medications available at all times. S2DON confirmed the above mentioned controlled medications should have been signed out on the resident's Individual Narcotic Record at the time they were administered to the residents.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received assistance with incontinent care for 2 (#7 and #85) of 4 residents reviewed for ADLs. Review of the facility's policy titled Toileting Resident, with a revision date of 01/24, revealed the following, in part: PurposeResidents are toileted safely on a routine basis in a timely manner according to their individual plan of care. Resident #7Review of Resident #7's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Dementia and Generalized Muscle Weakness. Review of Resident #7's Significant Change MDS with an ARD of 01/20/2026 revealed she had a BIMS of 12, which indicated she was moderately cognitively impaired. Further reviewed revealed she required partial/moderate assistance with toileting. Review of Resident #7's current Care Plan revealed the following, in part:Focus: Resident #7 has bowel incontinence related to dementia.Interventions: Check resident every two hours and assist with toileting as needed; Provide peri-care after each incontinent episode. Review of the facility's Grievance Log revealed Resident #7's family filed grievances on 02/04/2026, 02/17/2026, and 02/23/2026 related to Resident #7 not being changed in a timely manner. On 03/03/2026 at 12:00 p.m., an interview was conducted with Resident #7's family member. She stated she had concerns with staff not changing Resident #7 in a timely manner. On 03/04/2026 from 8:30 a.m. to 3:15 p.m., an observation was made of the residents on Unit 1. Resident #7 sat in the dining room of Unit 1, without being checked for incontinence, changed, or toileted until 1:50 p.m. On 03/04/2026 at 1:50 p.m., an observation was made of S8CNA and S9CNA bringing Resident #7 to her bathroom. Resident #7 was able to pivot from the wheelchair onto the toilet with assistance from S8CNA and S9CNA. Resident #7's brief was observed to be saturated with urine. There was a golf ball sized wet spot on the back of Resident #7's pants and wet residue in the center of Resident #7's wheelchair. At that time, S8CNA confirmed this observation. On 03/04/2026 at 3:12 p.m., an interview was conducted with S8CNA. She stated she was assigned to Resident #7 today. S8CNA stated Resident #7 was incontinent at times, but could use the restroom sometimes if brought to sit on the toilet. She confirmed from 8:30 a.m. to 1:50 p.m., Resident #7 was not changed, checked to see if she needed to be changed, or put on the toilet. She confirmed residents should be checked for incontinence every two hours and changed at least every two hours if needed. Resident #85Review of Resident #85's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which include Dementia and Muscle Atrophy and Wasting. Review of Resident #85's Quarterly MDS with an ARD of 02/09/2026 revealed she was unable to complete the BIMS interview. Further reviewed revealed she was dependent on staff for toileting. Review of Resident #85's current Care Plan revealed the following, in part:Focus: Resident #85 has bowel incontinence related to dementia.Interventions: Check resident every two hours and assist with toileting as needed; Provide peri-care after each incontinent episode. On 03/04/2026 from 8:30 a.m. to 3:15 p.m., an observation was made of the residents on Unit 1. Resident #85 sat in the dining room of Unit 1, without being checked for incontinence or changed, until 2:58 p.m. On 03/04/2026 at 2:58 p.m., an observation was made of S8CNA providing incontinence care to Resident #85. Resident #85 was observed to be wearing gray sweat pants which were observed to be saturated in the front and in the back. On 03/04/2026 at 3:00 p.m., an interview was conducted with S8CNA. S8CNA confirmed the observation above and confirmed Resident #85 had not been checked for incontinence or changed every two hours and should have been. On 03/05/2026 at 12:13 p.m., an interview was conducted with S2DON. S2DON stated staff should check to see if residents needed to be changed or toileted every two hours and as needed. She was notified of the above observations of Unit 1 and confirmed residents should have been checked for incontinence and changed every two hours.

Based on observations, interviews, and record reviews, the facility failed to ensure physical restraints were not imposed for the purpose of staff convenience and were used to treat a resident's medical symptoms for 1 (#113) of 2 residents reviewed for restraints. Review of the facility's policy titled Restraints and Safety Devices, with a revision date of 10/22, revealed the following, in part:It is the philosophy of this facility that a resident has the right to be free from any physical or chemical restraints not required to treat the residents' medical symptoms. Physical Restraint DefinitionAny manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove, restricts freedom of movement or normal access to one's body. Review of Resident #113's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Dementia and Frequent Falls. Review of Resident #113's Annual MDS with an ARD of 01/19/2026 revealed she had a BIMS of 4, which indicated severe cognitive impairment. Further review revealed she had no impairment of the lower extremity, and she required partial/moderate assistance for transfers. Review of Resident #113's current Physician's Orders revealed no order for restraints. Review of Resident #113's current Care Plan revealed the following, in part: Problem: The resident has had an actual fall with (no injury) Poor Balance, Unsteady gaitInterventions: 02/02/2026-Soft waist self-release belt applied while in wheelchair to reduce fall probability Review of Resident #113's Nurse's Notes revealed the following, in part:-02/02/2026 at 6:53 p.m. - Resident #113 was observed attempting to ambulate independently. Resident did not strike her head. Resident was immediately assessed. Resident able to move all extremities. No injuries noted at this time. Resident educated on the importance using her ambulatory device when ambulating. Will continue to monitor. -Signed, S3LPN-02/02/2026 at 7:07 p.m.- New fall intervention as followed -(1)Soft waist self-release belt applied while in wheelchair to reduce fall probability - floor nurse and staff assigned aware of new fall intervention - plan of care revised. -Signed, S6LPN Further review of Resident #113's Clinical Record revealed no Physical Restraint Assessment was completed. On 03/04/2026 at 8:28 a.m., an observation was made of Resident #113. She was sitting at the dining room table in her wheelchair on Unit 1. A soft seatbelt was observed fastened at her waist. On 03/05/2026 at 9:36 a.m., an observation was made of Resident #113. She was sitting at the dining room table in her wheelchair on Unit 1. A soft seatbelt was observed fastened at her waist. On 03/05/2026 at 1:24 p.m., an interview was conducted with S3LPN. S3LPN stated Resident #113 was able to stand and pivot. S3LPN stated she was assigned to Resident #113 and witnessed her fall on 02/02/2026. She stated on 02/02/2026, Resident #113 stood up in her wheelchair then fell before staff could get to her. She stated Resident #113 sustained no injuries. S3LPN stated the seatbelt was the intervention put into place for Resident #113 on 02/02/2026 for fall prevention. On 03/05/2026 at 10:20 a.m., an interview was conducted with S7CNA. She stated Resident #113 was a one person assist for transfers. She stated she did not know why Resident #113 had a seatbelt in place. She stated the seatbelt was fastened around Resident #113's waist while she was in her wheelchair. S7CNA stated she did not know if Resident #113 was able to release the seatbelt on her own. On 03/05/2026 at 10:25 a.m., an interview was conducted with S5LPN. S5LPN stated she was assigned to Resident #113 today. She stated Resident #113 was a one person assist for transfers and toileting. She stated after Resident #113's last fall, the seatbelt was the fall intervention that was initiated. She stated the seatbelt was in place to prevent Resident #113 from having another fall. She stated Resident #113 was to wear the seatbelt at all times while up in her wheelchair. She stated did not know if Resident #113 could remove the seatbelt by herself. On 03/05/2026 at 10:34 a.m., an observation was made of S5LPN asking Resident #113 to release her seatbelt. S5LPN asked Resident #113 to release the seatbelt four times. The fourth time, Resident #113 was observed putting her fingers on the release button, but did not release the belt. On 03/05/2026 at 10:36 a.m., a follow up interview was conducted with S5LPN. She confirmed Resident #113 was unable to release the seatbelt. S5LPN stated if a resident was unable to release a seatbelt, the seatbelt was considered a restraint. On 03/05/2026 at 11:02 a.m., an interview was conducted with S6LPN. S6LPN stated she was responsible for investigating falls and initiating fall care plans and interventions. She stated Resident #113 was a one person assist. She stated Resident #113 had an intervention initiated for a seatbelt on 02/02/2026. She stated the purpose for the seatbelt was to prevent Resident #113 from falling out of her wheelchair. She stated Resident #113's seatbelt was to be worn while she was up in her wheelchair. She stated Resident #113's seatbelt was not a restraint, but a safety device. She stated Resident #113 was not supposed to be able to remove the seatbelt, because if she were able to, it would not have been an effective safety device. She stated there had been no restraint assessment completed for Resident #113's seatbelt. On 03/05/2026 at 12:13 p.m., an interview was conducted with S2DON. S2DON stated seatbelts served as a safety device to remind residents on Unit 1 to stay seated and not get up without assistance. She stated seatbelts were not considered restraints for residents who resided on Unit 1 because the residents were non-ambulatory, so the seatbelts were not restricting their movements. S2DON further stated no restraint assessments were completed by the facility for residents who had seatbelts initiated. On 03/05/2026 at 1:51 p.m., a follow up interview was conducted with S2DON. She reviewed Resident #113's Nurse's Notes dated 02/02/2026 indicating Resident #113 had a fall after attempting to ambulate independently. S2DON confirmed Resident #113's seatbelt would restrict her from standing up.

Based on record reviews, observations, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (#91) of 2 residents reviewed for enteral feedings. The facility failed to ensure the enteral feeding bag was appropriately labeled.Findings: Review of the facility's policy titled, Tube Feeding, and dated 12/2015 revealed the following: Procedures for administering tube feedings are in place and address:e. Labeling of the container. Review of the clinical record for Resident #91 revealed he was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction due to Thrombosis of Left Middle Cerebral Artery, Hemiplegia and Hemiparesis following Cerebral Infarction, Aphasia following Cerebral Infarction, Dysphagia, Oropharyngeal Phase, Encounter for attention to Gastrostomy, unspecified, Cerebral Infarction. Review of the current Physician Orders for Resident #91, revealed, in part, the following: Start date: 03/02/2026 tube feeding formula: Diabetasource AC at 75 ml/hour, continuous. 03/03/2026 9:12 a.m., an observation of Resident #91's tube feeding bag with no name, date, time or rate noted on bag of Diabetasource AC running 75ml/hour per pump. 03/03/2026 9:14 a.m., an interview was conducted with S4LPN. S4LPN stated she would spike a new bag of the proper tube feeding formula, label the bag with Resident's name, the date, time, rate of infusion. S4LPN stated if she found the tube feeding bag unlabeled she would discontinue the present bag and hang a new bag of feeding after labeling it properly. 03/03/2026 9:23 a.m., an observation of Resident #91's tube feeding was conducted with S2DON. S2DON confirmed Resident #91 tube feeding was unlabeled with his name, date and time initiated and should have been.

Based on interviews and record reviews, the facility failed to maintain accurate records in accordance with professional standards of practice by failing to ensure medication administration was accurately documented on the MAR for 3 of 3 (#1, #2, and #3) residents in the sample. This deficient practice had the potential to affect a current census of 119 residents. Findings: Resident #1Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part, Primary Generalized Osteoarthritis and was currently receiving treatment for multiple wounds. Further review revealed he was admitted to a local Hospice agency on 03/14/2024 and in a current Certification Period of 11/04/2025 through 01/02/2025. Review of Resident #1's Physician Orders, dated 09/01/2025 through 12/09/2025, revealed, in part, an order written on 08/21/2025 for Oxycodone/Acetaminophen Tab 10-325mg. Give 1 tablet by mouth every 6 hours as needed for pain related to Primary Generalized Osteoarthritis.Review of Resident #1's Narcotic Log Sheet for Oxycodone/Acetaminophen Tab 10-325mg, dated 09/23/2025 through 10/31/2025, revealed, in part, the following:09/24/2025 at 10:21 a.m. - 1 tablet administered;09/24/2025 at 8:00 p.m. - 1 tablet administered; 10/05/2025 at 9:15 a.m. - 1 tablet administered; and 10/09/2025 at 2:30 a.m. - 1 tablet administered.Review of Resident #1's September 2025 MAR for Oxycodone/Acetaminophen Oral Tablet 10-325mg, dated 09/01/2025 through 09/30/2025, revealed, in part, the following: 09/24/2025 at 10:21 a.m. - No administration documented; and 09/24/2025 at 8:00 p.m. - No administration documented.Review of Resident #1's October 2025 MAR for Oxycodone/Acetaminophen Oral Tablet 10-325mg, dated 10/01/2025 through 10/31/2025, revealed, in part, the following: 10/05/2025 at 9:15 a.m. - No administration documented; and 10/09/2025 at 2:30 a.m. - No administration documented. Resident #2Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, a Stage 2 Pressure Ulcer to the Sacrum and Chronic Pain. Further review revealed she was admitted to a local Hospice agency on 08/20/2025 and in a current Certification Period of 08/20/2025 through 11/17/2025.Review of Resident #2's Physician Orders, dated 08/20/2025 through 09/11/2025, revealed, in part, an order written on 08/20/2025 for Morphine Sulfate Concentrate Oral Solution 100mg/5mL. Give 1 ml by mouth every 1 hour as needed for Pain/Shortness of Breath.Review of Resident #2's Narcotic Log Sheet for Morphine Sulfate Concentrate Oral Solution 100mg/5mL, dated 09/10/2025 through 09/11/2025, revealed, in part, the following: 09/10/2025 at 5:55 a.m. - 1mL administered.Review of Resident #2's September 2025 MAR for Morphine Sulfate Concentrate Oral Solution 100mg/5mL, dated 09/01/2025 through 09/30/2025, revealed, in part, the following: 09/10/2025 at 5:55 a.m. - No administration documented. Resident #3Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part, Spinal Stenosis and a Stage 2 Pressure Ulcer to the Sacrum. Further review revealed he was admitted to a local Hospice agency on 08/14/2025 and in a current Certification Period of 11/12/2025 through 02/09/2025. Review of Resident #3's Physician Orders, dated 08/14/2025 through 12/09/2025, revealed, in part, the following:08/14/2025 - Oxycodone/Acetaminophen Oral Tablet 10-325mg. Give 1 tablet by mouth every 4 hours as needed for Pain. Discontinued on 09/26/2025; 09/27/2025 - Oxycodone/Acetaminophen Oral Tablet 10-325mg. Give 1 tablet by mouth three times a day for Pain. Discontinued on 11/10/2025; and 11/10/2025 - Oxycodone-Acetaminophen Oral Tablet 10-325mg - Give 1 tablet by mouth every 6 hours as needed for Pain related to Spinal Stenosis, Lumbar Region Without Neurogenic Claudication and Give 1 tablet by mouth four times a day for Pain.Review of Resident #3's Narcotic Log Sheet for Oxycodone/Acetaminophen Tab 10-325mg, dated 08/29/2025 through 09/14/2025, revealed, in part, the following:09/01/2025 at 8:00 a.m. - 1 tablet administered; 09/02/2025 at 9:00 p.m. - 1 tablet administered;09/03/2025 at 9:00 a.m. - 1 tablet administered;09/06/2025 at 5:45 a.m. - 1 tablet administered;09/06/2025 at 10:30 a.m. - 1 tablet administered;09/07/2025 at 5:00 a.m. - 1 tablet administered;09/10/2025 at 4:30 a.m. - 1 tablet administered;09/10/2025 at 1:55 p.m. - 1 tablet administered;09/11/2025 at 9:30 a.m. - 1 tablet administered; and 09/12/2025 at 9:35 a.m. - 1 tablet administered. Review of Resident #3's September 2025 MAR for Oxycodone/Acetaminophen Oral Tablet 10-325mg, dated 09/01/2025 through 09/30/2025, revealed, in part, the following: 09/01/2025 at 8:00 a.m. - No administration documented; 09/02/2025 at 9:00 p.m. - No administration documented;09/03/2025 at 9:00 a.m. - No administration documented;09/06/2025 at 5:45 a.m. - No administration documented;09/06/2025 at 10:30 a.m. - No administration documented;09/07/2025 at 5:00 a.m. - No administration documented;09/10/2025 at 4:30 a.m. - No administration documented;09/10/2025 at 1:55 p.m. - No administration documented;09/11/2025 at 9:30 a.m. - No administration documented; and 09/12/2025 at 9:35 a.m. - No administration documented.An interview was conducted on 12/09/2025 at 3:15 p.m. with S2LPN. S2LPN confirmed she worked at the facility as a floor nurse and was familiar with the facility's procedures for administration of narcotics. S2LPN confirmed when administering a narcotic, the nurse should count the remaining tablets to ensure the Narcotic Log remained accurate, then document they have pulled the medication for administration with the date/time they pulled it to administer. S2LPN stated the nurse should then administer the medication to the resident. S2LPN stated after the medication was administered, the nurse should then document the administration in the MAR. S2LPN confirmed a resident's Narcotic Log should match their MAR. An interview was conducted on 12/09/2025 at 3:30 p.m., with S1DON. S1DON confirmed when administering a narcotic, she expected the nurse to count the remaining tablets to ensure the Narcotic Log remained accurate, then document they have pulled the medication for administration with the date/time they pulled it to administer. S1DON confirmed the nurse should then administer the medication to the resident and after the medication was administered, the nurse should document the administration in the MAR. S1DON confirmed if a medication was logged in the resident's Narcotic Log as pulled for administration, she expected the resident's MAR to accurately reflect the administration of the pulled medication. S1DON confirmed a resident's Narcotic Log should match their MAR and Resident #1, #2, and #3's did not.

