Every finding on record at Knollwood Healthcare

Based on interviews, record review, review of a Facility Reported Incident (FRI's), review of the facility's investigative files, review of facility's policies titled, Elopement Prevention, Visitors Screening and Accidents and Incidents, and a facility document titled, Lifting Machine, Using a Mechanical, the facility failed to provide adequate supervision to prevent elopement for Resident Identifier (RI) # 68 a resident with a known history of wandering daily and attempting to leave the facility and failed ensure that resident environment remained free from accident hazardsSpecifically:1) On 06/18/2026, RI #68 was assessed by the facility for elopement risk and identified as at risk for elopement. On 06/24/2026, RI #68 attempted to follow a visitor out of the front door. On 06/27/2026 around 4:15 PM, RI #68 approached the front door and the receptionist failed to verify RI #68's identity, unlocked the door using an electronic system, and without knowing that RI #68 was a resident identified as an elopement risk, allowed RI #68 to exit the building unsupervised. The receptionist did not identify whether RI #68 was a visitor or a resident and did not follow the facility's procedure which required nursing verification permitting a resident to exit the facility. The facility was unable to provide documentation that the receptionist was provided training on the facility's procedure for elopement prevention and response prior to the 06/27/2026 elopement. Further, the receptionist did not immediately report that RI #68 had exited when questioned by staff who were searching inside the building for RI #68. The failure to report that RI #68 had exited delayed critical emergency response steps. After being questioned multiple times, the receptionist reported to staff that RI #68 had exited. Around 5:00 PM, the facility staff found RI #68 walking along a busy highway approximately 1.8 miles away from the facility and the temperature was over 90 degrees Fahrenheit.It was determined the facility's noncompliance with one or more requirements of participating has cause, or likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.25 Quality Care.On 08/08/2026 at 3:28 PM, the Administrator, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) were provided with the IJ template and notified of the findings at the immediate jeopardy level and substandard quality of care at F689 Free of Accident Hazards/Supervision/Devices.The IJ began on 06/27/2026 and continued until 08/09/2026 when the facility implemented corrective actions. The immediate jeopardy was removed on 08/11/2026.This deficient practice was cited as a result of the investigation of incident/complaint/report number 3064873.2) Additionally, the facility failed to ensure the safe transfer of RI #6 while using a mechanical lift, resulting in the resident being injured during transfer. This deficient practice was cited at actual harm that was not immediate jeopardy.This deficient practice was cited as a result of the investigation of complaint/report number 3121346.These deficient practices affected two of three residents sampled for accidents. Findings include: Review of facility policy titled Elopement Prevention and Response Policy with effective date of 08/2024 and revised date of 06/27/2026 documented: Purpose To ensure the safety of all residents by identifying those at risk for wandering or elopement, implementing preventive measures, and providing a coordinated facility-wide response should an elopement or attempted elopement occur. Policy (named facility) is committed to providing a safe environment and maintaining adequate supervision and interventions to prevent resident elopement. All staff are responsible for resident safety and must immediately report and respond to any suspected elopement or missing resident. Definitions Elopement: A resident who leaves the facility or a secured area without staff knowledge, supervision, or authorization, placing the resident at risk for harm. Wandering: Movement by a resident that may place them at risk for exiting a safe environment. Elopement Risk: A resident identified through assessment as having a history, behavior pattern, cognitive impairment, or other factors indicating potential risk of leaving the facility unsupervised. Preventive Measures For residents identified at risk . include: . Increased observation. Frequent safety checks. Family involvement. Staff Responsibilities All Employees All employees. are responsible for: Being alert for residents attempting to leave the facility. Report incidents promptly. When a Resident is Suspected Missing. Immediate Actions The receptionist shall: Initiate a facility-wide elopement alert. Administrator/Director of Nursing/Supervisors shall assign staff to search designated areas. Check resident room and common areas. Review recent resident whereabouts. Review of facility policy titled Screening Policy initiated 08/2024, revised 06/27/2026 documented: 1.Purpose To ensure the safety and well-being of our residents by implementing a standardized screening process. 2. Scope This policy applies to all visitors. and residents. 3. Visitor Screening Procedure . d. Visitor Registration: All visitors must sign in and out. by the kiosk. 5. Restrictions Front desk will verify with nurse that any residents wishing to go outside is either care planned or has an OUT ON PASS form signed. Front desk will only let out visitors out by physically accompanying the visitor exiting and pressing the code and not utilizing the remote buzzer after visitors check out using the kiosk. Resident Identifier (RI) #68 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Cerebral Infarction, Dementia, Altered Mental Status, Delirium, and Muscle Weakness. Review of RI #68's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/23/2026 revealed RI #68 had a Brief Interview for Mental Status (BIMS) score of 6 of 15 which indicated he/she was cognitively impaired. Review of RI #68's Elopement Risk assessment completed on 06/11/2026 at 2:45 PM per Unit Manager (UMGR) indicated RI 68 was not a risk for elopement. Review of RI #68's medical record included: admission Note documented by the Assistant Director of Nursing (ADON) dated 06/12/2026. The note included . History of Present Illness: admission to skilled nursing facility following recent hospitalization for altered mental status and stroke. Nurses Note documented by the Unit Manager (UMGR) dated 06/12/2026 documented RI #68 . Walks constantly looking for exit. Skilled Note documented by the UMGR dated 06/13/2026 documented . Behavior concerns: hallucinations, delusions, socially inappropriate behavior, rejection of care , wandering, all over the place. A progress note documented by the Nurse Practitioner (NP) dated 06/13/2026 documented that RI #68 was sent to the hospital for evaluation for disorientation. RI #68's Elopement Risk assessment completed by the UMGR on 06/18/2026 at 6:00 PM indicated RI #68 was a risk for elopement. RI #68's Care Plan initiated on 06/18/2026 with goal of Will not leave facility unattended revealed the facility identified the resident as an elopement risk related to dementia and wandering and indicated repeated wandering and exit-seeking behaviors prior to the 06/27/2026 elopement. Specifically, the care plans included: On 06/20/2026, RI #68 attempted to enter the dietary/kitchen area to speak with the manager. On 06/21/2026, RI #68 was observed in another resident's room. On 06/22/2026, RI #68 was observed wandering. On 06/24/2026, RI #68 attempted to follow a visitor out of the facility's front entrance. The care plan further revealed social services added that referrals had been initiated for placement in memory-care settings due to RI #68's wandering behaviors. On 06/28/2026 at 4:29 PM, the state agency received an online Facility Report Incident (FRI) of elopement. According to the initial report, RI #68 left the facility at approximately 4:15 PM unsupervised by staff. He/She was observed on the road by staff and then driven back to the facility at approximately 5:00 PM by a staff member. Included within the facility's investigative file was a summary dated 07/02/2026 which documented: On June 28, 2026, the reported an elopement regarding RI #68. Receptionist (RCP) #2 let the resident out of the front door mistaking him/her for a visitor. The (Certified Nursing Assistant) CNA #16 who was assigned to RI #68 stated that she last saw him/her around 4:15 PM. A nurse was informed and both floors were searched for RI #68. CNA #14 got into her vehicle to search for RI #68 and he/she was located and returned to the facility. The facility substantiated that RI #68 left the facility. Included in the facility's investigative file was a handwritten witness statement dated 06/27/2026 signed by CNA #14 which documented: At approximately 4:15 PM, CNA #16 came to the third floor asking staff was RI #68 on the floor. The staff stated they had not seen RI #68 on the third floor. The nurse asked CNA #14 to go outside the building to look for him/her. CNA #14 got in her car and drove through the neighborhood and on a busy highway and observed RI #68 walking by the road. CNA #14 assisted the resident into her car, called the facility to let them know he had been found and returned him to the facility. A review of RI #48's medical record included a Nursing Note documented by Licensed Practical Nurse (LPN) #15 dated 06/27/2026 at 5:30 PM documented that RI #68 was last seen by LPN #15 at 4:15 PM when he/she asked for some water. LPN #15 documented that RI #68 was pleasantly