Based on observation, interviews, and record review, the facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing perineal care to a resident who was on Enhanced Barrier Precautions (EBP) for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for infection control. Findings: Review of the facility's policy titled, Enhanced Barrier Precautions revised on 03/2024, revealed the following, in part: Enhanced Barrier Precautions are indicated for residents with any of the following: Chronic wounds include .pressure ulcers . For residents whom EBP are indicated, EPB is employed when performing the following high-contact resident care activities: Changings briefs or assisting with toileting. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnoses including Pressure Ulcer of Sacral Region. Review of Resident #3's current Physician Orders revealed the following, in part: Start date 08/01/2024: Enhanced Barrier Precautions related to a sacral pressure ulcer. An observation was made on 03/19/2025 at 1:58 p.m., of the Enhanced Barrier Precautions sign posted on Resident #3's door. The Enhanced Barrier Precautions sign revealed the following, in part: Providers and staff must: Wear gloves and a gown for the following high-contact resident care activities: Changing briefs or assisting with toileting. An observation was made on 03/19/2025 at 2:00 p.m. of S2CNA providing perineal care to Resident #3. S2CNA did not wear a gown while changing Resident #3's brief and providing perineal care. An observation was made on 03/19/2025 at 2:25 p.m. with S2CNA. She stated Resident #3 was on EBP for a wound. She confirmed she did not wear a gown while providing perineal care and should have. An interview was conducted on 03/19/2025 at 3:50 p.m. with S1DON. She was notified of the above observation on 03/19/2025. S1DON confirmed when a resident was on EBPs, staff should wear a gown while providing perineal care and changing briefs.

Based on record reviews and interviews, the facility failed to ensure an allegation of neglect was reported immediately, but not later than 2 hours after the incident occurred to the State Survey Agency and local law enforcement in accordance with State law for 1 (#3) of 4 ( #1, #2, #3, and #R1) residents reviewed for abuse. The provider failed to report Resident #3's elopement from the facility on 02/08/2025 to local law enforcement and the state agency. This deficient practice resulted in an Immediate Jeopardy situation on 02/08/2025 when Resident #3, a resident that resided on the locked unit of the facility due to wandering behaviors, was noted missing from the facility by staff. Resident #3 was admitted to the facility with a known protective order and open EPS case against family members. On 02/08/2025 around 7:07 p.m., staff allowed 2 unknown family members to remove Resident #3 from the facility's locked unit and bring her outside unsupervised. CNA staff went to check on the resident and realized she had been removed from the facility. Resident #3 was located 2 days later with a family member. S1ADM was notified of the Immediate Jeopardy on 02/20/2025 at 6:26 p.m. This deficient practice continued at the potential for more than minimal harm for all residents residing in the facility. The Immediate Jeopardy was removed on 02/21/2025 at 6:00 p.m., as confirmed by onsite verification through record reviews and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: Cross reference F656 and F689 Review of facility's policy titled, Incident Investigation & Reporting, with a revision date of 05/2024 revealed, in part the following: Purpose: Additional incidents that must have a thorough investigation and may require reporting, as determined by the NF especially in consideration to abuse and/or neglect, to the state agency with the implementation of corrective actions(s), and referrals, as applicable to the appropriate authorities/agencies. 5. To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to local law enforcement, and others as required by state and federal requirements. To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes. G. Elopement Review of Resident #3's Clinical Record revealed an admitted [DATE], with diagnoses which included Dementia, Encephalopathy, Altered Mental Status, and Housing Instability. Further review revealed an active protective order against Resident #3's Responsible Party (RP) which was filed on 01/13/2025 and effective through 11:59 p.m. on 02/26/2025 against Resident #3's RP for domestic abuse. Review of Resident #3's Progress Noted dated 01/19/2025-02/19/2025 revealed, the following, in part: On 02/08/2025 at 10:18 p.m. S9LPN noted Resident #3's daughter and granddaughter arrived to visit with the resident. The daughter asked a CNA if she could take Resident #3 outside on the patio to visit and did not return with the resident. The CNA went to make sure the resident did not need anything, and it was then discovered Resident #3 was not outside anymore. The aide checked Resident #3's room and all of her belongings were missing, except the clothing in her closet. Resident #3 was removed from the premises without staff's knowledge through the exterior of the building. On 02/14/2025 at 2:36 p.m. S11SW noted she followed up with Resident #3's EPS worker to see if Resident #3 was home, and discovered Resident #3 was at home with her daughter. Review of the facility's Incident log dated 01/17/2025 to current revealed no entries for Resident #3. Review of the facility's State Reporting logs dated 12/12/2024 to current revealed no entries for Resident #3. Review of Resident #3's local hospital Discharge Summary dated 01/31/2025, revealed the following, in part: Housing Instability Resident #3's Power of Attorney (POA) stated she had an open EPS case against two siblings. POA's other siblings stated there was a protective order against POA. EPS recommended placement, as there had been multiple reports and protective order between multiple parties in this situation. On 02/21/2025 at 11:30 a.m., an interview was conducted with S8CNA. She stated she was the CNA assigned to Resident #3 on 02/08/2025 when Resident #3 went missing from the facility. She stated when she realized the resident was gone, she reported it to the nurse on duty, and the nurse notified S3DON. On 02/19/2025 at 1:26 p.m., a telephone interview was conducted with S9LPN. She stated on 02/08/2025 at 7:07 p.m. Resident #3 was missing from the facility. S9LPN stated she immediately informed S3DON of the incident. S9LPN stated S3DON told her she would notify S1ADM. On 02/19/2025 at 2:39 p.m., an interview was conducted with S3DON. She stated S9LPN called her on 02/08/2025 to inform her Resident #3 was missing, and she immediately notified S1ADM. She stated while she called S1ADM, and she accessed the facility's video camera and saw Resident #3 leaving the facility with unknown family members. She stated she called and left a voicemail with Resident #3's EPS Case Worker about the incident, but the facility did not hear back from him until 02/10/2025. She stated on 02/10/2025 she was made aware of Resident #3's whereabouts from S11SW. S3DON confirmed she did not notify law enforcement when the resident was noted missing from the facility. On 02/20/2025 at 9:21 a.m., an interview was conducted with S11SW. She stated she was notified by S1ADM of Resident #3 leaving the facility on Sunday, 02/09/2025. She stated she returned to work on the Monday, 02/10/2025, and contacted Resident #3's EPS case worker who informed her Resident #3 was home with her daughter. She stated she did not notify the authorities because that would be S1ADM's responsibility. On 02/20/2025 at 12:38 p.m., an interview was conducted with S1ADM. He stated on 02/08/2025, S3DON informed him Resident #3 was missing from the facility. S1ADM stated Resident #3 did not struggle on the video footage and she acted as if she wanted to leave. S1ADM confirmed he did not notify law enforcement or the state agency. S1ADM verified he could not identify the family members he observed on the facility's video footage which left with Resident #3 on 02/08/2025. S1ADM stated he was made aware of Resident #3's whereabouts on 02/10/2025 when Resident #3's EPS case worker informed S11SW, she was at home with her daughter. On 02/20/2025 at 5:30 p.m., an interview was conducted with S2RVP. He stated he and S1ADM agreed not to call local law enforcement or report to state agency because they did not think Resident #3 eloped because she left with family. The facility implemented the following actions to correct the deficient practice on 02/20/2025: On 02/08/2025 Resident #3 left the facility and did not return. On 02/08/2025 NFA contacted Elderly Protective Services to alert them Resident #3 left the facility. On 02/08/2025 NFA alerted the facility Ombudsman that the resident's family removed her from the facility. o All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit). o All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection on 02/20/2025 at 7:50 pm. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned at this time. o 02/21/25 all resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan. o Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. 02/21/25 Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system. o Regional [NAME] President will review all SIMs reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately. o An immediate in-service was initiated by the Director of Nurses on 02/20/2025 at 7:40 pm with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurse's station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff on 02/20/2025 and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member. o (Beginning 02/21/25) To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission for the next 30 days. The DON, will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress. Beginning 02/21/25 the NFA or designee will Interviews 5 staff members 3 x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident. o An Emergency QA was held on 02/21/2025 with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases. o Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination. o Completion date - The likelihood for serious harm will no longer exist on 02/21/2025. As of 02/21/2025, the facility asserts the likelihood for serious harm to any recipient no longer exists. Throughout the survey from 02/20/2025 to 02/21/2025, interviews, and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the new process to ensure residents at risk for elopement were properly identified, staff knew the process to identify those residents, staff knew the process to notify the proper authorities and when to notify local law enforcement, and staff knew when and what to report to the local law enforcement and state agency.

Based on record reviews and interviews, the provider failed to develop and implement a Comprehensive Person-Centered Care Plan to meet the needs of 1 (#3) of 7 (#1, #2, #3, #R1, #R2, #R3, and #R4) sampled residents. The facility failed to ensure staff were aware of Resident #3's active protective order and an open Elderly Protective Service (EPS) case against 3 family members. This deficient practice resulted in an Immediate Jeopardy situation on 02/08/2025 when Resident #3, a resident that resided on the locked unit of the facility due to wandering behaviors, was noted missing from the facility by staff. Resident #3 was admitted to the facility with a known protective order and open EPS case against family members. On 02/08/2025 around 7:07 p.m., staff allowed 2 unknown family members to remove Resident #3 from the facility's locked unit and bring her outside unsupervised. CNA staff went to check on the resident and realized she had been removed from the facility. Resident #3 was located 2 days later with a family member. S1ADM was notified of the Immediate Jeopardy on 02/20/2025 at 6:26 p.m. This deficient practice continued at the potential for more than minimal harm for the current 121 residents residing in the facility whom required a Comprehensive Person-Centered Care Plan to meet their needs. The Immediate Jeopardy was removed on 02/21/2025 at 6:00 p.m., as confirmed by onsite verification through record reviews and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: Review of facility's policy titled, Care Plan Process, with revision date of 12/2024 revealed, in part the following: Baseline Care Plan and Summary The facility must develop a comprehensive care plan for each resident which includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs, including culturally -competent and trauma- informed as well as, these items or services which would be required but are not due to the exercise of resident rights (refusal). The comprehensive care plan is an interdisciplinary team (IDT) communication tool. The IDT will minimally include the; attending physician, register nurse with responsibility for the care of the resident, a nurse aide with responsibility for the resident, and any other disciplines as appropriate. The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident #3's Clinical Record revealed an admitted to the facility of 01/31/2025, with diagnoses which included Dementia, Encephalopathy, and Altered Mental Status. Further review revealed an active protective order against Resident #3's Responsible Party (RP) which was filed on 01/13/2025 and effective through 11:59 p.m. on 02/26/2025 against RP for domestic abuse. Review of Resident #3's Current Comprehensive Plan of Care revealed no developed care plan or interventions to ensure staff were aware of Resident #3's current protective order or the open EPS case against three family members. Review of Resident #3's local hospital Discharge Summary dated 01/31/2025, revealed the following, in part: Housing Instability Resident #3's Power of Attorney (POA) stated she had an open EPS case against two siblings. POA's other siblings stated there was a protective order against POA. EPS recommended facility placement, as there had been multiple reports and protective orders between multiple parties in this situation. On 02/21/2025 at 11:30 a.m., an interview was conducted with S8CNA. She stated the process of how information was usually communicated to CNA staff was verbal report and the task which are displayed on the kiosk during their shift. She stated she worked with Resident #3 on 02/08/2025. She stated Resident #3 resided on the locked unit of the facility. She stated on 02/08/2025, two family member's came to the facility to visit with Resident #3 and asked to bring her outside. She stated it was not unusual for Resident #3's family to take her outside. She stated she put the code in and allowed two of Resident #3's family members to take her outside. She further stated Resident #3 had another family member already outside. She stated she noticed two family members came back into the facility, and one stayed outside. S8CNA further stated, that's when she noticed Resident #3 had not come back inside and went to check on her. S8CNA stated all the gates were open and Resident #3 was missing. S8CNA stated if she had known about the current protective order and open EPS case against three family members, she would not have left Resident #3 unsupervised with family. On 02/19/2025 at 1:26 p.m., a telephone interview was conducted with S9LPN. She stated the process of how information was usually communicated to nursing staff was verbal report and resident's plan of care. S9LPN stated she was only told in report Resident #3 was a recent admit to the locked unit. She stated she worked with Resident #3 on 02/08/2025 when Resident #3 was noted missing. S9LPN stated she was passing medications when she noticed two unknown females walk onto the unit. She stated the two females entered the code and gained access to the unit and then entered the code and gained access to the female side of the locked unit. She stated S8CNA informed her she let Resident #3 out to smoke with her daughter and when she went to check on Resident #3 they were gone.S9LPN stated if she had known about the current protective order and an open EPS case against three family members, she would have been more cautious when Resident #3 was with family. On 02/19/2025 at 2:11 p.m., an interview was conducted with S4CM. She stated she was responsible for completing Resident #3's Comprehensive Plan of Care. She stated she did not include interventions for the EPS case or protective order for Resident #3. She stated she was aware of Resident #3's protective order and open EPS case when she reviewed Resident #3's hospital Discharge Summary. S4CM stated she was unsure how staff were made aware of the open EPS case and protective order for Resident #3, but she stated staff should have been made aware. On 02/20/2025 at 10:31 a.m., a telephone interview was conducted with S10AC. She stated she was made aware of Resident #3's current protective order for domestic abuse and open EPS case against 3 family members on 01/29/2025 by Resident #3's RP. She stated she did mention the family dynamic concerns to S11SW and S1ADM when the resident was being admitted to the facility. On 02/20/2025 at 9:21 a.m., an interview was conducted with S11SW. She stated she was aware of Resident #3's current protective order for domestic abuse and open EPS case against 3 family members prior to admission. S11SW stated those concerns were the reason for Resident #3's admission to the facility. On 02/20/2025 at 1:23 p.m., a telephone interview was conducted with Resident #3's EPS case worker. He stated he suggested to the local hospital that Resident #3 be placed in a nursing facility due to Resident #3's family dynamics and cases pending with EPS and a protective order. He further stated he called the nursing facility on 01/30/2025 to inform them of Resident #3's open EPS case and protective order for domestic abuse against Resident #3's RP and spoke with the S3DON. On 02/19/2025 at 2:39 p.m., an interview was conducted with S3DON. She stated she was made aware of an open EPS case and protective order against three family members for Resident #3 on 01/30/2025 by Resident #3's EPS caseworker, and she informed S1ADM. She stated the facility did not usually care plan EPS cases or protective orders.S3DON confirmed she did not communicate Resident #3's open EPS case or protective order with direct care staff. S3DON confirmed the facility did not develop a care plan or implement interventions to ensure staff were aware of the active protective order or open EPS case. S3DON stated if the staff had been aware, the elopement from the facility with unknown family members could have been prevented. On 02/20/2025 at 12:38 p.m., an interview was conducted with S1ADM. He stated he was made aware of Resident #3's open EPS case and protective order by S3DON on 01/30/2025. He stated the direct care staff was not made aware of Resident #3's open EPS case or order of protection. The facility had implemented the following actions to correct the deficient practice on 02/20/2025: Corrective actions for the alleged deficient practice of the facility failing to ensure a comprehensive person-centered care plan to ensure nursing staff were aware of Resident #3's needs and make staff aware of Resident #3's current protective orders against 3 family members. On 02/08/2025 Resident #3 left the facility and did not return. On 02/08/2025 NFA contacted Elderly Protective Services to alert them Resident #3 left the facility. On 02/08/25 NFA alerted the facility Ombudsman that the resident's family removed her from the facility. All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit). All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection on 02/20/2025 at 7:50 pm. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned at this time. 02/21/25 all resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan. Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. 02/21/25 Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system. Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately. An immediate in-service was initiated by the Director of Nurses on 02/20/2025 at 7:40 pm with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurses' station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff on 02/20/2025 and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member. (Beginning 02/21/25) To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission for the next 30 days. The DON, will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress. Beginning 02/21/25 the NFA or designee will interview 5 staff members 3 x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident. An Emergency QA was held on 02/21/2025 with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases. Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination. Completion date - The likelihood for serious harm will no longer exist on 02/21/2025. As of 02/21/2025, the facility has resolved the likelihood of serious harm or injury to any resident no longer exists. Throughout the survey from 02/20/2025 to 02/21/2025, observations, interviews, and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the new process to ensure residents are properly care planned to meet their needs, new process to properly care plan for a resident whom had an open EPS case and/or current protective order against family member(s).

Based on record reviews and interviews, the facility failed to ensure residents received adequate supervision to prevent elopement from the facility for 1 (#3) of 4 (#3, #R2, #R3, and #R4) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy situation on 02/08/2025 when Resident #3, a resident that resided on the locked unit of the facility due to wandering behaviors, was noted missing from the facility by staff. Resident #3 was admitted to the facility with a known protective order and open Elderly Protective Services (EPS) case against family members. On 02/08/2025 around 7:07 p.m., staff allowed 2 unknown family members to remove Resident #3 from the facility's locked unit and bring her outside unsupervised. CNA staff went to check on the resident and realized she had been removed from the facility. Resident #3 was located 2 days later with a family member. S1ADM was notified of the Immediate Jeopardy on 02/20/2025 at 6:26 p.m. The Immediate Jeopardy was removed on 02/21/2025 at 6:00 p.m., as confirmed by onsite verification through record reviews and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. This deficient practice continued at a likelihood to cause more than minimal harm to the remaining residents residing in the facility who were at risk for elopement. Findings: Cross reference F656 and F609 Review of facility's policy titled, Elopement/Wandering, with revision date of 01/2023 revealed, in part the following: Elopement occurs when a resident who is incapable of adequately protecting themselves leaves the premises without necessary supervision to do so. 1. All resident shall be observed and evaluated for demonstration of elopement risk by using Admission/Readmission Nursing screening on admission and Nurse Data Collection and Screening in the observation period of each Minimal Data Set (MDS). e. The following items shall be used to increase staff awareness of residents at risk to wander/elope. i. A list of residents shall be available at the nurse's stations with residents at risk for wandering indicated. ii. Orientation of all staff to potential wanderers will be performed on an ongoing basis. Review of Resident #3's Clinical Record revealed an admitted [DATE], with diagnoses which included Dementia, Encephalopathy, Altered Mental Status, and Housing Instability. Further review revealed a protective order filed against Resident #3's Responsible Party (RP) on 01/13/2025 effective through 11:59 p.m. on 02/26/2025 for domestic abuse. Review of Resident #3's local hospital Discharge Summary dated 01/31/2025, revealed the following, in part: Housing Instability Resident #3's Power of Attorney (POA) stated she had an open EPS case against two siblings. POA's other siblings stated there was a protective order against POA. EPS recommended placement, as there had been multiple reports and protective order between multiple parties in this situation. Review of Resident #3's Nurse Data Collection and Screening dated 02/06/2025, Elopement risk section, revealed questions 1 through 3 were answered yes. Question 6, asked if the resident was at risk for elopement and indicated if any of the above questions (1-5) were answered yes, the resident was at risk. Question 6 was observed to be answered as No. Further review revealed the resident was not documented as using a wander guard. Review of Resident #3's Current Comprehensive Plan of Care revealed, the following in part: Onset date: 02/03/2025 Problem: The resident has impaired thought process related to encephalopathy: Risk for elopement Interventions: Cue, reorient, and supervise as needed; and On 02/04/2025 wander guard to right ankle. Further review failed to reveal interventions to ensure staff were aware of Resident #3's current protective order and open Elderly Protective Services (EPS) case against three family members. Review of Resident #3's Progress Noted dated 01/19/2025 to 02/19/2025 revealed, the following, in part: On 02/04/2025 at 3:01p.m., notified Resident #3's Responsible Party (RP), resident would be placed on memory care unit due to wandering. Signed S11SW Review of facility's Wanderers' Binder located at the nurse's station revealed a wander guard list dated 01/31/2025. Further review revealed a list of elopement risk residents which did not include Resident #3. The facility had implemented the following actions to correct the deficient practice on 02/20/2025: Corrective actions for the alleged deficient practice of the facility failing to provide adequate supervision to prevent Resident #3 from eloping on 02/08/25. o On 02/08/25 Resident #3 left from the facility and did not return. 02/08/25 Facility NFA contacted Elderly Protective Services to alert them resident #3 left the facility. 02/08/25 NFA alerted the facility Ombudsman that the resident's family removed her from the facility. o All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit). o All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection on 02/20/2025 at 7:50 pm. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned at this time. o 02/21/25 all resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan. o Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. 02/21/25 Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system. o Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately. o An immediate in-service was initiated by the Director of Nurses on 02/20/2025 at 7:40 pm with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurse's station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff on 02/20/2025 and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member. o (Beginning 02/21/25) To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission for the next 30 days. The DON, will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress. o Beginning 02/21/25 the NFA or designee will interview 5 staff members 3 x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident. o An Emergency QA was held on 02/21/2025 with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases. o Should the above referenced A measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination. o Completion date - The likelihood for serious harm will no longer exist on 02/21/2025. As of 02/21/2025, the facility has resolved the likelihood of serious harm or injury to any resident no longer exists. Throughout the survey from 02/20/2025 to 02/21/2025, observations, interviews, and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the new process to ensure residents are properly care planned to meet their needs, ensure supervision to prevent an elopement of a resident, they were able to state the process to identify residents on the wander guard and elopement risk list, as well as the process if a resident was noted to be missing or eloped. On 02/20/2025 at 10:53 a.m., a telephone interview was conducted with Resident #3's RP. She stated she informed the facility of the open EPS case against two of her siblings and protective order for domestic abuse against herself for Resident #3 prior to her admission. She stated she informed S11SW and S3DON prior to admission her mother had previous episodes of wandering. On 02/21/2025 at 11:30 a.m., an interview was conducted with S8CNA. She stated she was not aware Resident #3 was an elopement risk and did not know there was a protective order and open EPS case against family members. She stated the process to identify a resident who was an elopement risk was to review the wanderers' binder at the nurse's station every shift. She stated she was the CNA assigned to Resident #3 on 02/08/2025 when Resident #3 went missing from the facility. She stated she put the code in for the back door of the locked unit and allowed two of Resident #3's family members to go outside with Resident #3 unsupervised. S8CNA stated when she went to check on her, Resident #3 was missing. S8CNA stated she reported it to S9LPN. S8CNA stated if she had known Resident #3 was an elopement risk, had a current protective order, and open EPS case against three family members, she would not have left Resident #3 unsupervised with family. On 02/19/2025 at 1:26 p.m., a phone interview was conducted with S9LPN. She stated she was not aware Resident #3 was an elopement risk and did not know there was a protective order and open EPS case against family members. She stated the process to identify a resident who was an elopement risk was to review the plan of care. She stated on 02/08/2025 she reported Resident #3 was missing to S3DON. She stated the incident occurred around 7:07 p.m. S9LPN stated she was passing medications when she noticed two unknown females walk onto the unit. She stated S8CNA informed her she let Resident #3 out to smoke with her daughter unsupervised and when she went to check on Resident #3 they were gone. S9LPN stated she immediately informed S3DON of the incident. S9LPN stated S3DON told her she would notify S1ADM. S9LPN stated if she had known Resident #3 was an elopement risk, had a current protective order, and an open EPS case against three family members, she would have been unsupervised with family. On 02/19/2025 at 2:11 p.m., an interview was conducted with S4CM. She stated the process for the staff to be made aware of a resident with a wander guard and/or an elopement risk was to review the facility's wandering binder located at the nurse's station at beginning of their shift. S4CM confirmed she was responsible for assessing residents by doing an assessment and implementing interventions to reduce hazards and accidents. S4CM reviewed Resident #3's Nurse Data collection and Screening dated 02/06/2025, and confirmed the assessment was completed inaccurately and Resident #3 was an elopement risk. She stated she was responsible for completing Resident #3's Comprehensive Plan of Care. She stated the process of her being made aware of Resident #3's protective order and open EPS case by reviewing hospital discharge paperwork. She stated she did not include interventions for the EPS case or protective order for domestic abuse for Resident #3. S4CM confirmed Resident #3's plan of care did not contain interventions for supervision due to being an elopement risk, EPS case, or protective order for domestic abuse. On 02/19/2025 at 2:39 p.m., an interview was conducted with S3DON. She stated the process for the staff to be made aware of a resident with a wander guard and/or an elopement risk was to review the facility's wandering binder located at the nurse's station at beginning of their shift. She stated she was responsible for ensuring the list was updated weekly. She stated she expected all staff to code/answer all assessments correctly. She stated when Resident #3 was ordered a wander guard and placed on the locked unit on 02/04/2024, she did not communicate the changes to staff. S3DON confirmed she did not add Resident #3 to the wander guard list nor to the elopement risk list, and should have. S3DON further confirmed Resident #3's plan of care did not contain interventions for increase supervision due to being an elopement risk, open EPS case, or protective order for domestic abuse. S3DON stated if staff had been aware, the elopement from the facility with unknown family members could have been prevented. On 02/20/2025 at 12:38 p.m., an interview was conducted with S1ADM. He stated the process for the staff to be made aware of a resident with a wander guard and/or an elopement risk was to review the facility's wandering binder located at the nurse's station at beginning of their shift. S1ADM confirmed Resident #3 resided on the locked unit, had a wander guard, and was an elopement risk. He further confirmed Resident #3 had open EPS case and protective order for domestic abuse against 3 family members. S1ADM stated the direct care staff were not made aware of Resident #3's open EPS case or protective order. He stated on 02/08/2025, S3DON informed him Resident #3 was missing from the facility. S1ADM stated when he viewed the video footage from 02/08/2025, he could not identify the family members Resident #3 left with.

Based on interviews and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to ensure: 1. Administrative Staff communicated resident care needs to direct care staff to prevent elopement for 1 (#3) of 7 (#1, #2, #3, #R1, #R2, #R3, and #R4) sampled residents; and 2. Administrative staff reported an elopement to the state agency and local police in accordance with state law for 1 (#3) of 4 (#1, #2, #3, and #R1) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 02/08/2025 when Resident #3, a resident that resided on the locked unit of the facility due to wandering behaviors, was noted missing from the facility by staff. Resident #3 was admitted to the facility with a known protective order and open EPS case against family members. On 02/08/2025 around 7:07 p.m., staff allowed 2 unknown family members to remove Resident #3 from the facility's locked unit and bring her outside unsupervised. CNA staff went to check on the resident and realized she had been removed from the facility. Resident #3 was located 2 days later with a family member. S1ADM was notified of the Immediate Jeopardy on 02/20/2025 at 6:26 p.m. This deficient practice continued at the potential for more than minimal harm for all residents residing in the facility. The Immediate Jeopardy was removed on 02/21/2025 at 6:00 p.m., as confirmed by onsite verification through record reviews and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: Cross Reference F609, F656, and F689. 1. Review of Resident #3's Clinical Record revealed an admitted to the facility of 01/31/2025, with diagnoses which included Dementia, Encephalopathy, and Altered Mental Status. Further review revealed an active protective order against Resident #3's Responsible Party (RP), which was filed on 01/13/2025 and effective through 11:59 p.m. on 02/26/2025 against RP for domestic abuse. Review of Resident #3's Current Comprehensive Plan of Care revealed there was no developed care plan or interventions to ensure staff were aware of Resident #3's current protective order or the open EPS case against three family members. Review of Resident #3's local hospital Discharge Summary dated 01/31/2025, revealed the following, in part: Housing Instability Resident #3's Power of Attorney (POA) stated she had an open EPS case against two siblings. POA's other siblings stated there was a protective order against POA. EPS recommended facility placement, as there had been multiple reports and protective orders between multiple parties in this situation. Review of Resident #3's Nurse Data Collection and Screening dated 02/06/2025, Elopement risk section, revealed questions 1 through 3 were answered yes. Question 6, asked if the resident was at risk for elopement and indicated if any of the above questions (1-5) were answered yes, the resident was at risk. Question 6 was observed to be answered as No. Further review revealed the resident was not documented as using a wander guard. On 02/20/2025 at 9:21 a.m., an interview was conducted with S11SW. She stated she was aware of Resident #3's current protective order for domestic abuse and open EPS case against 3 family members prior to admission. S11SW stated those concerns were the reason for Resident #3's admission to the facility. On 02/19/2025 at 2:11 p.m., an interview was conducted with S4CM. S4CM confirmed she was responsible for assessing residents by doing an assessment and implementing interventions to reduce hazards and accidents. She confirmed she completed Resident #3's assessment inaccurately and marked her as not being an elopement risk. She stated she was responsible for completing Resident #3's Comprehensive Plan of Care. She stated she did not include interventions for the EPS case or protective order for Resident #3. She stated she was aware of Resident #3's protective order and open EPS case when she reviewed Resident #3's hospital Discharge Summary. S4CM stated she was unsure how staff were made aware of the open EPS case and protective order for Resident #3, but she stated staff should have been made aware. On 02/19/2025 at 2:39 p.m., an interview was conducted with S3DON. She stated the process for the staff to be made aware of a resident with a wander guard and/or an elopement risk was to review the facility's wandering binder located at the nurse's station at beginning of their shift. She stated she was responsible for ensuring the list was updated weekly. She stated when Resident #3 was ordered a wander guard and placed on the locked unit on 02/04/2024, she did not communicate the changes to staff. S3DON confirmed she did not add Resident #3 to the wander guard list nor to the elopement risk list, and should have. She stated she was made aware of an open EPS case and protective order against three family members for Resident #3 on 01/30/2025 by Resident #3's EPS caseworker, and she informed S1ADM. She stated the facility did not usually care plan EPS cases or protective orders. S3DON confirmed she did not communicate Resident #3's open EPS case or protective order with direct care staff. S3DON confirmed the facility did not develop a care plan or implement interventions to ensure staff were aware of the active protective order or open EPS case. S3DON stated if the staff had been aware, the resident's elopement from the facility with unknown family members on 02/08/2025 could have been prevented. On 02/20/2025 at 12:38 p.m., an interview was conducted with S1ADM. He stated he was made aware of Resident #3's open EPS case and protective order by S3DON on 01/30/2025. He stated the direct care staff was not made aware of Resident #3's open EPS case or order of protection. 2. Review of Resident #3's Progress Noted dated 01/31/2025 - 02/19/2025 revealed, the following, in part: On 02/08/2025 at 10:18 p.m., S9LPN noted Resident #3's daughter and granddaughter arrived to visit with the resident. The daughter asked a CNA if she could take Resident #3 outside on the patio to visit and did not return with the resident. The CNA went to make sure the resident did not need anything, and it was then discovered Resident #3 was not outside anymore. The aide checked Resident #3's room and all of her belongings were missing, except the clothing in her closet. Resident #3 was removed from the premises without staff's knowledge through the exterior of the building. On 02/14/2025 at 2:36 p.m., S11SW noted she followed up with Resident #3's EPS worker to see if Resident #3 was home, and discovered Resident #3 was at home with her daughter. Review of the facility's Incident log dated 01/17/2025 to current revealed no entries for Resident #3. Review of the facility's State Reporting logs dated 12/12/2024 to current revealed no entries for Resident #3. On 02/19/2025 at 2:39 p.m., an interview was conducted with S3DON. She stated S9LPN called her on 02/08/2025 to inform her Resident #3 was missing, and she immediately notified S1ADM. She stated while she called S1ADM, she accessed the facility's video camera and saw Resident #3 leaving the facility with unknown family members. She stated she called and left a voicemail with Resident #3's EPS Case Worker about the incident, but the facility did not hear back from him until 02/10/2025. She stated on 02/10/2025, S11SW made her aware of Resident #3's whereabouts. S3DON confirmed she did not notify law enforcement when the resident was noted missing from the facility. On 02/20/2025 at 9:21 a.m., an interview was conducted with S11SW. She stated she was notified by S1ADM of Resident #3 leaving the facility on Sunday, 02/09/2025. She stated she returned to work on the Monday, 02/10/2025, and contacted Resident #3's EPS case worker, who informed her Resident #3 was home with her daughter. She stated she did not notify the authorities because that was S1ADM's responsibility. On 02/20/2025 at 12:38 p.m., an interview was conducted with S1ADM. He stated on 02/08/2025, S3DON informed him Resident #3 was missing from the facility. S1ADM stated Resident #3 did not struggle on the video footage, and she acted as if she wanted to leave. S1ADM confirmed he did not notify law enforcement or the state agency. S1ADM verified he could not identify the family members he observed on the facility's video footage whom left with Resident #3 on 02/08/2025. S1ADM stated he was made aware of Resident #3's whereabouts on 02/10/2025 when Resident #3's EPS case worker informed S11SW, she was at home with her daughter. On 02/20/2025 at 5:30 p.m., an interview was conducted with S2RVP. He stated he and S1ADM agreed not to call local law enforcement or report to state agency because they did not think Resident #3 eloped because she left with family. The facility implemented the following actions to correct the deficient practice on 02/20/2025: Corrective actions for the alleged deficient practice of the facility failing to ensure administration used its resources effectively and efficiently to ensure effective systems were in place to ensure nursing staff were aware of Resident #3's needs and to report allegations of elopement to state and law enforcement. On 02/08/2025, Resident #3 left from the facility and did not return. On 02/08/2025, Facility NFA contacted Elderly Protective Services to alert them Resident #3 left the facility. On 02/08/2025, NFA alerted the facility Ombudsman that the resident's family removed her from the facility. All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit). All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection on 02/20/2025 at 7:50 pm. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned at this time. On 02/21/2025, all resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately, so that this information could be communicated to staff via the care plan. Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. On 02/21/2025, Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system. Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately. Regional [NAME] President will oversee in-servicing/monitoring of the NFA and administrative staff to ensure all audits are completed appropriately and timely. Should monitoring/reporting not happen appropriately or timely staff will face progressive discipline up to and including termination. An immediate in-service was initiated by the Director of Nurses on 02/20/2025 at 7:40 p.m. with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurse's station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff on 02/20/2025 and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member. (Beginning 02/21/2025) To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission for the next 30 days. The DON, will audit 5 residents who are an elopement risk 3 X times a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance (QA) Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress. Beginning 02/21/25, the NFA or designee will interview 5 staff members 3 times x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident. An Emergency QA was held on 02/21/2025 with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases. Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination. Completion date - The likelihood for serious harm will no longer exist on 02/21/2025. As of 02/21/2025, the facility asserts the likelihood for serious harm to any recipient no longer exists. Throughout the survey from 02/20/2025 to 02/21/2025, observations, interviews, and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the new process to ensure residents are properly care planned to meet their needs, identify elopement risk residents, properly care plan for a resident whom had an open EPS case and/or current protective order against family member(s), staff knew the process to notify the proper authorities and when to notify local law enforcement, and staff knew when and what to report to the local law enforcement and state agency.