confused and told her he/she needed to get his/her clothes for church from his/her mama's house. LPN #15 stated RI #68 began following her during medication pass. LPN #15 documented that about ten minutes later CNA #16 came and asked had she seen RI #68. The staff began searching all floors for RI #68 but could not locate him/her. LPN #15 documented that RCP #2 was asked three times if she had let anyone out the door and on third questioning RCP #2 stated she did let a person out the door. On 08/04/2026 at 3:35 PM, during an interview with CNA #14, she stated she participated in the search for RI #68. CNA #14 stated she traveled from the facility along the road the facility was on, through the community while looking for RI #68. She stated she located RI #68 approximately 1.5 miles from the facility in a parking lot area. CNA #14 stated RI #68 was walking when she located him/her, it was hot and the temperature that day was approximately 89 to 91 degrees Fahrenheit. RI #68 was wiping sweat with a hand towel and wanting water. CNA #14 stated she asked RI #68 where he/she was going and RI #68 responded going home. She stated she asked RI #68 was he/she hot and RI #68 replied yeah, I'm hot I'm about to pass out. CNA #14 transported RI #68 back to the facility in her private vehicle. CNA #14 described the roadway the facility was a very busy roadway where vehicles traveled at speeds above posted limits and that the resident would have had to walk along the side of the roadway in the grass. On 08/06/2026 during surveyor's observation of the route between the facility and the location where RI #68 was reportedly found, the route included a busy roadway with posted speed limit 40 miles per hour, portions without sidewalks, grassy roadside areas and other environmental hazards. The location where the resident was found was approximately 1.5 to 1.8 miles from the facility. Included in the facility's investigative file was a handwritten witness statement dated 06/27/2026 signed by Receptionist (RCP) #2 document: On 06/27/2026 (resident's name) RI #68 walked out of the door and I let him/her out not aware that he/she was a resident. On 08/04/2026 at 5:11 PM during an interview, RCP #2, stated her job duties included checking individuals in and out of the main entrance and opening the secure front door for guests. She stated she was to verify residents before letting them exit. RCP #2 stated RI #68 did not sign out using the kiosk and approached the front entrance and mumbled something. RCP #2 stated she told him/her to have a good day then she activated the remote control that released the secured front door and allowed RI #68 to exit the facility unaccompanied. On 08/05/2026 at 5:09 PM during a follow up interview with RCP #2, she stated that high risk residents were identified in an elopement book maintained at the receptionist desk. RCP # 2 stated staff were expected to verify residents before allowing individuals to exit the facility. RCP #2 stated she did not look in the elopement book to see if RI #68 was in the book. RCP #2 stated she did not recognize RI #68 as a resident because she had worked at the facility for only approximately one month prior to 06/27/2026. On 08/07/2026 at 6:30 PM surveyor reviewed the personnel file of RCP #2 and there was no documentation of receptionist training nor elopement training prior to 07/12/2026. Surveyor only found training for RCP #2 related to elopement as evidenced by a certificate for elopement training dated 07/12/2026. On 08/05/2026 during an interview, the Assistant Director of Nursing (ADON) stated the facility staff were aware of RI #68's wandering behavior and that the resident was listed in the facility's elopement book prior to 06/27/2026. The ADON stated RI #68 had attempted to elope on 06/24/2026. ADON stated staff repeatedly questioned RCP #2 regarding whether anyone had been allowed to exit the facility. The ADON stated RCP #2 acknowledged after the third time she allowed a person whom she believed was a visitor left through the front door. On 08/06/2026 at 6:10 PM during an interview with the Social Services Director (SSD) stated she was familiar with RI #68 and was aware of his/her wandering behavior prior to the elopement. SSD stated RI #68 would wander into other residents' rooms and that the family told her he/she wandered prior to admission to the facility. The SSD stated she advised the daughter she would make referrals for RI #68 to Memory-Care facilities due to resident's wandering and safety needs. The SSD stated the elopement could have been prevented if the receptionist was paying better attention as to who she was letting out. On 08/07/2026 at 9:07 AM during an interview the Director of Nursing (DON) confirmed that staff were aware of RI #68's wandering behavior and that reception staff were expected to identify whether a person approaching the secured entrance was a resident or a visitor before allowing the individual to exit. The DON stated the elopement could have been prevented if the receptionist had not let him/her out the facility. On 08/07/2026 at 10:35 AM during an interview, the Administrator (ADM) confirmed that on 06/27/2026 RI #68 was found off facility property near a business adjacent to a busy highway/Interstate. The ADM estimated RI #68 was outside the facility approximately 30 to 45 minutes. The ADM stated the facility did not have a wander guard system. The ADM stated the elopement could have been prevented by better screening at the receptionist desk. On 08/07/2026 at 11:45 AM during an interview with the Responsible Party (RP) of RI #68, she stated she was notified on 06/27/2026 of RI #68's elopement at approximately 4:30 PM by the SSD. The RP stated a few days prior to the elopement RI #68 was sitting in the lobby and she told the receptionist that was a dangerous place for him/her to be because someone could mistake RI #68 as a visitor. The RP stated RI #68 was residing at her residence after being discharged from the hospital. 2) A review of a facility policy titled, Accidents and Incidents with a review date of 04/2025, documented the following: . Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Review of a facility undated document titled, Lifting Machine, Using a Mechanical documented the following: . Purpose The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device . General Guidelines 1. At least (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for task that require: . b. Transferring a resident from bed to chair; c. Lateral transfers . Steps in the Procedure . 8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition. 11. Lower the sling bar closer to the resident. 12. d. Examine all hooks, clips or fasteners. e. Check the stability of the straps. f. Ensure that the sling is securely attached and sound. RI #6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Hemiplegia and Hemiparesis Following Cerebral, Infarction Affecting Right Dominant Side and, Other Chronic Pain. On 05/28/2026 he/she was given a diagnosis which included: Unspecified Fracture Of Upper End Of Right Humerus, Initial Encounter For Closed Fracture. RI #6's Quarterly MDS assessment with an ARD of 04/17/2026 indicated a BIMs score of 15 of 15 which indicated the resident had no impaired cognition. RI #6 required the assistance of two or more helpers for transfer from chair/bed-to chair under section GG. RI #6's Care Plan documented: . REQUIRES ASSISTANCE WITH ADL'S R/T CVA WITH RIGHT HEMIPLEGIA-FEBRUARY 2017 CONTRACTURE OF RIGHT UPPER & LOWER EXTREMITY date initiated 07/21/2025. Interventions. 2 PERSON ASSIST WITH MECHANICAL LIFT FOR TRANSFERS POTENTIAL FOR INJURY FALL RISK 05/28/2026- Fell: lift pad appears to have torn. Review of RI #6's progress notes dated 05/28/2026 documented by (RN) #13 . Resident was being transferred via Hoyer lift with assistance of CNA when sling pad gave way during transfer. Upon assessment resident lying on floor. Resident complains of right shoulder pain on assessment. Unable to tolerate ROM . Notified CRNP with status report received new order to x-ray right shoulder. Review of RI #6's progress notes dated 05/28/2026 documented by RN #13 . Received call from regarding x-ray Local Imaging Company, . reports resident has a right humerus fracture. received new order to send to ER for evaluation (eval) and treatment (tx) . Review of RI #6's Nurses Note dated 05/29/2026 documented by the DON . Post event note for (resident's name) RI #6 . 