48912 Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status for 3 (#3, #R2, and #R3) of 7 (#1, #2, #3, #R1, #R2, #R3, and #R4) sampled residents by failing to ensure Residents #3, #R2, and #R3 were coded correctly for wander/elopement alarms. Findings: Resident #3 Review of Resident #3's Clinical Record revealed an admitted [DATE], with diagnoses which included Dementia. Review of Resident #3's Admission MDS with an Assessment Reference Date (ARD) of 02/06/2025, Section P revealed: Physical Restrains, Line P200- Alarms section E: Wander/Elopement alarm was coded No which indicated not used. Review of Resident #3's facility task revealed a wander guard task was initiated on 02/04/2025. Documentation revealed staff checked yes for functioning and placement of wander guard daily from 02/04/2025 to 02/08/2025. Unable to make an observation of Resident #3 due to her being discharged from the facility. Resident #R2 Review of Resident #R2's Clinical Record revealed an admitted [DATE], with diagnoses which included Alzheimer's disease, Dementia, Restlessness and Agitation, and Unsteadiness of feet. Review of Resident #R2's Quarterly MDS with an ARD of 01/19/2025, Section P revealed: Physical Restrains, Line P200- Alarms section E: Wander/Elopement alarm was coded No which indicated not used. Review of Resident #R2's facility's task revealed a wander guard task was initiated on 07/31/2024. Documentation revealed staff checked yes for functioning and placement of wander guard daily for the previous 30 days. On 02/21/2025 at 4:44 p.m., an observation was made of Resident #R2 wearing wander guard on his left ankle. Resident #R3 Review of Resident #R3's Clinical Record revealed an admitted [DATE], with diagnosis which included Dementia. Review of Resident #R3's Quarterly MDS with an ARD of 12/18/2024, Section P revealed: Physical Restrains, Line P200- Alarms section E: Wander/Elopement alarm was coded No which indicated not used. Review of Resident #R3's facility's task revealed a wander guard task was initiated on 07/31/2024. Documentation revealed staff checked yes for functioning and placement of wander guard daily for the previous 30 days. On 02/21/2025 at 4:52 p.m., an observation was made of Resident #R3 wearing wander guard on his left ankle. On 02/19/2025 at 2:11 p.m., an interview was conducted with S4CM. She stated she was responsible for MDS. She stated for an Admission Assessment the look back period was seven days prior to ARD. She confirmed Resident #3 had a wander guard initiated on 02/04/2025. She reviewed Resident #3's Admission MDS with an ARD of 02/06/2025 Section P: Physical Restrains, Line P200- Alarms section E: Wander/Elopement alarm. S4CM confirmed the MDS assessment was not coded accurately and should have been coded as Yes. On 02/21/2025 at 6:15 a.m., an interview was conducted with S5MDS. She confirmed both Resident #R2 and #R3 had a wander guard in place with both being initiated on 07/31/2024. She reviewed Resident #R2's Quarterly MDS with an ARD of 01/19/2025 Section P: Physical Restrains, Line P200- Alarms section E: Wander/Elopement alarm and confirmed it was coded No which indicated not used. She reviewed Resident #3's Quarterly MDS with an ARD of 12/18/2024 Section P: Physical Restrains, Line P200- Alarms section E: Wander/Elopement alarm and confirmed it was coded No which indicated not used. S5MDS further confirmed the aforementioned MDS assessments were not coded accurately and should have been coded as Yes. On 02/21/2025 at 6:22 p.m., an interview was conducted with S3DON. She stated she expected staff to code MDS assessments accurately. S3DON reviewed the findings for Residents #3, #R2 and #R3, and confirmed their MDS assessments were not coded accurately and should have been coded as Yes.

Based on observations, and interviews the facility failed to ensure a safe, functional, sanitary and comfortable environment. The facility failed to ensure: 1.) Resident air conditioners (AC) were sanitary in Room B and Room E; 2.) Ceiling Tiles were maintained in clean and functional manner on Hall A and Room B; 3.) Floor tiles were maintained in a safe and functional manner in Room C ; and 4.) Bath D was maintained in a sanitary manner for staff and the public. Findings: Review of Facility's Policy Titled Resident Environment dated 09/2015 revealed, the following, in part: It is the policy of this facility to provide a safe, clean, comfortable and homelike environment. 1.) An observation was conducted on 02/18/2025 at 11:58 a.m. of Room B. The AC unit vent had copious amount of small specks of a black substance throughout the return vent. An observation was conducted on 02/18/2025 at 12:00 p.m. of Room E which had dry brown and red liquid on the AC Unit. 2.) An observation was conducted on 02/18/2025 at 2:00 p.m. of Hall A. There was a ceiling tile at the front of Hall A which had a crack across the entire ceiling tile. Room B had two ceiling tiles above the AC unit which had brown water spots on them. 3.) An observation was conducted on 02/19/2025 at 1:00 p.m. of Room C. Room C had two chipped floor tiles. The missing chip in the corner of the floor tiles was approximately 3 to 4 inches wide. 4.) An observation was conducted on 02/18/2025 at 10:00 a.m. of Bath D. The light fixtures had a copious amount of fluffy gray colored substance, the ceiling vent had copious amounts of fluffy gray colored substance, and the laminate flooring had spaces between each floor tile which were filled with black residue. The flooring was covered in a sticky residue. A second observation was conducted on 02/19/2025 at 12:00p.m. of Bath D. Bath D remained in the same unsanitary condition as stated above. An interview was conducted on 02/18/2025 at 12:05 p.m. with Resident #R1. Resident #R1 noted to be short of breath and wheezing. She stated she was concerned the back substance on her AC unit, in Room B, could worsen her breathing issues. An interview was conducted on 02/19/2025 at 2:08 p.m. with S7MS. S7MS stated he changed ceiling tiles as needed. He reported being aware the ceiling tile down the front of Hall A was cracked and needed to be changed. He confirmed two ceiling tiles in room B above the AC unit needed to be changed from water spots. He confirmed the flooring tiles in Room C were chipped. He stated the tiles were old and he did not have the extra matching tiles to change the chipped tiles. An interview was conducted on 02/19/2025 at 2:50 p.m. with S6HKS. She confirmed the aforementioned observations. She reported the AC units should be wiped daily during daily room cleaning. She reported bathrooms should be cleaned at least once daily. After observing Room B she confirmed the copious amounts of black spots on the AC vents should be cleaned. After observation of Room E she confirmed the substance on the AC unit was coffee and juice, and should have been cleaned. After observation of Bath D she confirmed Bath D was flooded a year ago and the flooring was spaced due to the glue coming up from the laminate and the flooring needed cleaning. S6HKS confirmed the copious amount of gray fluffy substance on the light fixtures, and ceiling vent should be cleaned. She confirmed Bath D should be cleaned twice daily and had not been. An interview was conducted on 02/20/2025 at 9:16 a.m. with S1ADM . S1ADM confirmed that the AC units in resident rooms should be maintained clean and sanitary and it was unacceptable to have spilled liquids or black spotted substance on AC units if staff were cleaning them daily. He reported the flooring in Bath D should be fixed. He reported Bath D should be maintained and clean as well. He reported he was unaware of the flooring being chipped in Room E, and it should be replaced.

Based on interviews and record reviews, the facility failed to ensure a resident received trauma-informed care and services in accordance with professional standards of practice for 1 of 1 (#100) residents reviewed with a diagnosis of Post-Traumatic Stress Disorder (PTSD). Findings: Review of Resident #100's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included PTSD. Review of Resident #100's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/2024 revealed Section I: Active Diagnoses, Psychiatric/Mood Disorder I6100-PTSD was not checked. Review of Resident #100's most recent Care Plan revealed Resident #100 was not care planned for PTSD. Review of Resident #100's Social History assessment dated [DATE] trauma section revealed the following questions and answers: Has resident experienced a traumatic event in the past? No. Does resident experience trauma-related symptoms? No. Review of Resident #100's Social assessment dated [DATE] trauma section revealed the following questions and answers: Has resident experienced a traumatic event in the past? No. Does resident experience trauma-related symptoms? No. Does resident experience an impact to their daily routine? No. Is resident in a current treatment plan? No. Review of Resident #100's Physician's Progress Notes dated 09/05/2024 to current revealed an active problem list which included PTSD as a diagnosis. Review of Resident #100's Psychiatric Notes dated 10/03/2024 and 11/08/2024 revealed diagnoses which included PTSD. On 12/11/2024 at 10:24 a.m., an interview was conducted with S5LPN. She confirmed she was assigned to Resident #100. She stated she was not aware of Resident #100's PTSD diagnosis nor interventions to prevent triggers or trauma reoccurrence. She stated she would have known Resident #100 had a PTSD diagnosis and interventions for the diagnosis by reviewing the care plan. On 12/11/2024 at 12:13 p.m., an interview was conducted with S12CNA. She confirmed she was assigned to Resident #100's. She stated she was not aware of Resident #100's PTSD diagnosis nor interventions to prevent triggers or trauma reoccurrence. On 12/11/2024 at 12:20 p.m., a telephone interview was conducted with S14PNP. He confirmed he provided psychiatric care to Resident #100. He stated she had diagnoses of PTSD and Major Depressive Disorder. He stated he was made aware of Resident #100's PTSD diagnosis from her Medical Records and History and Physical. He stated he had not asked Resident #100 about her PTSD diagnosis and triggers because she was nonverbal. S14PNP confirmed he did not contact Resident #100's responsible party to inquire about the PTSD diagnosis and possible triggers. He stated he was not aware of any guidance or process to follow when a resident had a PTSD diagnosis. He stated staff should have been aware of the PTSD diagnosis as it was documented on the monthly psychiatric progress notes. On 12/11/2024 at 1:21 p.m., an interview was conducted with S11SW. She stated herself or her assistant was responsible for completing a social assessment on a resident when he/she was admitted . She stated she would refer residents with the diagnosis of PTSD or history of PTSD out to a behavioral service provider and they would initiate interventions for proper care which would be reflected in the care plan. She stated the process was to review the resident's diagnosis list on admission and refer them to the appropriate services. She stated she was not aware of Resident #100's diagnosis of PTSD. She reviewed Resident #100's list of diagnoses and confirmed Resident #100 had a diagnosis of PTSD. She reviewed Resident #100's social history assessment dated [DATE] and verified the trauma section questions were answered no. She reviewed Resident #100's social assessment dated [DATE] and verified the trauma section questions all were answered no. S11SW confirmed based on Resident #100's diagnosis, both assessments should have been answered yes. She reviewed Resident #100's referral summary active problems section, and she confirmed PTSD was listed as a diagnosis. S11SW confirmed staff should have been aware Resident #100 had PTSD. On 12/11/2024 at 2:47 p.m., an interview was conducted with S13LPN. She confirmed she was Resident #100's nurse. She stated she was not aware of Resident #100's PTSD diagnosis nor interventions to prevent triggers or trauma reoccurrence. She stated she would have known Resident #100 had a PTSD diagnosis and interventions for the diagnosis by reviewing the care plan. On 12/11/2024 at 3:07 p.m., an interview was conducted with S9LPN. She stated she was responsible for MDS assessments and care plans. She stated MDS diagnoses were coded from Referral packets from other facilities, Hospital discharge paperwork, or Home face to face visits with the doctor. She stated when the MDS department selected the diagnoses on the MDS, it triggered staff to input interventions for the diagnosis on the care plan. S9LPN reviewed Resident #100's list of diagnoses, and confirmed Resident #100 had an active diagnosis of PTSD. She reviewed Resident #100's Admission MDS with an ARD of 03/13/2024, and confirmed PTSD was not checked and should have been. She further confirmed, if the diagnosis was correctly selected, the system would have prompted staff to create a care plan. S9LPN reviewed Resident #100's Care plan and confirmed Resident #100 was not care planned for PTSD and should have been. On 12/11/2024 at 3:34 p.m., a phone interview was conducted S15SWA. She stated she was responsible for assisting with resident's assessments. She confirmed she remembered completing a social history and social assessment on Resident #100, but could not remember the details of completion. S15SWA stated she does not use the medical records when completing assessments. On 12/11/2024 at 5:42 p.m., an interview was conducted with S2DON. She stated she was not aware of Resident #100's PTSD diagnosis. S2DON reviewed Resident #100's care plan and confirmed she was not care planned for PTSD, and should have been. S2DON reviewed Resident #100's Admission's MDS with an ARD of 03/13/2024 and confirmed PTSD was not coded and should have been. On 12/11/2024 at 4:24 p.m., an interview was conducted with S1ADM. He confirmed Resident #100 was not properly assessed for PTSD diagnosis. S1ADM confirmed he expected staff to complete a care plan for Resident #100's PTSD diagnosis and triggers, and it was not done and should have been.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5% for 2 (#23 and #31) of 4 (#23, #31, #45, and #75) residents observed during medication administration. A total of 39 opportunities were observed with 16 medication errors, which resulted in a medication error rate of 41.03%. This failed practice had the potential to affect any of the 116 residents currently residing in the facility. Findings: Review of the facility's policy titled Drug Administration and Documentation with a revision date of 04/2021 revealed the following, in part: Read the medication and compare it with the MAR (Medication Administration Record). Remember the five rights: 2. Right time Review of the facility's policy titled Administration of Medications with a revision date of 01/2024 revealed the following, in part: Procedure: 3. Drugs and biologicals are administered no more than one hour before or no more than one hour after the dosage time on the order. Oral Medication Administration Procedure 3. Verify the physician's order, comparing the medication label to the MAR to verify the following: d. Right time 5. Ensure the resident does not have any contraindications or special considerations for this medication. Resident #23 Review of Resident #23's Clinical Record revealed Resident #23 was admitted to the facility on [DATE] and had diagnoses, which included Chronic Obstructive Pulmonary Disease, Essential Hypertension, and Edema Unspecified. Review of Resident #23's current Physician's Orders revealed the following, in part: 11/01/2024 Furosemide 20 MG Give 1 tablet by mouth two times a day related to Edema. Hold for systolic less than 100. Review of Resident #23's vital signs from 12/01/2024 to 12/10/2024 revealed no documentation of Resident #23's blood pressure. On 12/10/2024 at 8:16 a.m., an observation was made of S5LPN administering Resident #23 1 tablet of Furosemide 20 MG by mouth. S5LPN did not obtain Resident #23's blood pressure. On 12/10/2024 at 9:20 a.m., an interview was conducted with S5LPN. S5LPN confirmed she did not check Resident #23's blood pressure this morning. S5LPN reviewed Resident #23's orders and confirmed the order for Furosemide 20 MG read to hold if the systolic pressure was less than 100. S5LPN confirmed Resident #23's blood pressure should have been obtained prior to administering the Furosemide 20 MG. Resident #31 Review of Resident #31's Clinical Record revealed Resident #31 was admitted to the facility on [DATE] and had diagnoses, which included Chronic Diastolic Heart Failure, Vascular Dementia, Sjogren's Syndrome, Dyspnea, Wheezing, Hypertensive Urgency, Major Depressive Disorder, Gout, and Essential Hypertension. Review of Resident #31's current Physician's Orders revealed the following, in part: Qvar RediHaler Inhalation Aerosol Breath Activated 40 MCG/ACT 2 puff inhale orally two times a day Savella Oral Tablet 50 MG Give 1 tablet by mouth two times a day Hydralazine HCI Tab 25 MG Give 1 tablet by mouth three times a day Uloric Oral Tablet 40 MG (Febuxostat) Give 1 tablet by mouth one time a day Multiple Vitamins-Minerals Tablet Give 1 tablet by mouth one time a day Pantoprazole Sodium EC Tab 40 MG Give 1 tablet by mouth one time a day Abilify Oral Tablet 15 MG (Aripiprazole) Give 1 tablet by mouth one time a day Carvedilol Tab 25 MG Give 1 tablet by mouth two times a day Cholecalciferol Tablet 1000 UNIT Give 2 tablets by mouth one time a day 2 tablets to equal 2000 IU Furosemide Tab 40 MG Give 1 tablet by mouth one time a day Olmesartan Medoxomil Tab 20 MG Give 1 tablet by mouth one time a day Pilocarpine HCL Tab 5 MG Give 1 tablet by mouth two times a day Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth one time a day Buspirone HCLTablet 10 MG Give 1 tablet by mouth three times a day Aspirin Chew Tablet 81 MG Give 1 tablet by mouth one time a day Review of Resident #31's MAR for 12/2024 revealed the following medications were scheduled for administration at 8:00 a.m.: Qvar RediHaler Inhalation Aerosol Breath Activated 40 MCG/ACT 2 puff inhale orally two times a day Savella Oral Tablet 50 MG Give 1 tablet by mouth two times a day Hydralazine HCI Tab 25 MG Give 1 tablet by mouth three times a day Uloric Oral Tablet 40 MG (Febuxostat) Give 1 tablet by mouth one time a day Multiple Vitamins-Minerals Tablet Give 1 tablet by mouth one time a day Pantoprazole Sodium EC Tab 40 MG Give 1 tablet by mouth one time a day Abilify Oral Tablet 15 MG (Aripiprazole) Give 1 tablet by mouth one time a day Carvedilol Tab 25 MG Give 1 tablet by mouth two times a day Cholecalciferol Tablet 1000 UNIT Give 2 tablets by mouth one time a day 2 tablets to equal 2000 IU Furosemide Tab 40 MG Give 1 tablet by mouth one time a day Olmesartan Medoxomil Tab 20 MG Give 1 tablet by mouth one time a day Pilocarpine HCL Tab 5 MG Give 1 tablet by mouth two times a day Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth one time a day Buspirone HCLTablet 10 MG Give 1 tablet by mouth three times a day Aspirin Chew Tablet 81 MG Give 1 tablet by mouth one time a day On 12/09/2024 at 9:45 a.m., an observation was made of S4LPN passing the above listed medications to Resident #31. S4LPN stated the medications administered to Resident #31 were scheduled to be administered at 8:00 a.m. On 12/09/2024 at 12:05 p.m., an interview was conducted with S4LPN. S4LPN stated if a resident has a medication scheduled for 8:00 a.m. she should administer the medication between 7:00 a.m. to 9:00 a.m. S5LPN confirmed she passed the above listed medications to Resident #31 after 9:00 a.m. On 12/10/2024 at 2:17 p.m., an interview was conducted with S2DON. S2DON stated when a resident had a medication order with a parameter the expectation was for the parameter to be followed. S2DON confirmed S5LPN should have checked Resident #23's blood pressure prior to administering the Furosemide 20 MG. S2DON confirmed this was a medication error. S2DON confirmed medications should be administered an hour before or an hour after the scheduled time. S2DON confirmed if a medication was scheduled for 8:00 a.m., the medication should be administered between 7:00 a.m. to 9:00 a.m. S2DON confirmed Resident #31's medications were administered outside of the window and this was a medication error.