05/28/2026 . Fall secondary to ripped lift pad . Patient returned from (name of hospital) ED (Emergency Department) . Right arm sling in place. New order for Methocarbamol four times a day (QID) as needed (PRN) times (x)7 days and instruction to follow up with primary care provider within the week . RI #6's Diagnostic Image Report dated 05/28/2026 documented: . EXAM: RIGHT SHOULDER X-RAY SERIES HISTORY: SHOULDER PAIN . FINDINGS: There is an acute appearing, complex, dominant horizontal fracture through the proximal humeral metaphysis and nonsurgical humeral neck, with up to 1.2 centimeters (cm) impaction and up to 8 milliliters (mm) medial step-off of the distal humeral fracture moiety. Review of RI #6's Emergency Department Patient Summary documented . YOUR DIAGNOSIS Fall, 05/29/2026 Fracture of humeral head, 05/29/2026 . Humerus Fracture Treated With Immobilization . The humerus is the large bone in the upper arm. A broken (fractured) humerus is often treated by wearing a cast, splint, or sling. This holds the broken pieces in place (immobilization) so they can heal.This condition may be caused by: A fall A hard, direct hit to the arm. Review of RI #6's Fall Incident Report dated 05/28/2026 documented by RN #13 . Incident Description Resident was being transferred via Hoyer lift with assistance of CNA when sling pad gave way during transfer. Upon assessment resident lying in floor in room alert and responsive. Residents complain of right should pain on assessment. Unable to tolerate ROM. Immediate Action Taken . Nursing assessment performed. Vital signs obtained, (name of CRNP) notified of incident with new order to obtain right should x-ray . On 08/08/2026 at 4:27 PM, an interview was conducted with RI #6. RI #6 said on 05/28/2026 the CNA #12 came into the room to put him/her in bed with the Hoyer lift and the sling came loose or broke. RI #6 said he/she fell on the floor and complained of pain to his/her right arm and was sent to the hospital. RI #6 said he/she had to wear a sling to the right arm. When RI #6 was asked how many CNAs transferred him/her in the Hoyer Lift on 05/28/2026, she said it was just one CNA, but it should have been two CNAs. On 05/28/2026, a signed handwritten statement from CNA #12 documented the following: . I attempted to put him/her in bed by myself, and the Hoyer pad popped and snapped loose and broke, he/she . complained . of right arm pain . On 08/07/2026 at 12:55 PM, an interview was conducted with CNA #12, and she was asked about the incident that occurred on 05/28/2026 when using the Hoyer lift to transfer RI #6. She acknowledged that she used the Hoyer lift by herself to transfer RI #6 and while transferring the resident she heard a pop and noticed the sling/pad had ripped. CNA #12 said RI #6 complained of pain to arm and was sent out for an X-ray and the resident did have an injury to his/her arm. She said she should have waited for another CNA to assist her with the transfer using the Hoyer lift. She said that residents that require the use of Hoyer lift are a two person assist and she did not follow the facility's procedure regarding the use of Hoyer lift. When asked what was the potential harm of not following the facility's procedure using a Hoyer lift for transfer, CNA #12 said a resident could get hurt. On 05/28/2026, a signed handwritten statement from RN #13, documented the following: . I entered resident room and observed him/her on floor with CNA at side. I observed what appeared to be tear in sling fabric causing resident . to floor. Resident complained of right (r) should pain. CRNP notified . new order to x-ray (R) shoulder . On 08/08/2026 at 8:25 PM, an interview was conducted with RN #13 regarding the incident that occurred on 05/28/2026 when CNA #12 transferred RI #6 using a Hoyer lift. RN#13 said when she entered RI #6's room, she observed the resident on the floor guarding his/her right arm and the sling/pad had a tear in it. The resident complained that his/her right arm or shoulder was hurting, the CRNP was notified and an x-ray was ordered. RN #13 said the x-ray results indicated a hair line fracture of his/ her right arm and RI #6 wore a sling and had to follow up with the orthopedic doctor. RN #13 said that CNA #12 said she transferred RI #6 by herself using the Hoyer lift. RN #13 said when using a Hoyer lift there should be two staff assisting with transfer and RI #6 was care planned as a two person assist for transfers. RN #13 further said, not following the facility's procedure/policy when using a mechanical (Hoyer) lift could cause the resident to have a serious injury. On 08/08/2026 at 11:25 AM an interview was conducted with the DON regarding the incident that occurred on 05/28/2026 when CNA #12 transferred RI #6 using the Hoyer lift. The DON said she received a call from RN #13 that CNA #12 transferred RI #6 from the wheelchair to the bed and the lift pad strap had ripped, CNA #12 tried to catch RI #6 from falling but RI #6 fell on the right side of his/her arm. RI #6 complained of pain to his/her right arm and the CRNP was notified and ordered an X-Ray which showed RI #6 sustained a fracture humerus. The resident was also sent to the ER, and they did another x-ray to validate it was a fracture to the humerus. When asked how many CNA's transferred RI #6 using the Hoyer lift on 05/28/2026, she said it was one CNA #12 and according to the facility's procedure/protocol for using a Hoyer lift there should have been two CNA's/staff. The DON said the CNA should have waited until another CNA was available or asked the nurse on the unit for assistance. The DON said if staff did not follow the facility's procedure for using a Hoyer lift a resident could get injury. The DON further said that CNA #12 received a discipline action and 1 to 1 education to include return demonstration. Review of RI #12's DISCIPLINARY ACTION FORM signed and dated 05/29/2026 documented: 1st written warning . CNA #12 (employee's name) used lift by herself . Strap on Hoyer pad broke. Injury resulted 1:1 education provided . On 08/10/2026, the facility submitted an acceptable removal plan which documented: ************************************************************************************* On June 27, 2026, RI #68 eloped from the facility. RI #68 was found uninjured. RI #68 was allowed out of the facility by a PRN receptionist. The PRN Receptionist thought RI #68 was a visitor. The receptionist was not adequately following the established procedure requiring nursing verification prior to permitting a resident to exit the building. I. Immediate Corrective Action The resident was last seen at around 4:15pm. He/She was located at approximately 5pm and safely returned to the facility. The resident received a complete nursing assessment, including physical assessment, vital signs, and evaluation for injuries by ADON and RN Supervisor on 06/27/2026. The attending physician and responsible party were notified. The resident's care plan was reviewed and revised to reflect current elopement risk and additional interventions by the DON. An incident report was completed by RN assigned to RI #68, and all required regulatory notifications were made according to facility policy. ADPH, and the Ombudsman were notified. AD HOC QAPI Initiated on 06/27/26 between Administrator, Governing Body, Director of Nursing. Elopement and Screening Policy were updated and reviewed with corrections 06/27/26 by the NHA, DON, and Governing Body to indicate that all visitors (ie. Anyone without a badge) must check out using the kiosk (red wrist bands, pictures on the walls for the elopement policy) Screening policy was implemented to ensure visitors are screening in and out of the facility as well as physically opening the door before visitors' leaving the facility. 1 on 1 education to receptionist who let the resident out of the facility was conducted on 6/27/26 by Director of Nursing and Human Resources Director. Education to all receptionists and staff began 6/27/26 by HR director for the receptionists. All 4 receptionists were in-serviced on elopement policies. RN Supervisor started elopement education on 6/27/2026 with nursing. Audits on the front door, side door by bathrooms, and both dining room doors were conducted by maintenance director on 6/27/26. Debris and rust prevented the door from opening easily on 8/4/26 and was immediately fixed by the maintenance director. The nursing/ interdisciplinary team reviewed all current residents with: Elopement risk assessments. Wandering behavior. Exit-seeking behaviors. Cognitive impairment. All active residents, 60 total residents, were reviewed for elopement risk, 5 residents were deemed to be a high risk. The 5 residents identified as an elopement risk had their photo and face sheets printed and placed in elopement binders and on the wall in the reception office by the Director of Nursing. In addition, residents at high risk received a red bracelet to help make them become more identifiable. II. Education All staff received mandatory education on the updated screening and elopement policy beginning 6/27/26. This education was given by department heads to the staff including: Receptionists # 4/4 Nursing staff (RN/LPN/CNA # 24/24 Social Services # 1/1 Activities # 1/1 Therapy # 19/19 Housekeeping # 10/10 Dietary # 11/11 Administration # 8/8 Maintenance # 1/1 Education included: Elopement Prevention Policy Identifying wandering and exit-seeking behaviors/ elopement binder Proper response when a resident approaches an exit Notification process Emergency response to missing residents Screening Policy Checking in and out using the kiosk Visitor Passes (print outs) /IDs Physically opening the door to allow exit RN Nurse assessment or reports of wandering behaviors will immediately report findings to the Director of Nursing and the receptionist. The Human Resources Director was trained to train receptionists on elopement and door screening policy upon hire. III. Systemic Changes I. On 06/27/26 the facility revised on its elopement policy and its visitors/resident screening policy. The following changes were implemented: Reception staff and all personnel are prohibited from allowing any resident to leave the building without nursing approval. All new hires will be trained on the elopement policy upon hire to the facility by Human Resources or Designee. [TRUNCATED]