Based on record reviews and interviews, the facility failed to coordinate assessments with the resident's Pre-Admission Screening and Resident Review (PASARR) Level II by failing to incorporate PASARR Level II determinations and recommendations into each resident's assessment and care plan for 4 (#2, #10, #27 and #100) of 5 (#2, #10, #27, #29 and #100) residents reviewed for PASARR. Findings: Review of the facility's policy titled, Social Services Program, with a revision date of 11/2017 revealed the following, in part: Policy: The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Purpose: To assure that sufficient and appropriate social services are provided to meet the resident's needs. Procedure s: The individual responsible for the provision of the social service program shall: 1. Identify the medically-related social service needs of the resident and assure the needs are met by appropriate disciplines. 2. Arrange for social services from outside sources, or furnish the services directly. 4. Participate in the comprehensive assessment and care plan process. 5. Complete an individualized social history, assessment, and other documentation as required by Federal and State guidelines. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Paranoid Schizophrenia, Major Depressive Disorder, Schizoaffective Disorder, and Anxiety Disorder. Review of Resident #2's BHSF Form 142 revealed she was approved for admission by Level II Authority for a temporary period effective 12/28/2023 through 12/26/2024. Review of Resident #2's PASRR Level II Evaluation Summary and Determination Notice, dated 01/09/2024, revealed the following, in part: Recommendations for Lesser Services: Short term counseling to adjust to the nursing facility, crisis intervention plan/safety plan, occupational therapy evaluation, structured leisure activities, and physical therapy evaluation. Specialized Services Recommendations: Outpatient therapy - individual, family, and group. Review of Resident #2's current Care Plan revealed no documentation of a Level II PASRR. Further review revealed no documentation the above mentioned OBH recommendations for services were implemented and/or offered. Review of Resident #2's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/2024 revealed the following, in part: A1500: Preadmission Screening and Resident Review (PASRR): Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Enter Code: 0, which indicated Resident #2 did not have a PASRR Level II. On 12/11/2024 at 4:48 p.m., an interview was conducted with S9LPN. She stated she and S10LPN were responsible for resident assessments and care plans. She reviewed Resident #2's significant change MDS dated [DATE] and confirmed A1500 PASRR was inaccurately coded. She reviewed Resident #2's care plan and confirmed she was care planned for Schizophrenia and Psychosis, but not a Level II PASARR. Resident #10 Review of Resident #10's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Dementia, Schizoaffective Disorder, Major Depressive Disorder, and Insomnia. Review of Resident #10's BHSF Form 142 revealed he was approved for admission by Level II Authority for a temporary period effective 03/05/2024 through 03/04/2025. Review of Resident #10's OBH-PASRR Level II Evaluation Summary and Determination Notice, dated 03/08/2024, revealed the following, in part: Recommendations for Lesser Services: Training in independent living skills, crisis intervention plan/safety plan, and structured leisure activities. Specialized Services Recommendations: Outpatient therapy - individual and group. Review of Resident #10's current Care Plan revealed no documentation of a Level II PASRR. Further review revealed no documentation the above mentioned OBH recommendations for services were implemented and/or offered. Review of Resident #10's Significant Change MDS with an ARD of 07/31/2024 revealed the following, in part: A1500: Preadmission Screening and Resident Review (PASRR): Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Enter Code: 0, which indicated Resident #10 did not have a PASRR Level II. On 12/11/2024 at 4:48 p.m., an interview was conducted with S9LPN. She reviewed Resident #10's significant change MDS dated [DATE] and confirmed A1500 PASRR was inaccurately coded. She reviewed Resident #10's care plan and confirmed he was care planned for Schizophrenia and Dementia, but not a Level II PASARR. Resident #27 Review of Resident #27's Clinical Record revealed he was admitted to the facility on [DATE] with diagnosis which included Paranoid Schizophrenia and Dementia. Review of Resident #27's BHSF Form 142 revealed he was approved for admission by Level II Authority for a temporary period effective 05/11/2024 through 05/10/2025. Review of Resident #27's OBH-PASRR Level II Evaluation Summary and Determination Notice, dated 05/21/2024, revealed the following, in part: Recommendations for Lesser Services: Crisis intervention plan/safety plan, training in independent living skills, and structured leisure activities. Specialized Services Recommendations: Outpatient therapy - individual. Review of Resident #27's current Care Plan revealed no documentation of a Level II PASRR. Further review revealed no documentation the above mentioned OBH recommendations for services were implemented and/or offered. Review of Resident #27's Significant Change MDS with an ARD of 10/21/2024 revealed the following, in part: A1500: Preadmission Screening and Resident Review (PASRR): Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Enter Code: 0, which indicated Resident #27 did not have a PASRR Level II. On 12/11/2024 at 4:45 p.m., an interview was conducted with S10LPN. She stated she and S9LPN were responsible for resident assessments and care plans. She reviewed Resident #27's significant change MDS dated [DATE] and confirmed A1500 PASRR was inaccurately coded. She reviewed Resident #27's care plan and confirmed he was care planned for Schizophrenia, but not a Level II PASARR. Resident #100 Review of Resident #100's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Post Traumatic Stress Disorder, Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder. Review of Resident #100's BHSF Form 142 revealed he was approved for admission by Level II Authority for a temporary period effective 02/16/2024 through 02/14/2025. Review of Resident #100's OBH-PASRR Level II Evaluation Summary and Determination Notice, dated 02/28/2024, revealed the following, in part: Recommendations for Lesser Services: Assisting in obtaining medical appliances and devices, training in independent living skills, crisis intervention plan/safety plan, and structured leisure activities. Review of Resident #100's current Care Plan revealed no documentation of a Level II PASRR. Further review revealed no documentation the above mentioned OBH recommendations for services were implemented and/or offered. Review of Resident #100's Admission MDS with an ARD of 03/13/2024 revealed the following, in part: A1500: Preadmission Screening and Resident Review (PASRR): Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Enter Code: 0, which indicated Resident #100 did not have a PASRR Level II. On 12/11/2024 at 4:48 p.m., an interview was conducted with S9LPN. She reviewed Resident #100's Admission's MDS dated [DATE] and confirmed A1500 PASRR was inaccurately coded. She reviewed Resident #100's care plan and confirmed she was care planned for Anxiety, Depression, and Bipolar disorder, but not a Level II PASARR. On 12/11/2024 at 5:15 p.m., an interview was conducted with S11SW. She stated she was responsible for the facility's PASARRs. She stated once she received a resident's OBH-PASRR Level II Evaluation Summary and Determination Notice she reviewed it for recommendations. She stated she provided S9LPN and S10LPN with a list of PASARR Level II residents and a copy of the Level II PASARRs. She stated S9LPN and S10LPN also had access to the residents Level II PASARRs as they were scanned into the resident's electronic record. On 12/11/2024 at 5:45 p.m., an interview was conducted with S2DON. She reviewed Resident #2's Level II PASARR and Significant change MDS dated [DATE]. She confirmed Resident #2's Level II PASARR was inaccurately coded on the MDS. She reviewed Resident #2's care plan and confirmed she was care planned for Schizophrenia and Psychosis, but not a Level II PASARR. She reviewed Resident #10's Level II PASARR and Significant change MDS dated [DATE]. She confirmed Resident #10's Level II PASARR was inaccurately coded on the MDS. She reviewed Resident #10's care plan and confirmed he was care planned for Schizophrenia and Dementia, but not a Level II PASARR. She reviewed Resident #27's Level II PASARR and significant change MDS dated [DATE]. She confirmed Resident #27's Level II PASARR was inaccurately coded on the MDS. She reviewed Resident #27's care plan and confirmed he was care planned for Schizophrenia, but not a Level II PASARR. She reviewed Resident #100's Level II PASARR and Admission MDS dated [DATE]. She confirmed Resident #100's Level II PASARR was inaccurately coded on the MDS. She reviewed Resident #100's care plan and confirmed he was care planned for Anxiety, Depression, and Bipolar Disorder, but not a Level II PASARR. She further confirmed the above mentioned recommendations for Residents #2, #10, #27 and #100 were not included in their care plans, and should have been. 47546 48912

Based on observation, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure medication carts were free of loose pills for 1 (Med Cart B) of 2 (Med Cart A and Med Cart B) medication carts observed. This deficient practice had the potential to effect the 116 residents currently residing in the facility. Findings: Review of the facility's policy titled Medication Storage with a revision date of 11/2017 revealed the following, in part: -Medication rooms, refrigerators, and medication/treatment carts shall be maintained in a clean and orderly manner per the facility's policy and procedures. On 12/09/2024 at 1:37 p.m., an observation was made of Med Cart B with S6LPN, which revealed the following: 22 loose medication pills. On 12/09/2024 at 1:37 p.m., an interview was conducted with S6LPN. S6LPN confirmed there should be no loose medication pills on the cart. On 12/10/2024 at 2:17 p.m., an interview was conducted with S2DON. S2DON confirmed there should be no loose medication pills on the medication carts.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 1 (#30) of 3 (#30, #82, and #88) resident's reviewed for perineal care. The facility failed to ensure staff performed hand hygiene and proper glove use for Resident #30 during perineal care. Findings: Review of the facility's policy titled, Perineal Care with a revision date of 01/2024, revealed the following, in part: Purpose: To prevent irritation or infection Procedure: Female without catheter 5. Wash genital area, moving front to back . 14. Remove gloves and perform hand hygiene. Review of Resident #30's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Personal History of Urinary Tract Infections. Review of Resident #30's Care Plan revealed the following, in part: Problem: 09/23/2024-The resident has a Urinary Tract Infection (UTI) - 11/06/2024-UTI, 11/26/2024 -UTI. Intervention: Proper pericare. Problem: 11/26/2024-Resident needs assist with toileting. Intervention: Provide assist as needed. Review of the facility's Infection Log revealed Resident #30 was treated for UTI's on the following dates: 09/23/2024, 11/06/2024, and 11/26/2024. On 12/10/2024 at 12:32 p.m., an observation was made of S7CNA performing perineal care for Resident #30. S7CNA was observed performing hand hygiene, applied gloves, and assisted Resident #30 to stand up off the toilet. S7CNA stood behind Resident #30 and used a perineal wipe to clean the resident's buttocks and perineal area. S7CNA removed the soiled gloves and without performing hand hygiene applied clean gloves. S7CNA stood in front of Resident #30 and used a perineal wipe to clean the resident's perineal area. Without changing gloves or performing hand hygiene, S7CNA lifted the resident's shirt, applied a clean brief, pulled up the resident's pants, pulled down the resident's shirt, readjusted her clothing, and flushed the toilet. Resident #30 sat down in a wheelchair. S7CNA pushed the resident's wheelchair to the bathroom sink with soiled gloves on. S7CNA removed the soiled gloves and performed hand hygiene. On 12/10/2024 at 12:40 p.m., an interview was conducted with S7CNA. S7CNA said Resident #30 had frequent UTI's. S7CNA confirmed the above observations and stated she should have performed hand hygiene and changed her gloves when going from dirty to clean. On 12/10/2024 1:10 p.m., an interview was conducted with S8CNAS. S8CNAS said CNAs should perform hand hygiene and change gloves, before, during, an after perineal care and when going from dirty to clean. S8CNAS was made aware of the above findings. S8CNAS confirmed she would have expected the CNA to perform hand hygiene and change soiled gloves when going from dirty to clean. On 12/10/2024 at 2:00 p.m., an interview was conducted with S2DON. S2DON said CNAs should perform hand hygiene and apply gloves prior to perineal care, clean the resident, remove the soiled gloves, perform hand hygiene, apply clean gloves and then apply a clean brief and the resident's clothing. S2DON was made aware of the above findings. S2DON said she would have expected the CNA to perform hand hygiene and change soiled gloves when going from dirty to clean during perineal care. S2DON confirmed a CNA using soiled gloves when going from dirty to clean during perineal care could potentially lead to Urinary Tract Infections.

Based on record reviews, and interviews, the facility failed to protect each residents' right to be free from physical abuse for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility failed to ensure Resident #1 was free from physical abuse by Resident #2. Findings: Review of the facility's policy titled, Resident Abuse, with a review date of 1/2024, revealed the following, in part: Conduct that results in Resident Abuse is strictly prohibited. Resident #1 Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with diagnosis which included Alzheimer's disease, Mood Disorder, and Anxiety. Review of Resident #1's quarterly MDS with an ARD of 10/14/2024 revealed the provider assessed the resident as having a BIMS of 9, which indicated the resident was cognitively impaired. Review of the facility's state agency reportable incidents for Resident #1 revealed the following: Accused Allegations: Physical Abuse Date: 10/11/2024 Incident Description: Resident #1 was found on smoking patio with scratches to right arm and face. Review of Resident #1's nurse's note dated 10/11/2024 revealed the following in part, Resident #1 was involved in an altercation on the smoking patio. Resident #2 Review of Resident #2's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Right Side Hemiplegia/Hemiparesis following CVA, Aphasia, and Schizoaffective disorder. Review of Resident #2's quarterly MDS with an ARD of 10/02/2024 revealed the provider assessed the resident as having a BIMS of 15, which indicated she was cognitively intact. Review of Resident #2's current Plan of Care revealed the resident has physical behavioral symptoms directed towards others. (10/11/2024) Review of Resident #2's nurses' note dated 10/11/2024 , revealed in part: Resident #2 got into an altercation with Resident #1 on the smoking patio. Resident #2 scratched and hit Resident #1 which caused injuries to her face and arm. On 10/20/2024 at 8:45 a.m., an interview was conducted with S4LPN. She stated she was working on 10/11/2024 and was caring for Resident #1. She stated the Director of Nurses told her Resident #2 hit Resident #1 on 10/11/2024. On 10/30/2024 at 11:10 a.m., an interview was conducted with Resident #1. She stated she was hit by Resident #2 on the smoking patio. On 10/30/2024 at 12:45 p.m. an interview was conducted with S5H. She stated on 10/11/2024, she saw Resident #1 on the smoking patio with scratches to her arm and face. She stated that she immediately reported this to the DON. On 10/30/2024 at 12:50 a.m. an interview was attempted with DON, she was unavailable. On 10/30/2024 at 1:00 p.m., an interview was conducted with S2ADON. She stated on 10/11/2024, S5H notified administration that Resident #1 was on the smoking patio with scratches to her right arm and face. S2ADON stated Resident #1 was unable to say what happened. On 10/30/2024 at 2:00 p.m., an interview was conducted with S6RN. She stated she assessed Resident #1 on 10/11/2024 after the incident on the smoking patio. She stated the resident had scratches to her right arm and face. She stated the NP was notified and the wounds were cleaned and antibiotic ointment was applied. On 10/30/2024 at 2:50 p.m., an interview was conducted with S1ADM. S1ADM stated on 10/11/2024, he was notified there was an altercation between Resident #1 and #2. He stated he reviewed video footage from the smoking patio on 10/11/2024 and confirmed he observed Resident #2 hit Resident #1. S1ADM stated the residents were immediately separated, Resident #1's injuries were assessed and treated, and Resident #2 was sent out to the emergency room for evaluation. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. On 10/30/2024 at 5:00 p.m., an interview was conducted with S1ADM. He provided documentation the facility initiated an effective Plan of Correction on 10/11/2024 which included: 1. Problem identified: Resident #2's wheel chair gets caught on Resident #1's wheelchair and Resident#1 scratches her while trying to get unlatched. 2. Plan of action with projected completion date 11/01/2024 - Immediate action conducted with Resident #1 and Resident #2 were separated. - First aid was provided/assessed by medical staff. - Resident #2 on one on one supervision until being send to geriatric psych. - Local police department was called to the scene (Report #24-260763). - The new smoking patio opened to keep Resident #1 and Resident #2 apart initially. - In-services were performed to keep Resident #1 and Resident #2 apart and abuse/neglect. 3. The following monitoring was conducted: - S1ADM supervised smoking patio when Resident #2 was reintroduced to regular smoking patio 3+ times a week for three weeks or until determined safe. - High risk meetings held weekly with ID team to determine if residents are safe together. 4. Current plan of action was effective.