Based on interview, resident record review, and review of a facility policy titled Abuse Policy, the facility failed to ensure an allegation of sexual abuse was reported to the State Agency in accordance with reporting requirements after the Administrator (ADM) was informed by a local hospital of a request for a rape kit to be performed on Resident Identifier (RI) #7, a vulnerable and cognitively impaired resident, due to semen found present in RI #7's urine sample. On 02/10/2026 at 9:04 AM the State Agency received an anonymous Complaint (number 2746917) alleging Resident Identifier (RI) #7 was sent to a local hospital and semen was found in his/her urine. On 10/03/2025 the facility transferred RI #7 to a local hospital due to coughing up blood. While RI #7 was at the hospital, a routine urinalysis resulted in the abnormal presence of semen in the urine. The ADM stated he received a phone call on 10/06/2025 or 10/07/2025 from a local hospital reporting to him semen had been detected in the urine of RI #7 and a rape kit was needed. The ADM said the facility had been informed earlier on the same day, the urine sample received repeat testing and revealed no semen present in RI #7's urine. The ADM said the facility had no documented evidence of receiving the phone calls from the hospital regarding the rape kit request or the urine results indicating the presence of semen in RI #7's urine. Further review revealed there was no evidence the facility reported the allegation of RI #7 having semen in his/her urine to the State Agency after receiving the notification. This deficient practice affected RI #7 one of four residents sampled for abuse and was cited as a result of complaint number #2746917. Findings Include: A facility policy titled Abuse Policy, updated 8/2022, documented: . The following table describes the different reporting requirements.What is to be reported. All alleged violations of abuse, neglect, .When . All alleged violations- 1) Immediately but not later than 2 hours * if the alleged violation involves abuse . RI #7 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] and had diagnoses to include Parkinson's Disease, Huntington's Disease, Dementia and Schizoaffective Disorder. RI #7's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date of 07/08/2025 documented a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. RI #7's hospital history and physical dated 10/03/2025 documented: . Physical Exam . Nonverbal frail [AGE] year-old . with intellectual disability . sperm is noted to be in patient's urine have consulted case management for . possible sexual abuse . Sperm Urine 10/03/25 21:56 present abnormal . RI #7's urinalysis report with results amended on 10/07/2025, after retesting of the 10/03/2025 urine sample, documented the urine sample was negative for sperm in the urine. On 03/03/2026 at 2:35 PM the ADM was asked about RI #7's hospital visit on 10/03/2025. The ADM said, RI #7 was sent out for coughing up blood. The ADM said he received a call from the hospital and he was told a rape kit was being done and the detective in the case was referring to Department of Human Resources (DHR), and a representative from DHR had been to the facility twice to check on RI #7 since being readmitted . On 03/05/2026 at 6:15 PM in a follow up interview, the ADM was asked to provide more information about RI #7's hospital visit and the request for the rape kit to be performed. The ADM said, he became aware the rape kit was being done on 10/06/2025 or 10/07/2025 and did not remember who he had spoken to at the hospital. The ADM stated, despite the determination that the initial urinalysis was incorrect, the local police department still requested a rape kit be performed on RI #7. When asked about the protocol for reporting allegations of abuse, the ADM said abuse should be reported within a two-hour timeframe. On 03/06/2026 at 9:59 AM during another follow up interview, the ADM was asked if there was any documented evidence of the call with the hospital for what the call was about. The ADM said, no, there was not any documented evidence with the date and time when he was made aware of the rape kit request or the sperm in the urine for RI #7.

Based on interview, record review and review of a facility policy titled Accidents and Incidents - Investigating and Reporting the facility failed to thoroughly investigate the cause of a bruise observed on the left side of Resident Identifier (RI) #44's face which was observed by Licensed Practical Nurse (LPN) #10. Specifically, the facility failed to complete an incident report following an allegation of a fall reported by RI #44's family member on 02/10/2026. RI #44's family member alleged a new bruise was located on the left side of RI #44's face. This failure had the potential to affect the residents by limiting the facility's ability to evaluate the circumstances of the event and implement measures to reduce the risk of further accidents.This affected one of five residents reviewed for accidents and was cited as a result of the investigation of complaint #2747676.Findings Include: An undated policy titled Accidents and Incidents-Investigating and Reporting documented: Policy StatementAll accidents or incidents involving residents . occurring on our premises shall be investigated and reported to the Administrator.Policy Interpretation and Implementation1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place;b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.);c. The circumstances surrounding the accident or incident;d. Where the accident or incident took place;e. The name(s) of witnesses and their accounts of the accident or incident;f. The injured person's of the accident or injury; g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions'h. The date and time the injured person's family was notified and by whom;i. The condition of the injured person, including his/her vital signs;j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home;k. Any corrective action taken;l. Follow-up information;m. Other pertinent data as necessary or required; andn. The signature and title of the person completing the report.RI #44 was admitted to the facility on [DATE] and discharged on 02/10/2026.On 03/05/2026 at 11:05 AM during an interview, LPN #10 stated she had been informed that RI #44's daughter reported that RI #44 had a fall. LPN #10 said she assessed RI #44 and observed a small raised, bruised knot on the left side of his/her face, near the eyebrow. LPN #10 stated she did not complete an incident report, although one should have been complete. LPN #10 said the issue with not completing an incident report was the facility required documentation of the events that occured. On 03/05/2026 at 12:40 PM during an interview Registered Nurse/Unit Manager (RN) #7 stated that on 02/10/2026 at approximately 07:40 AM she heard RI #44's daughter screaming that RI #44 had fallen. RN #7 stated that upon assessment she noted an unraised bruise on the left side of RI #44's face. When asked whether an incident report had been completed, RN #7 stated she had not prepared one and did not find one in the medical record. RN #7 said an incident report should have been completed and the concern of not completing an incident report was that documentation was needed for follow up, identifying the root cause and implementing preventive measures.On 03/05/2026 at 3:20 PM during an interview the Director of Nursing (DON) said RI #44's daughter had made her aware of an unwitnessed fall involving RI #44. She said RI #44 had a bruise on his/her left cheek which could have resulted from hitting the side rail. The DON further stated that RI #44's daughter was adamant that RI #44 had experienced a fall and requested that he/she be taken to the hospital for evaluation. When questioned regarding the existence of an incident report, she indicated that interviews had been conducted with RN #4 and Certified Nursing Assistant (CNA) #15, and no one had claimed to have seen the resident on the floor or to have assisted him/her back to bed; however, she was uncertain if an incident report had been completed. The DON explained that the person who received the report of the fall would have been responsible for completing the incident report. She said the concern of not completing an incident report would be not doing a complete investigation. A review of signed witness statements dated 02/10/2026 provided by the facility documented RN #4 and CNA #15 did not witness RI #44 fall.On 03/05/2026 at 4:01 PM, the Assistant Director of Nursing (ADON) reported she was informed on 02/10/2026 of an unwitnessed fall involving RI #44. The ADON said she assessed the resident who appeared confused, lethargic, and expressed a reluctance to go to the hospital. The ADON said the daughter of RI #44 insisted on the resident being taken to the hospital. She described a light purple bruise extending from the resident's cheek to the eyebrow on the left side of his/her face. The ADON stated she contacted the Nurse Practitioner (NP) who gave an order to transport RI #44 to the hospital. The ADON said that an incident report should have been completed and that she would have been responsible for its completion. The ADON stated she did not complete the incident report. When questioned about the concern of not filing an incident report, she said the resident could have sustained an internal injury.On 03/05/2026 at 4:44 PM the Administrator (ADM) was asked about his knowledge of an unwitnessed fall involving RI #44. The ADM indicated he had been informed of a bruise located on the left side of RI #44's face. He said he observed the bruise, describing its color as light blue, extending from the cheekbone to the midpoint of the eye. The ADM reported that RI #44's daughter, the DON, and the ADON, had communicated that RI #44 had experienced a fall. The ADM stated that in accordance with policy an incident report should have been completed, and the failure to complete such a report was a concern due to not following facility policy.

Based on interview, record review and review of facility policies titled Administering Medications and Controlled Substances, the facility failed to ensure controlled medications were were handled and documented as required including the recording of controlled medications on the Medication Administration Record (MAR) after controlled medications were administered to Resident Identifier (RI) #65, one of one resident reviewed for the accurate account of controlled medications.Specifically, RI #65's controlled substance inventory record documented Lorazepam and Morphine were given on 01/29/2026 and 01/30/2026; review of RI #65's MAR revealed no evidence the medications were administered to RI #65. This failure had the potential to affect the RI #65 by limiting the facility's ability to ensure accurate controlled medication administration, record keeping, and monitoring.This was cited as a result of the investigation of complaint #2786698. Findings include:A facility policy titled: Controlled SubstancesPolicy Statement The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. l. Signature of nurse administering medication.A facility policy titled Administering Medications. Policy StatementMedications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .12. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones RI #65 was originally admitted to the facility on [DATE] and had diagnoses that included Senile Degeneration of the Brain, Acute Respiratory Failure with Hypoxia, Acute Ischemic Heart Disease, and Sepsis. RI #65 was admitted to hospice on 02/13/2025.RI #65's Controlled Substance Inventory Record (CSIR) documented Licensed Practical Nurse (LPN) #3 signed out for Lorazepam and Morphine; two doses of each on 01/29/2026 and three doses of each 01/30/2026.RI #65's January 2026 MAR documented LPN #3 failed to record administration of Lorazepam and Morphine to RI #65 for two doses each day, of each controlled medication, on 01/29/2026 and 01/30/2026. On 03/05/2026 at 3:29 PM during an interview LPN #3 stated she administered Morphine and Lorazepam to RI #65 but could not remember the exact frequency. LPN #3 stated she documented the administration Morphine and Lorazepam on the MAR approximately 85 percent of the time. LPN #3 said that if the medication was documented on the controlled substance sheet but not on the MAR it would be incomplete documentation.On 03/05/2026 at 12:38 PM the Assistant Director of Nursing (ADON) said staff should record PRN medications on the MAR as well as on the controlled substance narcotic sign-out sheet. Upon reviewing the MAR and the controlled substance sheet, the ADON said there was no documentation on the MAR for the administration of Lorazepam and Morphine on 01/29/2026, at 12:20 and 15:20. The ADON said that on 01/30/2026 Lorazepam and Morphine were signed out on the controlled substance sheet at 10:15 and 13:15, yet there was no documentation on the MAR. The ADON said the facility process required staff to document the administration of a PRN controlled substance on both the MAR and the narcotic sign-out sheet.

Based on observations, interviews and review of facility policies titled, DATING AND LABELING POLICY, COMPLETING LOGS POLICY, and DISH WASHING AND POT WASHING, the failed to ensure:1) food items in dry storage and the freezer were dated and labeled,2) a styrofoam cup was not left in the flour bin,3) the freezer temperatures for the evening shift were recorded on 09/04/2025, 09/05/2025, and 09/06/2025 and;4) plates were free of food debris on the tray line.This had the potential to affect 54 of 55 residents who receive meals from the kitchen. Findings Include: 1) Review of an undated policy titled, DATING AND LABELING POLICY revealed: Policy: All foods are to be labeled and dated appropriately to ensure food safety regulations are followed. Procedure: 1. Upon receiving and storing all items must be labeled with the name of food and receive date. On 09/07/2025 at 2:46 PM, the surveyor toured the dry storage area and the freezer with [NAME] #1. The surveyor observed a ten-pound bag of spaghetti, enriched macaroni and raisin bran cereals with no open and no use by date in dry storage. The surveyor observed in the freezer two bags of peppers and onions opened with no open and use by date. On 09/10/2025 at 8:44 AM, an interview was conducted with [NAME] #1. [NAME] #1 stated that there were several items in dry storage and in the freezer that did not have an open and use by date. The items include spaghetti, macaroni noodles, raisin bran cereal and peppers and onions in the freezer. [NAME] #1 stated that the items were opened by someone and improperly stored. [NAME] #1 stated that items should be labeled and dated as soon as they are used and before storing them. According to [NAME] #1, the label should contain the name of the items, the open date, the use by date and the person's initial. The [NAME] #1 stated that whoever opened the product was responsible for labeling and dating it. [NAME] #1 stated that the facility's policy on labeling was soon as the product was opened date, label and store it. The cook stated that it was important that food items are dated and labeled because they would need to know the expiration date. On 09/10/2025 at 9:12 AM, an interview was conducted with the Food Service Director (FSD). She stated that it was important that foods are labeled to ensure quality and to make sure no bacteria or hazardous things grow on it. The FDS stated that the facility's policy was to date and labeled everything opened and everyone in the kitchen was responsible for labeling. 2) On 09/07/2025 at 2:46 PM the surveyor along with [NAME] #1 observed a styrofoam cup on top of the flour in the flour bin. On 09/10/2025 at 8:51 AM an interview was conducted with [NAME] #1. He stated that a white 16 ounces cup was in the flour bin. [NAME] #1 stated that it was used for scoping flour. [NAME] #1 stated that the facility's policy states that nothing should be in the flour bin. [NAME] #1 stated that every cook was responsible for making sure nothing was in the flour bin. According to [NAME] #1, dipping items for the flour should be washed, cleaned, sanitized and stored after use. The [NAME] #1 stated that cups should not be left in the flour bin to prevent cross contamination. On 09/10/2025 at 9:15 AM, an interview was conducted with the FSD. The FSD stated nothing should be in the flour bin but flour. She stated that it was important that cups were not left in the flour bin to ensure no contamination of he flour. 3) Review of an undated policy titled, COMPLETING LOGS POLICY, revealed: Policy: To accurately and effectively track and recording temperatures . Procedure 1. Refrigerator temperatures are to be taken by the opening and closing cooks. All temps should be logged . Review of a facility document titled, FREEZER TEMPERATURE RECORD . dated Sept (September) 2025. There were no dates logged for 09/04/2025, 09/05/2025 and 09/06/2025. On 09/07/2025 at 2:46 PM, the surveyor observed no recorded temperatures for the evening shift on 9/04/2025, 09/05/2025 and 09/06/2025. On 09/10/2025 at 9:08 AM, an interview was conducted with [NAME] #1. [NAME] #1 stated there was no recorded temperature for 09/04/2025, 09/05/2025 and 09/06/2025. Cook #1 stated that the morning temperature was recorded and not the evening. [NAME] #1 was asked what the facility policy was on documenting on the temperature log. He stated that all temperatures must be recorded twice daily in the morning and evening before going home. The [NAME] stated that the temperatures should be documented to prevent food from spoiling, and to let them (kitchen staff) know the equipment was cooling properly. On 09/10/2025 at 9:24 AM an interview was conducted with the FSD. She stated that temperatures should be recorded on the freezer log in the morning and evening. The cook should record the temperatures on the freezer log to ensure the temperature was in range to keep the food safe. 4) Review of an undated policy titled, DISH WASHING AND POT WASHING . revealed: .v Dishwasher Operation: . Inspecting items. Check items as they come out of the machine and put through again if not clean. On 09/09/2025 at 10:32 AM, the surveyor observed [NAME] #2 pull four dirty plates off the food line and served food in three of those four dirty plates. The surveyor observed black spots in three plates. On 09/10/2025 at 9:05 AM, an interview was conducted with [NAME] #2. She was asked what was in the plates that was pulled from the tray line, and she stated something was on them, they were not clean. She stated she had no idea why food debris was in the plates. According to [NAME] #2, whoever washed the dishes was responsible for clean plates at the tray line. [NAME] #2 stated that the facility policy on dirty plates was to remove them from the tray line and [NAME] # 2 said she put food of 2 dirty plates that were removed from the tray line. On 09/10/2025 at 9:21 AM, an interview was conducted with the FSD. She was asked what she saw in plates pulled from the tray line. She stated stains and food debris. According to the FSD, the plates were not inspected properly after cleaning. She stated that it was important that plates were clean at the tray line to ensure no contamination or bacteria was transferred to the residents.

Based on observation, interviews and a review of a facility policy titled GARBAGE AND TRASH DISPOSAL POLICY, the facility failed to ensure the door of the trash dumpster on the front side was closed. This had the potential to affect 55 of 55 residents who reside at the facility. Findings Include: Review of an undated facility policy titled GARBABE AND TRASH DISPOSAL POLICY revealed: PURPOSE: To educate all new hires and current employees on the proper procedures for garbage and trash disposal. PROPER GARBAGE AND TRASH DISPOSAL: . Dumpsters should be properly maintained: Dumpster door . must be closed at all times when not in use. On 09/07/2025 at 3:01 PM, the surveyor and the evening [NAME] #1 toured the dumpster area. The dumpster door was opened on the front side. On 09/10/2025 at 8:57 AM, an interview was conducted with [NAME] #1. [NAME] #1 stated that the dumpster door was opened. He stated that someone did not close the dumpster. According to [NAME] #1, everyone was responsible for keeping the dumpster door closed. [NAME] #1 stated that the dumpster door should be closed because of rodents and odors. [NAME] #1 stated that the facility's policy states that the dumpster should be closed at all times. According to [NAME] #1, everyone in the facility could be affected by the dumpster doors being left open because of food and trash. On 9/10/2025 at 9:18 AM, an interview was conducted with the FSD. The FSD stated that the dumpster should be closed at all times unless it was in use. She stated the person who was using the dumpster was responsible for keeping it closed. According to the FSD, the dumpster doors should be closed to ensure animals do not enter and for safety reasons.