Based on record reviews and interviews, the facility failed to provide documentation of the notice of discharge to the Ombudsman for a facilitated initialed discharge of a hospitalized resident for 1 (#1) of 3 (#1, #2, and #3) resident's records reviewed. This deficient practice had the potential to affect any of the 119 residents who reside in the facility. Findings: Review of Resident #1's clinical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. Review of the facility's Emergency Transfer Log dated August 2024 revealed Resident #1 was transferred from the nursing facility to a local hospital on 08/06/2024. Review of the transfer/discharge notification revealed in part: Dear, Resident #1, This letter is to inform you of the facility initiated transfer/discharge to the local hospital on 08/06/2024 due to an emergency situation for the following reasons: We are no longer able to meet your needs in this facility and the transfer is necessary for your welfare. The safety of individuals in this facility is endangered as a result of Behaviors. Discharge/transfer to local hospital. Effective date: 08/06/2024. Signed by the facility administrator on 08/07/2024. Further review of the notification form revealed the following in part: Number called: Resident #1's son number on 08/07/2024 at 12 p.m. No answer written to the side. Name of Resident Representative contacted: Resident #1's son Date mailed: 08/07/2024. On 09/05/2024 at 2:13 p.m., a telephone interview was conducted with the local state Ombudsman. She stated she was verbally notified by S1ADM that Resident #1 was transferred to the local emergency roiagnom on [DATE] for evaluation and treatment of behaviors. The Ombudsman confirmed she did not receive a copy of the involuntary discharge letter dated 08/06/2024 until 08/14/2024 after she requested it. She stated the facility initiated a discharge on Resident #1 on 08/07/2024 immediately after he exhibited behaviors on 08/06/2024. On 09/10/2024 at 11:15 a.m., an interview was conducted with S4AM. She confirmed the discharge of Resident #1 was a facility initiated discharge on 08/07/2024. She confirmed she had no documentation proving a copy of the notification of discharge was provided to the Ombudsman until 08/14/2024. She confirmed the Ombudsman should have been provided immediate notification of Resident #1's discharge.

Based on record reviews and interviews, the facility failed to ensure a resident's chart contained the required documentation in the medical record for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for emergency transfers. Findings: Review of Resident #1's clinical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. Review of the facility's Emergency Transfer Log dated August 2024 revealed Resident #1 was transferred from the nursing facility to a local hospital on 08/06/2024 and the facility was not accepting Resident #1 back to the facility. Review of Resident #1's physician notes and nursing notes from August 2024 revealed no documentation of the reason for discharge On 09/10/2024 at 9:41 a.m., a telephone interview was conducted with the social worker at the local hospital. She stated the hospital tried to discharge Resident #1 back to the nursing facility on 08/07/2024, and the DON said the resident could not return due to his aggressive behaviors and elopement risk. On 09/10/2024 at 10:13 a.m., an interview was conducted with S2DON. She confirmed there was no documentation in Resident #1's clinical record justifying the reason for discharge of Resident #1. She stated he had aggressive behaviors on 08/06/2024 which put the safety of other residents at risk. She stated he was an elopement risk and tried to leave the facility on 08/06/2024. She stated when he was originally admitted he was admitted to a bed on a non-secured hall and she felt it was not safe for him to return to a non-secured unit due to his elopement risk. She confirmed there was no documentation of the behaviors staff witnessed in Resident #1's chart and there should have been. On 09/10/2024 at 12:05 p.m., an interview was conducted with S1ADM. He stated Resident #1 displayed aggressive behavior to staff upon admission to the facility on [DATE], which was why he was transferred to the hospital. He stated the resident's aggressive behaviors put the safety of other residents at risk. He confirmed there was no documentation justifying the reason for discharge of Resident #1.

Based on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from sexual abuse by Resident #1 for 2 (#2 and #3) of 3 (#2, #3, and #4) residents reviewed for abuse. This deficient practice resulted in an immediate jeopardy situation on 10/11/2023 at 5:07 a.m. when Resident #1, a resident with a history of sexually inappropriate behaviors, touched Resident #2, a severely cognitively impaired resident, on the vagina in the facility's dining room. At 5:07 a.m., S5CNA observed Resident #1 touching Resident #2 inappropriately. At that time, S5CNA, alerted S6LPN of the incident. S6LPN failed to report the incident to administration and failed to implement adequate interventions after the incident. There was a likelihood for Resident #1 to sexually abuse female residents until the following morning of 10/12/2023, when Administration was made aware of the sexual abuse and placed Resident #1 on one to one supervision. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation. Findings: Review of the facility's policy titled, Incident Investigation and Reporting revealed the following, in part: 1. Each resident residing in this facility has the right to be free from any type of abuse including: sexual. 2. Relevant Terms: Sexual Abuse: Is nonconsensual sexual contact of any types with a resident. 6. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent occurrence and/or further potential abuse while the investigation is in progress. Any employee of the facility involved in incidents of abuse, neglect, misappropriation, and exploitation will be suspended pending investigation until such time as the facility investigation is complete. Consider Emergency QA meeting and processes as needed. 7. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. In the case of resident-to-resident suspected abuse, the parties will remain separated from one another until the investigation has been completed. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #1's Yearly MDS with an ARD of 05/09/2023 revealed, in part, a BIMS of 14, which indicated he was cognitively intact. Review of Resident #1's Care Plan revealed the following, in part: Problem: Resident exhibits behaviors and needs behavioral monitoring. History of inappropriate behaviors directed towards another resident. Interventions: 07/09/2023 - increased supervision 07/10/2023 - sent to Inpatient Psychiatric Facility Monitor for aggressive sexual behaviors every shift Review of Resident #1's Nurses' Notes dated July 2023 revealed the following, in part: 07/09/2023 at 1:30 p.m. by S7LPN: Charting for 07/09/2023 at 12:45 p.m. reported by S8CNA that resident was noted with his hand inappropriately under another female resident's dress in dining room. S1ADM and S2DON were made aware of incident. 07/10/2023 at 10:26 a.m. by S9SW: Sent referral to a local behavior hospital for behaviors. Review of Resident #1's Incident Report dated 07/09/2023 at 5:16 a.m. revealed the following, in part: Incident Reported By: S8CNA Person Completing Report: S7LPN Type of Incident: Behavior Location of Incident: Dining Room Narrative of Incident: Made aware per S8CNA that resident was noted with his hand inappropriately under a female resident's dress in dining room. Review of S8CNA's written witness statement dated 07/09/2023 revealed the following, in part: I was walking passed the dining room when I noticed Resident #1 had his hand up Resident #3's dress. Review of Resident #1's Paperwork from a local Psychiatric Hospital with an admitted [DATE] revealed the following, in part: Chief Complaint in patient's own words: Why are you here? Resident #1 stated, I did something bad. I touched a woman on her leg. Assessment: Patient interview: He stated, I hope you can let me go home .I made a silly mistake - I really regret what I did. They don't have to worry about me doing that. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Depression, Aphasia, Cognitive Communication Deficit, Anxiety Disorder, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition, and Alzheimer's Disease. Review of Resident #3's MDS with ARD of 05/03/2023 revealed a BIMS of 5, which indicated she was severely cognitively impaired. Review of Resident #3's current Care Plan revealed the following, in part: Problem: Resident has short term memory problems. Problem: Resident has altered thought process related to severely impaired cognition. Review of Resident #3's Nurses' Notes dated July 2023 revealed the following, in part: 07/09/2023 at 1:39 p.m. by S11LPN: CNA reported resident was observed sitting in the dining room during lunch time while another male resident had his hand under the resident's dress. Review of Resident #3's Incident Report dated 07/09/2023 at 12:45 p.m. revealed the following, in part: Incident Reported By: S8CNA Person Completing Report: S11LPN Type of Incident: Physical Contact - Resident Location of Incident: Dining Room Incident Description: CNA reported resident was observed sitting in the dining room during lunch time while another male resident had his hand under the resident's dress . Resident is confused and unaware of the incident. Review of the facility's Self-Reported Incident Report for Resident #3 revealed the following, in part: Occurred: 07/09/2023 at 12:30 p.m. Incident Investigation: NFA reviewed surveillance footage and found the following: At 12:30 p.m., Resident #3 can be seen rolling her wheelchair towards Resident #1's table. When she gets to his table, Resident #1 reaches out his hand and they shake hands. The two hold their hands together. At 12:31 p.m., Resident #1 releases his hand and touched Resident #3 on her thigh and rubs his hand up and down her leg. Within the same minute, Resident #1 puts his hand up Resident #3's dress. 34 seconds later, facility CNA separated the two . An interview was attempted with Resident #3 on 10/17/2023 at 10:47 a.m. She was unable to answer questions appropriately. Telephone interviews were attempted with S8CNA on 10/17/2023 at 10:00 a.m., 10:24 a.m., and 12:15 p.m. with no success. An interview was conducted with S13CN on 10/17/2023 at 11:10 a.m. She stated she was familiar with Resident #1 and he had a tendency to have sexual behaviors. She stated Resident #1 was transferred to a local psychiatric hospital in July 2023 for a sexual behavior incident involving Resident #3. An interview was conducted S9SW on 10/17/2023 at 11:34 a.m. She stated Resident #1 was sent to a local psychiatric hospital in July 2023 after an incident involving Resident #3. She stated Resident #1 was of sound mind. She stated Resident #3 did not have the capacity to consent to any type of sexual relationship or contact. An interview was conducted with S2DON on 10/18/2023 at 11:37 a.m. She confirmed Resident #3 did not have the capacity to consent to any type of sexual relationship or contact. She stated upon reviewing the video footage dated 07/09/2023, she could see Resident #1 touching Resident #3's thigh and rubbing her leg near the knee. An interview was conducted with S1ADM on 10/17/2023 at 2:01 p.m. He stated an incident occurred involving Resident #1 and Resident #3 on 07/09/2023. He stated during his interview with Resident #1 regarding the incident, Resident #1 stated he made a mistake. He stated he submitted a self-reported incident report and his observation of the video footage would have been accurate. He confirmed Resident #3 did not have the capacity to consent to any type of sexual relationship or contact due to her severely impaired cognitive state. He stated Resident #1 was transferred to a behavior hospital after the incident and when he returned, sexual behavior monitoring was implemented. He stated the monitoring for Resident #1 was for the staff to document on the monitoring every shift and report if Resident #1 exhibited any sexual behaviors. Resident #1 Review of Resident #1's Nurses' Notes dated 07/18/2023 revealed the following, in part: 1:46 p.m. by S10LPN: Resident #1 returned from a local psychiatric hospital today .His medications still the same as before and the nurse said all they did was have some therapy sessions and he realized what he did was wrong and inappropriate behavior Review of Resident #1's MDS with an ARD of 09/21/2023 revealed, in part, a BIMS of 10, which indicated he was moderately cognitively impaired. Review of Resident #1's Incident Report dated 10/11/2023 at 5:16 a.m. revealed the following, in part: Incident type: Other Incident reported by: S5CNA Report prepared by: S3ADON Narrative of Incident: This resident was witnessed touching another resident. Review of S5CNA's written witness statement dated 10/11/2023 revealed the following, in part: I, S5CNA, was coming around the nurses' station at 5:15 a.m. Wednesday morning when another resident got my attention pointing at Resident #1 that had his hand on Resident #2 inappropriately. Signed: S5CNA Review of the Police Department Incident Report for suspect Resident #1 dated 10/12/2023 revealed the following, in part: Charge: 14:43.1-Sexual Battery/Forcible Arrest Charge: 14:43.1-Sexual Battery/Forcible Offense: Sexual Battery On October 12, 2023, I, Detective with the local Police Department Special Victims Unit, responded to the facility regarding a possible sexual assault. .The facility found video of the incident in question which took place in the common area on October 11, 2023. I observed the video which showed Resident #2, who according to staff is nonverbal and cannot move, sitting in a chair when Resident #1 approaches in his wheelchair. Resident #1 taps Resident #2 and looks around before moving his hand under the blanket in Resident #2's lap. Resident #1 then switches hands and appears to be moving his hand. Resident #1 continues to do this until a staff member comes through the hall at which time, he backs away fast and then moves to the other side of the room. After a few minutes pass I observed Resident #1 then lift his hands to his nose. Resident #1 does this a second time before a bystander, who is also nonverbal, attempts to flag down someone to bring attention to Resident #1 and Resident #2. Another resident alerts the nurse who stands but Resident #1 had quickly backed away from Resident #2 once more. I contacted Resident #1 who according to staff was of sound mind and in the nursing home due to age, and advised him of his rights. Resident #1 advised he understood and was asked about the incident on the video. Resident #1 admitted to touching Resident #2's vagina with skin-to-skin contact. Resident #1 was placed under arrest and charged with Felony Sexual Battery. Case closed by arrest. Review of Resident #1's Nurses' Notes dated 10/12/2023 revealed the following, in part: 8:51 a.m. by S3ADON: Upon notification of inappropriate incident, resident was placed one-on-one supervision until sent out. Review of the facility's Emergency Transfer Log dated October 2023 revealed, in part, Resident #1 was transferred to jail on 10/12/2023 for an inappropriate sexual incident. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Cerebral Atherosclerosis, Generalized Anxiety Disorder, Muscle Wasting and Atrophy, Vascular Dementia without Behavioral Disturbance, and Cognitive Communication Deficit. Review of Resident #2's Yearly MDS with an ARD of 08/02/2023 revealed, in part, a BIMS of 99, which indicated Resident #2 was unable to complete the BIMS assessment related to a memory problem. Review of Resident #2's current Care Plan revealed the following, in part: Problem: Resident has short term memory problems and long term memory problems. Diagnosis: Vascular Dementia. Problem: Altered thought process related to Dementia. Severely impaired decision making. Review of Resident #2's Incident Report dated 10/11/2023 at 5:16 a.m. revealed the following, in part: Incident type: Other Incident reported by: S5CNA Report prepared by: S3ADON Narrative of incident: CNA reported another resident was touching this resident. Interviews were attempted with Resident #2 on 10/16/2023 at 11:29 a.m. and 10/17/2023 at 1:50 p.m. Resident #2 was unable to answer questions. An interview was conducted with S14CNA on 10/17/2023 at 9:27 a.m. She stated she frequently was assigned to Resident #2. She stated Resident #2 was unable to communicate effectively and did not have the capacity to consent to any type of sexual relationship or contact. She stated one resident touching another resident inappropriately or without consent was sexual abuse. An interview was conducted with S15LPN on 10/17/2023 at 10:53 a.m. She stated she had taken care of Resident #2 for four months. She stated Resident #2 could not meaningfully communicate and was unable to recall events. She stated Resident #2 did not have the capacity to consent to any type of sexual relationship or contact. She stated one resident touching another resident inappropriately or without consent was sexual abuse. An interview was conducted with S16LPN on 10/17/2023 at 1:13 p.m. She confirmed she was assigned to Resident #2 on 10/11/2023 from 6:00 a.m. to 2:00 p.m. She stated when she arrived for her shift, Resident #2 was in the dining room. She stated Resident #2 was not cognitive and was not capable of consenting to any type of sexual relationship or contact. She confirmed Resident #1 touching Resident #2 in the vaginal area was sexual abuse. Review of the facility's video footage of the dining room conducted on 10/17/2023 at 2:10 p.m. with S1ADM who confirmed the below observation: Video footage on 10/11/2023 beginning at 4:59 a.m.: 5:00 a.m. - Resident #1 placed his right hand on Resident #2's arm/torso area and then immediately backed away. 5:01:38 a.m. - Resident #1 saw a CNA coming from the locked unit and backed away from Resident #2. 5:05:39 a.m. - Resident #1 approached Resident #2 again and placed both of his hands near Resident #2's right leg. He lifted the blanket on Resident #2's lap with his left hand and placed his right hand under the blanket. 5:07:41 a.m. - Resident #1's hands remained under Resident #2's blanket until he saw S5CNA approach the dining room and backed away from Resident #2 waving at her. A telephone interview was conducted with Resident #2's hospice nurse on 10/18/2023 at 10:07 a.m. She stated Resident #2 did not have the capacity to consent to any sexual acts. An interview was conducted with S17CNA on 10/16/2023 at 3:32 p.m. She stated she frequently provided care for Resident #1. She stated Resident #1 had a history of being sexually inappropriate with the staff. She stated he would say things like, I've got a piece of wood for you, what are you going to do with it? She stated, on two occasions, Resident #1 pulled back the curtain in the shower room, and exposed himself masturbating. She stated she had to step back where she would not be visible to him. She stated one resident touching another resident on their legs or private areas without consent was sexual abuse. She confirmed she was assigned to Resident #1 from 2:00 p.m. to 10:00 p.m. on 10/11/2023, and she was unaware of the incident between Resident #1 and Resident #2. She stated Resident #1 went back and forth from his room to the dining room during her shift. An interview was conducted with S18CNA on 10/17/2023 at 9:07 a.m. She stated she was frequently assigned to Resident #1. She stated Resident #1 touching another resident on their legs or private area without consent was sexual abuse. She confirmed she was assigned to Resident #1 on 10/11/2023 and 10/12/2023 from 6:00 a.m. to 2:00 p.m. She stated she was unaware of the incident involving Resident #1 and Resident #2 until after breakfast on 10/12/2023. She stated on 10/11/2023, Resident #1 went to the dining room for breakfast and lunch during her shift as usual. An interview was conducted with S19LPN on 10/17/2023 at 10:40 a.m. She stated she began working at the facility in September 2023. She stated Resident #1 spent most of his time in the dining room. She stated Resident #1 rubbing another resident's leg or touching them in a private area without consent was sexual abuse. She confirmed she was assigned to Resident #1 on 10/11/2023 and 10/12/2023. She stated Resident #1 carried out his day as normal and remained in the dining room most of the day on 10/11/2023. She stated Resident #1 ate breakfast in the dining room on 10/12/2023. She stated she was made aware of the situation involving Resident #1 and Resident #2 between 8:30 a.m. and 9:00 a.m. on 10/12/2023 when Resident #1 was placed on one-on-one observation. An interview was conducted with S13CN on 10/17/2023 at 11:10 a.m. She stated she was familiar with Resident #1 and he had a tendency to have sexual behaviors. An interview was conducted S9SW on 10/17/2023 at 11:34 a.m. She stated Resident #1 was of sound mind. She stated Resident #2 did not have the capacity to consent to any type of sexual relationship or contact. An interview was conducted with S20LPN on 10/17/2023 at 2:56 p.m. She stated she frequently took care of Resident #2. She confirmed she was assigned to Resident #2 during the time of the incident on 10/11/2023. She stated Resident #2 did not have the capacity to consent to any type of sexual relationship or contact. She stated Resident #1 touching a non-cognitive resident in a private area or rubbing on their leg without consent was sexual abuse. An interview was conducted with S21CNA on 10/17/2023 at 3:11 p.m. She confirmed she was assigned to Resident #2 on 10/10/2023 from 10:00 p.m. to 6:00 a.m. She stated she got Resident #2 out of bed and into the dining room around 4:45 a.m. She stated Resident #1 had a history of exhibiting sexual behaviors toward staff. She stated around March of 2023, she showered Resident #1 and he made a sexual remark to her such as, I want to rub this big thing with the soap, referring to his penis. Telephone interviews were attempted with S5CNA on 10/17/2023 at 8:56 a.m. and 10:38 a.m. and 10/18/2023 at 10:01 a.m. with no answer. A telephone interview was conducted with S6LPN on 10/17/2023 at 11:57 a.m. She confirmed she was assigned to Resident #1 on 10/10/2023 from 10:00 p.m. to 6:00 a.m. She stated she was aware of the incident between Resident #1 and Resident #2. She stated around 5:00 a.m. on 10/11/2023, S5CNA came to her and stated, he's touching her, he's touching her. She stated she stood up and saw Resident #1 coming out of the dining room. She stated she asked S5CNA what she saw, and the aide walked away and stated, I don't like it. She stated Resident #1 touching another resident inappropriately, on the legs or vaginal area, without consent was sexual abuse. An interview was conducted with S3ADON on 10/17/2023 at 1:33 p.m. She stated on the morning of 10/12/2023, she received a written statement from S5CNA. She stated S5CNA's statement was for a sexually inappropriate incident involving Resident #1 and Resident #2 on 10/11/2023. She stated she interviewed S5CNA, and S5CNA reported she was flagged down by another resident and saw Resident #1 touching Resident #2 inappropriately. She stated S5CNA reported she saw Resident #1's hand between the pillow and Resident #2's leg under the blanket. She stated S5CNA reported that as soon as Resident #1 saw S5CNA, he quickly backed away from Resident #2. S3ADON stated when she reviewed video footage of the incident, it was obvious Resident #1 knew what he was doing was wrong because he would immediately back away when he saw staff. An interview was conducted with S1ADM on 10/17/2023 at 2:01 p.m. He stated on the morning of 10/12/2023, S3ADON received S5CNA's written statement. He stated S5CNA reported Resident #1 was touching Resident #2 in a sexually inappropriate manner. He stated the Special Victims Unit Officer reviewed the facility's video footage of the incident and questioned Resident #1. He stated he was present for the questioning of Resident #1, and Resident #1 confessed to touching Resident #2's vagina. An interview was conducted with S2DON on 10/18/2023 at 11:37 a.m. She stated Resident #1 did not have any increased monitoring from the time S5CNA observed him touching Resident #2 until Resident #1 was placed on 1:1 supervision on the morning of 10/12/2023. She stated the facility failed to protect Resident #2 or any other cognitively impaired residents from further abuse by Resident #1 from 10/11/2023 at 5:07 a.m. to the morning of 10/12/2023 when Resident #1 was placed on one on one supervision. An interview was conducted with S4NP on 10/18/2023 at 10:31 a.m. She stated Resident #1 had random inappropriate sexual behaviors. She stated there were two incidents of sexual behaviors with Resident #1. She stated the first instance, Resident #1 touched Resident #3's leg and the second incident, Resident #1 touched Resident #2's vagina. She stated Resident #2 and Resident #3 did not have the capacity to consent to any sexual acts. She confirmed the incidents involving Resident #1 and Resident #3 and Resident #1 and Resident #2 were sexual abuse. The facility had implemented the following actions to correct the deficient practice: 1. Measures implemented for action plan regarding to inappropriate sexual contact resident to resident: a. Resident #1 was removed from the environment. b. Police notified and threat removed. c. Pelvic exam completed by the hospice Registered Nurse d. MD and RP notified. 2. Residents with potential to be affected include all female residents. 3. Measures implemented to address problem identified in corrective action plan: a. In-services began regarding abuse and to reporting of suspected inappropriate sexual behavior or any other incidents/abuse, who to report to, consequences of not reporting. b. Emergency resident council held to discuss capacity to consent. Unwanted sexual behavior and reporting abuse. c. The facility will continue weekly abuse and abuse reporting in-services fro the next three weeks. d. Facility NFA, SSD or designee to have 1:1 conversation with each male resident to discuss: capacity to consent, inappropriate/unwanted sexual contact/advances and reporting abuse. 4. Monitoring of compliance will include the following: a. Facility DON or designee will interview 3 cognitive residents per week for 4 weeks to inquire if they witnessed inappropriate behavior. Questioned if anyone has made inappropriate sexual advances towards them. Questioned if they would feel comfortable reporting abuse or unwanted sexual advances. Any negative responses will be investigated immediately. b. NFA or designee will interview 3 staff members per week for 4 weeks to ensure they know what constitutes abuse and abuse reporting policies. Who to report to and timelines for reporting. c. NFA or designee will review video surveillance 3 times per week specifically focusing on non-cognitive female residents to ensure there is no inappropriate sexual contact toward these residents. Non-cognitive female residents will be identified and their room will be reviewed during this video surveillance as well. d. Results of these audits will be discussed daily M-F in the facility Morning Standup Meeting and quarterly as part of the facility QA for the next 2 quarters. Any negative responses during the audit will be investigated immediately. e. Staff who give incorrect answers during the facility QA interviews will be re-educated and face progressive discipline. f. Staff found to be non-compliant with the above mentioned QA measures will be re-educated and will face progressive discipline up to and including termination. Started 10/12/2023; Completed and all staff in-serviced by 10/14/2023. Throughout the survey from 10/16/2023 to 10/18/2023, random staff interviews revealed staff received training on the facility's abuse and abuse reporting policy and procedure, including reporting of suspected inappropriate sexual behavior or any other incidents of abuse immediately to a supervisor and supervisor reporting incidents to ADON, DON, or Administrator immediately. Observations were made throughout the survey with no sexual behaviors or abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified. 48537