Based on observations, interviews, medical record review and facility policies titled, Oxygen Administration and Oxygen Tubing and (&) Humidification Change Policy, the facility failed to ensure Resident Identifier (RI) #'s 9, #15, #42 and #54 Oxygen (O2) tubing was labeled/dated. The facility further failed to ensure RI #42 and RI #54's O2 concentrator water bottle was not empty during the administration of oxygen on 09/07/2025.This deficient practice affected RI #9, RI #15, RI #42 and RI #54 four of four residents sampled for respiratory care. Findings Include: Review of a facility policy titled, Oxygen Administration with a revision date of 2010, revealed: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps in the Procedure 12. Check the mask . humidifying jar, . to be sure they are in good working order . Be sure there is water in the humidifier . and the water level is high enough that the water bubbles as oxygen flows through. Review of a facility undated policy titled, Oxygen Tubing (And) & Humidification Change Policy, revealed: Purpose: To ensure the health, safety, and comfort of resident by maintaining clean and functioning respiratory equipment. Policy Details: 1. Tube Change: weekly -All respiratory tubing (including oxygen tubing, .) must be changed at least once a week . 2. Humidifier Change: -Humidifier water chambers and reservoirs must be emptied, cleaned, and refilled with sterile or distilled water at least once a week. 3. Procedure: - Staff must follow . instructions for cleaning and replacing tubing and humidifiers. RI #54 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis of Acute Respiratory Failure with Hypoxia. RI #54's Physician Orders for September 2025 revealed: Oxygen (O2) at @2L (liters)/NC (nasal cannula) AS NEEDED TO KEEP O2 SAT >90% as needed . Change O2 supplies included O2 tubing and humified water bottle. Label tubing and water bottle with date . On 09/07/2025 at 4:54 PM, the surveyor observed RI #54 lying in bed. RI #54's O2 machine was on but RI #54 was not wearing his/her oxygen mask. The surveyor observed no label/date on RI #54's oxygen tubing and no water in the humidifier. On 09/07/2025 at 5:40 PM an interview was conducted with the Assistant Director of Nurses (ADON). The ADON said RI #54's oxygen tubing was not labeled/dated but should have been labeled and dated. She said the night nurse was responsible for ensuring the oxygen tubing was labeled/dated. The ADON said the nurse should place her initials and date on the tubing, so the nursing staff would know when the oxygen tubing was changed. The ADON further said the humidifier bottle should be changed when ran out. RI #42 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure with Hypoxia. RI #42's Physician Orders for September 2025 revealed: Oxygen @2L PER N/C continuous for Shortness of Breath (SOB) and to keep sat>90% every shift, change O2 supplies including O2 tubing and humidified water bottle. Label tubing and water bottle with date . every night shift every Sunday (Sun) . On 09/07/2025 at 5:12 PM, the Surveyor observed resident with O2 on infusing per nasal cannula, there was no date on the oxygen tubing and no water in the humidifier/water bottle. On 09/07/2025 at 5:48 PM an interview was conducted with the ADON. The ADON stated RI # 42's oxygen tubing was not labeled/dated and there was no water was in the humidifier/water bottle. When asked what was the importance of ensuring the oxygen tubing was labeled and dated, she said the oxygen tubing expires every 7 days. The ADON further stated it was important to ensure the humidifier/water bottle was filled, because it keeps the nasal cavity moist; when there was no water in the humidifier it would dry the resident's nose. RI #9 was admitted to the facility on [DATE] with diagnosis of Chronic Respiratory Failure with Hypercapnia. Resident was readmitted to the facility on [DATE] with diagnoses to include Acute and Chronic Respiratory Failure with Hypoxia and Obstructive Sleep Apnea. A review of RI #9's Physician Order Report dated 07/21/2025, revealed an order to Clean O2 concentrator filter every night shift every Sun . Change oxygen tubing and canister every night shift every Sun. Change oxygen tubing and canister as needed. Oxygen at 2 Liters/minute Via: NC every shift. A review of RI #9's Physician Order Report dated 07/21/2025 revealed: BIPap with pressure settings12/6 as needed for during the day while napping. BIPap with pressure settings 12/6 at bedtime related to CHRONIC RESPIRATORY FAILURE WITH HYPERCAPNIA, OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC). A review of RI #9's Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) 08/27/2025 Section O indicated oxygen therapy and Noninvasive mechanical ventilator (BIPAP). On 09/07/202 at 4:00 PM, the surveyor observed RI #9 lying in bed. RI #9's oxygen was infusing via nasal cannula. There was no label nor date on the oxygen tubing nor humidified water bottle. The BIPAP mask was not labeled nor dated. On 09/07/2025 at 5:54 PM an interview was conducted with Licensed Practical Nurse (LPN) #12. LPN #12 escorted the surveyor to RI #9's room. The surveyor asked LPN #12 what she observed with RI #9's oxygen tubing and she stated it was not dated. Surveyor asked LPN #12 should the CPAP mask be covered and she stated yes it should be. LPN #12 stated that oxygen/nebulizer tubing and masks should be changed weekly. When asked the concern of the tubing not being changed and dated LPN #12 stated staff would not know when the tubing was changed and its a risk for infection. RI #15 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia and Sleep Deprivation. Resident was readmitted to the facility on [DATE]. A review of RI #15's Physician Order Summary Report dated 03/18/2025, revealed Continuous oxygen @2 L per NC A review of RI #15's Physician Order Summary Report dated 03/21/2025, revealed an order to Clean O2 concentrator and filters every night shift every Sun .Change O2 supplies including 02 tubing and humidified water bottle .Label tubing and water bottle with date. Apply ear protectors as resident will allow every night shift every Sun related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA (J96.11). On 09/07/2025 at 6:05 PM, surveyor observed RI #15 lying in bed. RI #15's oxygen was infusing via nasal cannula. There was no label nor date on the oxygen tubing nor humidified water bottle. On 09/09/2025 at 11:40 AM surveyor made an observation in RI #15's room and noted the oxygen tubing lying on the bedside table uncovered. On 09/09/2025 at 11:45 AM an interview was conducted with LPN #13 after escorting to RI #15's room. The Surveyor showed LPN #13 the oxygen tubing on the bedside table disconnected from the water bottle. When asked if the tubing should be disconnected, LPN #13 stated the tubing should not be disconnected from the water bottle or on this bedside table. She stated that the tubing should be in a plastic bag to protect from germs and bacteria. On 09/09/2025 at 3:56 PM Certified Nursing Assistant (CNA #14) was asked if a resident on oxygen or nebulizer with the mask not in use, where should the tubing be placed, and she stated it should be in a plastic bag with the date on it. On 09/11/2025 at 4:00 PM an interview was conducted with the Director of Nursing (DON). She was given the facility policy to review and was asked according to the oxygen tubing and Humidification Change Policy how often tubing was to be changed. She stated weekly and as needed should it appear damaged. The DON stated humidifier bottles and nebulizer masks should be changed weekly, labeled with name of resident with date and initials of person who changed it. The DON stated the RN or LPN changes the oxygen /nebulizer tubing/masks every Sunday on night shift and the change should be documented on the Medication Administration Record (MAR). The DON was asked why RI #9 and RI #15's oxygen tubing was not labeled on 09/07/2025 during the initial tour. The DON stated a staff nurse did not follow policy to label the tubing on 08/31/2025 even though it was documented on the MAR. The DON stated that oxygen tubing/nebulizer masks should be stored in a zip lock or plastic bag to help prevent infection and contamination. The DON stated it was important to date oxygen tubing/ humidifier bottles/masks to verify that it has been changed and to prevent risk of infection.