Based on interviews and record reviews, the facility failed to ensure an allegation of sexual abuse was reported to the facility administrator immediately, but not later than 2 hours after the allegation was made for 1 (#2) of 3 (#2, #3, and #4) residents reviewed for abuse. S6LPN failed to notify administration of an allegation Resident #1 sexually abused Resident #2. This deficient practice resulted in an immediate jeopardy situation on 10/11/2023 at 5:07 a.m. when Resident #1, a resident with a history of sexually inappropriate behaviors, touched Resident #2, a severely cognitively impaired resident, on the vagina in the facility's dining room. At 5:07 a.m., S5CNA observed Resident #1 touching Resident #2 inappropriately. At that time, S5CNA, alerted S6LPN of the incident. S6LPN failed to report the incident to administration and failed to implement adequate interventions after the incident. There was a likelihood for Resident #1 to sexually abuse female residents until the following morning of 10/12/2023, when Administration was made aware of the sexual abuse and placed Resident #1 on one to one supervision. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation. Findings: Review of the facility's policy titled, Incident Investigation and Reporting revealed the following, in part: 2. Relevant Terms: Sexual Abuse: Is nonconsensual sexual contact of any types with a resident. 3. In the event of any incident involving an allegation or suspicion of . abuse, . will be reported immediately to the Administrator of the facility . The administrator will begin an investigation. The administrator shall report to the State Survey Agency and local law enforcement entities in which the facility is located, any allegation or reasonable suspicion of a crime against any resident. The administrator shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion involve abuse . Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #2's Yearly MDS with an ARD of 08/02/2023 revealed, in part, a BIMS of 99, which indicated Resident #2 was unable to complete the BIMS assessment related to a memory problem. Review of the facility's Self-Reported Incident Report for Resident #2 revealed the following, in part: Entered: 10/12/2023 at 10:45 a.m. Resident Victim: Resident #2 Accused: Resident #1 Accused Allegations: Sexual Assault Interviews were attempted with Resident #2 on 10/16/2023 at 11:29 a.m. and 10/17/2023 at 1:50 p.m. Resident #2 was unable to answer questions. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #1's MDS with an ARD of 09/21/2023 revealed, in part, a BIMS of 10, which indicated he was moderately cognitively impaired. Review of S5CNA's written witness statement dated 10/11/2023 revealed the following: I, S5CNA, was coming around the nurses' station at 5:15 a.m. Wednesday morning when Resident #R5 got my attention pointing at Resident #1 that had his hand on Resident #2 inappropriate. I reported it to S6LPN, and her response was oh I don't see him doing anything. She then told Resident #1 you know you don't supposed to be putting your hands on nobody. She never let me know if she reported it. Signed: S5CNA Review of Resident #1's Nurses' Notes from June 2023 through October 2023 revealed the following, in part: 10/12/2023 at 8:51 a.m. by S3ADON: Upon notification of inappropriate incident, resident was placed one-on-one supervision until sent out. Review of the facility's video footage of the dining room was conducted on 10/17/2023 at 2:10 p.m. with S1ADM. Video footage on 10/11/2023 at 5:05 a.m. revealed and S1ADM confirmed Resident #1 had his hands placed under Resident #2's blanket in her perineal area until he saw S5CNA at 5:07 a.m. Review of the Police Department Incident Report for suspect Resident #1 dated 10/12/2023 revealed the following, in part: Charge: 14:43.1-Sexual Battery/Forcible Arrest Charge: 14:43.1-Sexual Battery/Forcible Offense: Sexual Battery On October 12, 2023, I, Detective with the local Police Department Special Victims Unit, responded to the facility regarding a possible sexual assault. .The facility found video of the incident in question which took place in the common area on October 11, 2023. I observed the video which showed Resident #2, who according to staff is nonverbal and cannot move, sitting in a chair when Resident #1 approaches in his wheelchair. Resident #1 taps Resident #2 and looks around before moving his hand under the blanket in Resident #2's lap. Resident #1 then switches hands and appears to be moving his hand. Resident #1 continues to do this until a staff member comes through the hall at which time, he backs away fast and then moves to the other side of the room. After a few minutes pass I observed Resident #1 then lift his hands to his nose. Resident #1 does this a second time before a bystander, who is also nonverbal, attempts to flag down someone to bring attention to Resident #1 and Resident #2. Another resident alerts the nurse who stands but Resident #1 had quickly backed away from Resident #2 once more. I contacted Resident #1 who according to staff was of sound mind and in the nursing home due to age, and advised him of his rights. Resident #1 advised he understood and was asked about the incident on the video. Resident #1 admitted to touching Resident #2's vagina with skin-to-skin contact. Resident #1 was placed under arrest and charged with Felony Sexual Battery. Case closed by arrest. An interview was conducted with S17CNA on 10/16/2023 at 3:32 p.m. She stated one resident touching another resident in a private area without consent was sexual abuse and should have been reported to the administrator immediately. An interview was conducted with S18CNA on 10/17/2023 at 9:07 a.m. She stated Resident #1 touching another resident's private area without consent was sexual abuse and should have been reported to the administrator immediately. An interview was conducted with S19LPN on 10/17/2023 at 10:40 a.m. She stated Resident #1 touching another resident's private area without consent was sexual abuse and should have been reported to administration immediately. An interview was conducted with S13CN on 10/17/2023 at 11:10 a.m. She stated she was not made aware of the incident of sexual abuse that occurred on 10/11/2023 between Resident #1 and Resident #2 until after breakfast on 10/12/2023. She stated the incident involving Resident #1 and Resident #2 should have been reported to administration immediately and it was not. Telephone interviews were attempted with S5CNA on 10/17/2023 at 8:56 a.m. and 10:38 a.m. and 10/18/2023 at 10:01 a.m. with no answer. A telephone interview was conducted with S6LPN on 10/17/2023 at 11:57 a.m. She confirmed she was assigned to Resident #1 on 10/10/2023 from 10:00 p.m. to 6:00 a.m. She stated around 5:00 a.m. on 10/11/2023, S5CNA came to her and stated, he's touching her, he's touching her. She stated she stood up and saw Resident #1 coming out of the dining room. She stated she asked S5CNA what she saw, and the aide walked away and stated, I don't like it. She stated she did not see Resident #1 touch Resident #2. She confirmed she did not report the incident to administration. She stated Resident #1 touching Resident #2's vaginal area without consent was sexual abuse. She confirmed abuse and abuse allegations should have been reported to S1ADM or S2DON immediately. An interview was conducted with S3ADON on 10/17/2023 at 1:33 p.m. She stated she was made aware of a sexually inappropriate incident involving Resident #1 and Resident #2 on 10/12/2023. She stated on the morning of 10/12/2023, she received a written statement from S5CNA reporting the incident of sexual abuse that occurred on 10/11/2023. She stated she should have been made aware of the incident when it occurred and she was not. An interview was conducted with S1ADM on 10/17/2023 at 2:01 p.m. He stated on the morning of 10/12/2023, S3ADON received a written statement from S5CNA regarding the incident on 10/11/2023. He stated S5CNA was interviewed and reported she told S6LPN Resident #1 was touching Resident #2 in a sexually inappropriate manner on 10/11/2023. He stated S6LPN should have notified administration immediately and she did not. An interview was conducted with S2DON on 10/18/2023 at 11:37 a.m. She stated S3ADON notified her of a sexual abuse incident on 10/12/2023 involving Resident #1 and Resident #2 which occurred on 10/11/2023. She confirmed she was at the facility on 10/11/2023 and was not aware of the incident and should have been. She stated Resident #1 could have been a risk to other residents during the timeframe of the incident occurring until the morning of 10/12/2023 when he was placed on one on one supervision. The facility had implemented the following actions to correct the deficient practice: 1. Measures implemented for action plan regarding to inappropriate sexual contact resident to resident: a. Resident #1 was removed from the environment. b. Police notified and threat removed. c. Pelvic exam completed by the hospice Registered Nurse d. MD and RP notified. 2. Residents with potential to be affected include all female residents. 3. Measures implemented to address problem identified in corrective action plan: a. In-services began regarding abuse and to reporting of suspected inappropriate sexual behavior or any other incidents/abuse, who to report to, consequences of not reporting. b. Emergency resident council held to discuss capacity to consent. Unwanted sexual behavior and reporting abuse. c. The facility will continue weekly abuse and abuse reporting in-services for the next three weeks. d. Facility NFA, SSD or designee to have 1:1 conversation with each male resident to discuss: capacity to consent, inappropriate/unwanted sexual contact/advances and reporting abuse. 4. Monitoring of compliance will include the following: a. Facility DON or designee will interview 3 cognitive residents per week for 4 weeks to inquire if they witnessed inappropriate behavior. Questioned if anyone has made inappropriate sexual advances towards them. Questioned if they would feel comfortable reporting abuse or unwanted sexual advances. Any negative responses will be investigated immediately. b. NFA or designee will interview 3 staff members per week for 4 weeks to ensure they know what constitutes abuse and abuse reporting policies, who to report to and timelines for reporting. c. NFA or designee will review video surveillance 3 times per week specifically focusing on non-cognitive female residents to ensure there is no inappropriate sexual contact toward these residents. Non-cognitive female residents will be identified and their room will be reviewed during this video surveillance as well. d. Results of these audits will be discussed daily M-F in the facility Morning Standup Meeting and quarterly as part of the facility QA for the next 2 quarters. Any negative responses during the audit will be investigated immediately. e. Staff who give incorrect answers during the facility QA interviews will be re-educated and face progressive discipline. f. Staff found to be non-compliant with the above mentioned QA measures will be re-educated and will face progressive discipline up to and including termination. Started 10/12/2023; Completed and all staff in-serviced by 10/14/2023. Throughout the survey from 10/16/2023 to 10/18/2023, random staff interviews revealed staff received training on the facility's abuse and abuse reporting policy and procedure, including reporting of suspected inappropriate sexual behavior or any other incidents of abuse immediately to a supervisor and supervisor reporting incidents to ADON, DON, or Administrator immediately. Observations were made throughout the survey with no sexual behaviors or abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.