Based on interviews, resident record review, review of a Facility Reported Incident (FRI), review of the facility investigative file, and review of a facility policy titled Accidents and Incidents, the facility failed to ensure Certified Nursing Assistant (CNA) #5 immediately reported an incident/accident to licensed nurses on 09/05/2025 when Resident Identifier (RI) #20 voiced discomfort during care and told CNA #5 someone ran over his/her foot with a wheelchair. CNA #5 failed to report to anyone RI #20's voiced discomfort and observed swelling to RI #20's foot. The incident/accident was not reported or investigated until 09/09/2025 when RI #20 was observed with bruising and swelling to the right knee and leg and x-ray results revealed an acute proximal tibia fracture. This deficient practice affected RI #20 one of two residents sampled for accidents and had the potential to result in delayed assessment and treatment. Findings Include: On 09/09/2025 the State Agency received a FRI from the facility alleging an injury of unknown origin was identified on 09/09/2025 at 8:33 AM when CNAs were bathing RI #20 and noticed bruising and swelling to the right knee and leg and called for the Director of Nursing (DON) and Assistant DON to come to the shower to observe the swollen knee and leg; upon x-ray a fractured proximal tibia was revealed; the doctor was notified and RI #20 was sent to the hospital. A facility policy titled Accidents and Incidents-Investigating and Reporting with a revision date of 2017 documented:Policy StatementAll accidents or incidents involving residents . shall be investigated and reported to the administrator. Policy Interpretation and Implementation 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the report of incident/accident form:a. The date and time the accident or incident took place;b. The nature of the injury/illness . c. The circumstances surrounding the accident or incident;d. Where the accident or incident took place; . RI #20 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Heart Failure, and a History of Pain in the Right Knee. RI #20's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/28/2025 documented a Brief Interview for Mental Status (BIMS) score one which indicated severe cognitive impairment. The facility investigative file for the FRI included RI #20's mobile imaging x-ray results with a date of service of 09/09/2025 and a conclusion of an acute proximal tibia fracture. The facility investigative file for the FRI included an undated summary of the incident signed by the Administrator which documented: . On 09/09/2025 a CNA bathing (RI #20) noticed bruising and swelling to (RI #20's) right knee and leg. x-rays were ordered . results confirmed a fracture to the . tibia. (RI #20) told 2 different sets of events. The first event . stated (he/she) fell, . The second event was when someone ran over (his/her) foot with the wheelchair. We interviewed staff, and on 09/05/25 a CNA reported some swelling but no bruising. She did not report this to the nurse . we are substantiating an injury of unknown origin.The investigative file contained a handwritten witness statement for CNA #5 on a facility document titled Staff Interview Questions dated 09/10/2025 signed by the DON as the interviewer. The statement documented the following: . 1. Have you noticed swelling or bruising to (RI #20's) leg? (RI #20) had a little swelling on Friday (9/5/2025) . 4. Has (RI #20) ever said Ouch or given any indication of pain . in the last 2 weeks? Yes. On Friday (he/she) said someone rolled over (his/her) foot with a wheelchair.On 9/11/2025 at 10:22 AM CNA #5 was asked to review her witness statement and she agreed that was her statement regarding RI #20. CNA #5 said, the last time she worked with RI #20 was on 09/05/2025 when RI #20 told her someone had ran over his/her foot with a wheelchair. CNA #5 said, she was putting a sock on RI #20 when RI #20 said, ouch, and that someone had ran over his/her foot with a wheelchair. CNA #5 said, she observed minimal swelling on RI #20's foot with no bruising. CNA #5 stated, she did not report this incident to anyone because RI #20 did not identify who had run over his/her foot, or when it occurred, and RI #20 described it as an accident. When asked if this incident should have been reported, CNA #5 said, it should have been reported due to RI #20's claim that his/her foot had been run over and reported pain when his/her foot was touched. CNA #5 said, the importance of reporting the incident was to ensure everyone was informed and RI #20 received appropriate care.Review of RI #20's medical record revealed a Weekly Body Audit form dated 09/03/2025, electronically signed by the DON, indicating no new skin alteration was identified. On 09/11/2025 at 12:05 Licensed Practical Nurse (LPN) #6 who worked on 09/05/2025 from 2:00 PM to 10:00 PM indicated that throughout her shift there were no reports of anyone having run over RI #20's foot with a wheelchair. LPN #6 said, if RI #20 had informed a CNA it should have been communicated to either herself or the supervisor. LPN #6 said, had this been reported to her she would have notified the supervisor and assessed the resident. LPN #6 said, it was important to ensure the resident received appropriate care. On 09/11/2025 at 12:39 PM LPN #7 was asked about the incident involving RI #20. LPN #7 stated she became aware of the injury of unknown origin on 09/09/25 when RI #20 was being transported to the shower room. LPN #7 said she observed swelling and discoloration on RI #20's leg. LPN #7 said that no CNA had reported to her that RI #20's foot had been run over by a wheelchair or that he/she had fallen. LPN #7 said, if a resident told a CNA someone ran over their foot with a wheelchair or they saw swelling, it should have been reported it to the nurse or supervisor. LPN #7 said this was important to ensure no delay in care.On 09/11/2025 at 12:49 PM Registered Nurse Supervisor (RNS) #8 was questioned regarding the incident involving RI #20. RNS #8 indicated she worked on 09/05/2025 from 2:00 PM to 10:00 PM, on 9/6/2025 from 2:00 PM to 10:00 PM, and from 10:00 PM to 6:00 AM on 9/7/2025. RNS #8 reported that during her shifts she saw RI #20 in his/her wheelchair. RNS #8 said, no staff members informed her of any pain experienced by RI #20 on either 09/05/2025 or 09/06/2025. The RNS stated that if staff had reported an incident concerning RI #20, she would have assessed the resident, checked for pain, and notified the Doctor and Director of Nursing (DON). RNS #8 stated, if an incident was not reported, it could result in a more serious issue and a delay in treatment.On 09/11/2025 at 1:17 PM the RN Unit Manager (RNUM) #9 was questioned regarding an incident involving RI #20. The RNUM confirmed she worked on 09/05/2025 from 9:00 AM to 2:00 PM. RNUM #9 stated, no staff members reported to her that RI #20 said someone had run over his/her foot with a wheelchair which resulted in swelling and had such a report been made she would have assessed the resident, prepared an incident report, notified the administrator and DON, and contacted the Medical Director (MD). RNUM #9 said the significance of reporting this incident would be to determine the extent of the injury, understand what transpired, and provide treatment as necessary to avoid any delays in care. The RNUM noted that during her shift on 09/05/2025 RI #20 did not report any pain. On 09/11/2025 at 4:51 the Certified Registered Nurse Practitioner (CRNP) was questioned regarding the incident involving RI #20. The CRNP indicated she first became aware of the incident concerning RI #20 on 09/09/2025 when she received a call reporting bruising, swelling, and an x-ray revealed a fracture. The CRNP said she wrote an order for RI #20 to be sent out for an evaluation. The CRNP stated she had not been informed on 09/05/2025 about any swelling or pain related to RI #20. The CRNP said, if a resident had reported on 09/05/2025 that someone had run over their foot with a wheelchair and swelling was observed she would expect the facility to conduct an x-ray and inform her of the results. On 09/11/2025 at 10:00 AM the DON was asked when she became aware of RI #20's injury. The DON said, the morning of 09/09/2025, the x-ray was done at the facility at 10:00 until 10:40 AM; the results were reported at 1:30 showing a broken tibia; and she informed the doctor. The DON said, RI #20 told them someone ran over his/her foot with a wheelchair. The DON said, during the facility investigation CNA #5 reported RI #20's leg was swollen on 09/05/2025.This citation was written as a result of Incident #2612850.