Based on interviews and record reviews the facility failed to provide the prescribed therapeutic diet for 1 (#3) of 6 (#1, #2, #3, #4, #5, #6) residents reviewed. The facility failed to ensure all staff was knowledgeable of the resident's ordered diet when passing bedtime snack so that the residents received the prescribed diet. This has the potential to affect 89 residents residing in the facility. This failure resulted in an Immediate Jeopardy situation for Resident #3 on 1/21/17 at 9:13pm when S8CNA gave Resident #3 a sandwich for a bedtime snack instead of the pureed diet snack that was on the snack cart. Resident #3 was later found in her bed and her face was a little cold, but her body was still warm. The nursing staff suctioned the resident and remove parts of the sandwich from her mouth. CPR was started and the local ambulance service was called and attempted to clear the airway upon arrival at the facility. The patient was noted to have copious amounts of food in airway. The patient was suctioned and intubated; vomit and food were noted in the endotracheal tube. The patient was given medications but remained asystole. The endotracheal tube was noted to get backed up and plugged. The patient was extubated and a King's airway placed. Resuscitation efforts continued for 30 minutes. A doctor at the nearest facility was contacted and resuscitation efforts were terminated at 10:17pm. The Immediate Jeopardy ended for resident #3 when she expired. The Immediate Jeopardy ended for the other resident receiving snacks on therapeutic diets on 1/22/17 when the facility fully implemented a corrective action plan which was completed prior to the State Agency's investigation, thus it was determined as Past Noncompliance at the Immediate Jeopardy scope and severity. On 6/23/17 at 12:59 pm, S1 ADM was informed of the Past Noncompliance at the Immediate Jeopardy level that began on 1/21/2017 and ended on 1/22/17 when the facility's full plan of correction was implemented and monitoring of the plan was begun. Findings: Resident #3: Review of the facility's Bedtime Snacks Policy, with a revision date of 08/2012, revealed in part the facility shall offer to all residents who receive food by mouth, a bedtime snack. Procedure: 1. The facility daily menu and modifications includes a planned bedtime snack for all diets. 2. The food service department prepares the planned snack and sends it in bulk to the nursing unit before closing the food service department. 3. The certified nursing assistants offer the bedtime snack to each resident. 4. The acceptance or rejection of the snack is documented in the medical record by nursing service. Resident #3 was admitted to the facility on [DATE] with an Admit [DIAGNOSES REDACTED]. Medical Record Review revealed on 7/11/2013 the resident was choking in the dining room and had to have the [MEDICATION NAME] Maneuver performed. On 7/17/2013 the resident's diet was downgraded to a Pureed, NSOT (no salt on table), LCS (low concentrated sugars) diet. The Pharyngogram, dated 7/18/2013, revealed Mild Oral Pharyngeal Dysphagia. Further review of the Medical Records revealed, in part, the following Diagnoses: [REDACTED]. Review of the MDS, dated [DATE], revealed a BIMS of 4 and no noted behaviors. Functional Status was as follows: - Transfers: Extensive assistance with one-person physical assist - Bed Mobility: Limited assistance with one-person physical assist - Eating: Independent with no help or staff oversight at any time. Set-up help only - Balance moving from seated to standing position: unsteady; only able to stabilize with staff assist Review of the most recent physician's orders [REDACTED].=Accepted, R=Refused, S=Sleeping) Review of the local ambulance service's Prehospital Care Report Summary, dated 1/21/2017, revealed in part a call was received from the facility at 10:29pm with a chief dispatch reason of cardiac/respiratory arrest. Medics arrived at the facility and initial patient contact was made at 10:40pm. Provider Impression: Airway Obstruction. The Narrative History Text revealed the patient was found lying on the floor beside her bed with nursing staff performing CPR. The patient was pulseless, apneic, pupils dilated and non-reactive, and her abdomen was severely distended. The nursing staff reported around 9:00pm the patient was given a sandwich; the patient had difficulty swallowing and was not supposed to have normal food. An attempt was made to clear the airway. The patient was noted to have copious amounts of food in airway. The patient was suctioned and intubated; vomit and food were noted in the endotracheal tube. The patient was given medications according to flows but remained asystole. The endotracheal tube was noted to get backed up and plugged. The patient was extubated and a King's airway placed. Resuscitation efforts continued for 30 minutes. A doctor at the nearest facility was contacted and resuscitation efforts were terminated at 10:17pm. Review of the Coroner's Report revealed on 1/21/2017 at 10:37pm the Coroner's Office was contacted by S10RN to report the natural death of Resident #3. S10RN reported the resident's medical history was [MEDICAL CONDITION], Type II DM, HTN, [MEDICAL CONDITION], and High Cholesterol. The date of death was pronounced at 10:20pm on 1/21/2017 by a physician. The cause of death on the report was ASCVD ([MEDICAL CONDITION] Cardiovascular Disease). The report stated the resident's pupils were equal in size bilaterally with significant petechial hemorrhaging bilaterally, no external signs of trauma, and the abdomen was abnormally distended. On 6/22/2017 at 12:14pm, a review of the video from 1/21/2017 was conducted with S1ADM. The video revealed in part: 9:08pm CNA pushing the snack cart down the hall. S9CNA going in and out of rooms 9:13pm S8CNA entered and exited Resident #3's room 9:26pm S8CNA and S9CNA go into and out of the resident's room 9:27pm S8CNA, S9CNA, and S6LPN entered the resident's room. 9:28pm S7CNA brings the crash cart into the resident's room. All nurses come to the resident's room 9:42pm the local ambulance service arrived 10:45pm S2DON seen at the nurses' station On 6/20/2017 at 11:45am, an interview was conducted with Resident #6. Resident #6 was the roommate of Resident #3 at the time of Resident #3's death. Resident #6 stated on the night Resident #3 passed away, an aide came into their room and passed snacks. She stated the curtain was pulled and did not see if the staff gave Resident #3 a snack. Resident #6 stated the aide gave her Jell-O. She stated that she personally did not give Resident #3 any food, not did Resident #3 come get food from her. She stated she heard Resident #3 coughing and a noise that sounded like she fell , but she could not see Resident #3 because the curtain was pulled. Resident #6 stated it had been a while before someone had come to check on them. She stated the police and ambulance came. On 6/21/2017 at 2:30pm an interview was conducted with S9CNA. She stated when she found Resident #3 on 1/21/2017 she was in her bed and her face was a little cold, but her body was still warm. She thought she was still asleep. She went and got her nurse, S6LPN. S9CNA stated she saw the staff move the resident to the floor to do CPR. She stated she heard S8CNA tell the nurses, S11LPN and S10RN, and some other aides that she gave Resident #3 a sandwich. She stated she saw the nursing staff suction the resident and remove parts of the sandwich from her mouth. The staff were suctioning her mouth and putting the contents in a cup. She stated the contents looked like smooshed up bread, soggy bread. On 6/22/2017 at 9:40am, a telephone interview was conducted with S6LPN. She stated she had worked at the facility for 1 year and was familiar with Resident #3. She stated she gave Resident #3 her medications and setup her meal trays. She stated Resident #3 tended to eat too fast and needed supervision. She stated Resident #3 normally took her meals in the dining room and followed her pureed diet. She did not know the resident to take food from other residents. S6LPN stated she was assigned to Resident #3 the night she passed away. She said that S8CNA told her the incident had occurred because she had given Resident #3 a snack that was not on her prescribed diet. While performing CPR and suctioning, the contents of the resident's throat appeared to be soft, bread-like material and meat. She stated there were sandwiches on the snack cart every night. When asked to describe the incident, she stated she was in the Medicine Room when S9CNA knocked on the Medicine Room door and told her that Resident #3 did not look right. She went to the resident's room and did a sternal rub and checked her pulse. She did not respond and she did not have a pulse. When she first went into the resident's room Resident #3 was lying flat, in a supine position on the bed. The resident was not normally flat; usually the head of the bed was up 45 to 90 degrees. The resident's eyes appeared to be fixed. She also stated Resident #3 was not able to get out of bed on her own. She ran to the chart to see if the resident was a DNR (Do Not Resuscitate) or full code and she was a full code. She stated she then got the crash cart, other nurses came to help, and CPR was started. She called the local ambulance service to report a resident who was a full code and unresponsive. S6LPN stated the particles from the resident's mouth were clogging the suction tubing. S6LPN notified S2DON that the resident was unresponsive to a sternal rub, had no pulse, and was a full code. S2DON came later that night. S6LPN also stated she informed S2DON that one of the aides reported giving Resident #3 a snack prior to this event. She stated typical snacks for pureed diets were pudding or applesauce. At the time of the incident the aid was responsible for giving out snacks. On 6/22/2017 at 11:47am, a telephone interview was conducted with S8CNA who stated she had just started working at the facility and was still in training when Resident #3 passed away. S8CNA stated she saw the snack cart and helped by passing out snacks; the aides could pass out snacks at the other places she had worked. She stated the weekend supervisor saw her passing them out and did not say anything. She stated she gave Resident #3 a sandwich and saw her eating it in her bed before she left the room. After passing the rest of the snacks, she took a 10-minute break and when she returned everybody was in Resident #3's room. She stated she did not know the resident was on a pureed diet; nobody told her. She stated the next day she was told from now on do not give out snacks. She stated the next day S2DON asked her what happened and she told him that she had given Resident #3 a sandwich and he said okay. On 6/22/2017 at 12:44pm, a telephone interview was conducted with S4RN. She had worked at the facility for over a year and was familiar with Resident #3, but was not aware of her diet or of any problems consuming her diet. She was the Weekend Supervisor on 1/21/2017 and that evening was called to Resident #3's room where CPR was already in progress. She took over performing respirations with the ambu bag. She stated she tilted the resident's head, did a finger sweep of the mouth, and got a small amount of food from the inside of her cheek. When asked to describe the food in the resident's mouth, she stated it was bread maybe or white mushed together potatoes. She stated S2DON was notified, but was not sure by whom. S4RN stated she informed S2DON that night when he arrived at the facility that the resident had possibly been given a sandwich. On 6/22/2017 at 1:41pm, an interview was conducted with S2DON who stated he had worked at the facility since 10/3/2014 and was familiar with Resident #3. He stated she was on a pureed diet. S2DON stated on the night of 1/21/2017 he received a call that Resident #3 had coded. He talked to S4RN that evening and she told him an aide gave the resident something and she wasn't sure what was going on with that. S2DON stated he went to the facility. He stated there was something about an aide passing snacks earlier that evening and then the resident was found unresponsive and they coded her. He stated the word sandwich kept floating around. He confirmed the aide was S8CNA. He recalled S8CNA saying that she went into the resident's room and put a sandwich down for Resident #3's roommate. He thinks he heard at times that Resident #3 would take other residents' food, but he never witnessed that himself. He stated he talked to S8CNA the next day along with S1ADM, S3ADON, and S5RN. He stated S8CNA admitted to taking the snack in the room, but she couldn't recall what the snack was. On 6/22/2017 at 2:21pm an interview was conducted with S1ADM, who stated she had worked at the facility for over two years and was familiar with Resident #3. S1ADM stated she received a call from S2DON on the evening of 1/21/2017 informing her that Resident #3 was found unresponsive and was coded. S1ADM stated that S2DON did not lead her to believe there was anything was out of the ordinary. She stated the next day she met with S3ADON and S8CNA. They discussed if there was food given to the resident and had S8CNA seen the food. S1ADM stated she could never differentiate if that was the cause of Resident #3's death. She stated S8CNA kept saying she did not give the snack to the resident; she just put it in the room on each residents' table. S1ADM stated she did not know what the snacks were. She stated the resident was known for grabbing things. S1ADM stated she knew the resident was on pureed diet. She stated the process for passing snacks, at the time of the incident, was for the aid to pass the snacks that were labeled. She stated some snacks were not labeled, but the aids would ask the nurse what the resident could have. She stated there were rumors that Resident #3 had eaten a sandwich. On Monday, 1/23/2017, she became aware that the paramedics said there was food in the resident's mouth. On 6/22/17 at 3:48 pm a telephone interview was conducted with one of the paramedics who responded to the 911 call on 1/21/17. She recalled arriving on the scene at the nursing home and finding the resident on the floor without a heartbeat; she and the other paramedic administered CPR and emergency response medications. She stated the facility staff reported the resident was recently alive. However, she stated the resident showed signs of death; the resident had no heartbeat and was flat lined for more than 10 minutes. She reported they were unsuccessful with resuscitating the resident. She stated there was difficulty obtaining an airway on the resident because there was some sort of food in her throat that looked like pieces of a sandwich and the food was clogging up the medical equipment. She stated an airway was finally obtained after suctioning most of the food out and possibly pushing some down the throat. She stated CPR continued and emergency drugs were administered; there was no change in the resident's status after 30 minutes. She stated the ER physician at the nearest hospital was contacted to pronounce the time of death. On 6/22/2017 at 4:20 pm a telephone interview was conducted with the other paramedic regarding a call she worked on the night of 1/21/17 at the facility. She stated when they arrived in the resident's room the nursing staff was performing CPR. She said there was turkey sandwich in the resident's airway. She stated that she and the other paramedic attempted to intubate the resident but were unable to get the tube in. She stated the airway was secured using a King airway. She stated there was a lot of turkey sandwich. She stated that she and the other paramedic were told by the facility staff that a new aide gave the resident a turkey sandwich instead of her pureed snack. She stated after 30 minutes there was no response to the code interventions and an emergency room physician was contacted and the code was called by the physician. She stated the sandwich was partially chewed and there were a few bigger chunks of bread not completely chewed. On 1/22/2017 the facility implemented a corrective action plan that included: 1. Problem Identified: Labeled Snacks. 2. Plan of Action: A. Immediate Action of: only a nurse will distribute snacks without labels B. Audit of: current residents on snacks C. In-service Provided (topic & attendees): Nursing staff in-serviced for Snack Protocol on 1/22/2017 and 1/24/2017. 3. Monitoring: DON/ADON/Designee will monitor snack distribution to ensure correct procedure is followed 3 times a week for 4 weeks and randomly thereafter. A Snack Audit Tool was implemented from 1/22/2017 through 4/9/2017 and used by the nurses to monitor if the snacks were being labeled and distributed according to policy and procedure. 4. Follow-up for Effectiveness: S2DON stated he has randomly checked snack pass and has had no further issues. On 6/22/2017 at 1:41pm during an interview conducted with S2DON, he informed the team that his immediate actions after Resident #3's death was to have the charge nurse pass out all snacks for the time being. He stated the snacks are now brought to the nurses' station from dietary and locked in the nurses' station medication room until the charge nurse passes out the snacks. He stated the remaining snacks are locked in the medication room overnight. S2DON stated he has randomly checked snack pass and has had no further issues.