Based on interviews, resident record review, and facility policies titled Pain Assessment and Management and Administering Pain Medications, the facility failed to ensure Licensed Practical Nurse (LPN) #6 conducted a pain assessment to include the location of pain or other pain characteristics prior to administering as needed (PRN) pain medication to Resident Identifier (RI) #20 on 09/03/2025. This deficient practice had the potential to result in inadequate evaluation of the resident's pain and inappropriate treatment and affected RI #20 one of two resident sampled for pain. Findings Include:A facility policy titled Pain Assessment and Management with revision date of October 2022 documented: PurposeThe purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of pain;e. Developing and implementing approaches to pain management;f. Identifying and using specific strategies for different levels and sources of pain;g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary.Assessing Pain4. Assess pain using a consistent approach .5. During the pain assessment gather the following information .c. Characteristics of pain:(1) Location of pain;(2) Intensity of pain .(3) Characteristics of pain (. aching, burning, crushing, numbness, burning .);(4) Pattern of pain (. constant or intermittent);(5) Frequency, timing, and duration of pain; . A policy titled Administering Pain Medications with a revision date of October 2022 documented: PurposeThe purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication.Steps in the Procedure1. Provide for resident privacy.2. Explain the purpose of the assessment to the resident.3. Conduct a pain assessment as indicated.4. Conduct an abbreviated pain assessment if there has been no change of condition . The assessment shall consist of at least the following components:a. Whether pain has improved or worsened since the last assessment;b. The general condition of the resident;c. Verbal and non-verbal signs of pain;d. Level of consciousness; ande. Evidence or reports of adverse consequences related to medications.9. Re-evaluate the resident's level of pain 30-60 minutes after administering.DocumentationDocument the following in the resident's medical record: 1. Results of the pain assessment; 2. Medication; 3. Dose; 4. Route of administration; and 5. Results of the medication (adverse or desired). RI #20 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Heart Failure and Essential Hypertension. RI #20's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/28/2025 documented a Brief Interview for Mental Status (BIMS) score of one which indicated severe cognitive impairment. A review of RI #20's care plan documented a potential for pain. Interventions included to administer medication as ordered and assess for effectiveness of medication and document. RI #20's Medication Administration Record (MAR) dated September 2025 documented RI #20 received 500 milligrams (MG) of PRN acetaminophen on 09/03/2025. The MAR indicated the PRN pain medication was effective.On 09/11/2025 at 6:01 PM an interview was conducted with Licensed Practical Nurse (LPN) #6. During this interview LPN #6 was questioned regarding the administration of PRN pain medication given to RI #20 on 09/03/2025. LPN #6 said RI #20 had expressed discomfort due to knee and back pain. When asked whether she had recorded RI #20's pain level before giving the pain medication LPN #6 indicated that she could not remember if such documentation had been made prior to the medication's administration. LPN #6 said, she believed that the pain level was no greater than three otherwise she would have contacted the medical doctor. LPN #6 said, she could have documented in a progress note but if it was not in the record, she did not document an assessment. LPN #6 said, she did not see the need to document the assessment because she thought RI #20 was fine after receiving the acetaminophen. On 09/11/2025 at 4:51 PM the Certified Registered Nurse Practitioner (CRNP) was questioned regarding RI #20 receiving PRN pain medication. The CRNP stated, when PRN pain medication was administered the nurse should evaluate the pain level using a scale from 1 to 10, and then reassess the pain after 30 minutes of medication administration. The CRNP indicated she would expect the nurse to record the pain level. The CRNP said it would be important to determine the pain level to see if the medication was working and if further assessment was needed.On 09/11/2025 at 5:20 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON was asked whether the nurse had performed a pain assessment before administering RI #20 pain medication on 09/03/2025. The DON stated there was not any documentation in the medical record confirming that a pain assessment had been conducted. Furthermore, the DON stated the LPN should have been aware of the necessity to carry out the pain assessment prior to administering the pain medication. The DON said the significance of performing a pain assessment before the administration of pain medication was to evaluate its effectiveness and to ascertain whether the pain was a new occurrence or a chronic issue. Additionally, the DON said, RI #20 was prescribed pain medication due to a history of surgeries on the right knee, right ankle, and right hip. When questioned about how nurses would assess pain in residents with dementia, she explained that the assessment would encompass observations of breathing patterns, negative vocalizations, facial expressions, body language, and the ability to be consoled. This citation was written as a result of Incident #2612850.

Number of residents sampled:Number of residents cited Based on observations and interviews the facility failed to ensure the most recent Survey Results were readily accessible and visible for residents and visitors to review. Further, on 09/09/2025 during resident council, 10 out of 10 residents were not aware of how to access the Survey Results. The surveyor observed no Survey Results book in the front lobby area, or on the units on four out of the five days of survey. This deficient practice had the potential to affect 55 out of 55 residents residing in the facility and any visitor. Findings Include: Upon entering the facility on 09/07/2025 at 2:00 PM, the surveyor observed there were not any Survey Results posted, visible, or accessible in the lobby area for residents and visitors. On 09/07/2025 at 3:00 PM, the surveyor observed the bulletin board on the main hallway with postings of Resident Rights information, Grievance Forms and instructions, Ombudsman contact name and number, and a sign above the Grievance Forms that documented: Most recent results are available for your review and can be found in the front lobby . On 09/08/2025 at 8:27 AM and at 6:33 PM, the surveyor observed there were not any Survey Results posted in a visible area in the lobby area for residents and visitors. On 09/09/2025 at 2:00 PM a Resident Council meeting was held, and 10 out of 10 residents were unaware of where to access the Survey Results book. On 09/09/2025 at 9:04 AM and at 3:30 PM the surveyor observed both halls of the facility and there were no Survey Results posted or visible on either hall. On 09/10/2025 8:38 AM, the surveyor observed there were not any Survey Results posted in a visible area in the lobby area for residents and visitors. On 09/10/2025 at 9:05 AM an interview was conducted with the Social Services Director (SSD) about Survey Results postings. The SSD said the Survey Results were posted for families and residents to view and were kept in the front lobby. The surveyor and SSD walked to the front lobby for observation of the Survey book, and the SSD said it was supposed to be in the lobby. When asked why the book was not in the lobby, the SSD said, it should be and it must have been moved. The SSD said, it was important to have the Survey Results book accessible for residents and families to view.

Based on interviews, resident record review, the facility investigative file, and a facility policy titled, Abuse Policy, the facility failed to protect the resident's right to be free from physical abuse on 04/30/2025 when Resident Identifier (RI) #2 hit RI #21. The facility's staff failed to supervise RI #2 and intervene to prevent the incident. RI #2 had a history of verbal and physical behaviors. RI #2 was observed irritable, cursing, and upset as staff were attempting to take RI #2 to his/her bed. The Certified Nursing Assistant (CNA) left RI #2 at his/her doorway and another CNA witnessed RI #2 hit RI #21 on the arm. Staff said someone in that situation being hit would feel shocked. This deficient practice affected RI #21 one of three residents sampled for abuse and was cited as a result of the investigation of complaint/report number AL00051090. Findings include: On 04/30/2025 at 3:58 PM the State Agency received a Facility Reported Incident (FRI) alleging RI #2 hit RI #21 with a closed fist and cursed RI #21. RI #21 had no injury, the residents were separated, RI #2 was sent out to the emergency department, and notifications were made to Resident Representatives and doctor. Review of the facility's abuse policy titled Abuse Policy, updated 08/2022 revealed the following: Our residents have the right to be free from abuse . Policy Interpretation and Implementation Definitions To help with recognition of incidents of abuse, the following definitions of abuse are provided: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Prevention . 1. The facility's goal is to achieve and maintain an abuse-free environment. 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: 3. Training all staff . how to resolve conflicts appropriately; . 9. Training staff to understand and manage a resident's verbal or physical aggression; . 12. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; . 13. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; . The facility's investigative file contained a summary of the incident involving RI #2 and RI #21 signed by the Administrator (ADM) that documented: . Knollwood Healthcare reported an allegation of residents on resident abuse April 30, 2025. Statements gathered from the staff involved reported that they were trying to persuade (RI #2) to go to bed or lay down; (he/she) had said no several times, and they backed away. They brought (him/her) to (his/her) room, as they were rolling up to (his/her) room, (his/her) roommate (RI #21) was leaving (his/her) room. (RI #21) came out of the room trying to get by when (RI #2) hit (him/her). the facility will substantiate resident on resident abuse . RI #2 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include: Severe Intellectual Disabilities and Anxiety Disorder. RI #2's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/08/2025 documented a Brief Interview for Mental Status (BIMS) score of zero of 15, which indicated severely impaired cognition. RI #2's care plans were reviewed and included a plan of care initiated on 03/03/2020 with a revision date of 02/25/2025 addressing focus areas of verbal and physical behaviors such as: speech was usually unclear garbled unless he/she was cursing, was easily agitated, and history of combative behaviors; and a plan of care initiated on 05/13/2024 addressing focus areas of mood and behaviors including physically and verbally aggressive, verbal outbursts and fist shaking at staff to indicate he/she is upset. RI #2's care plans did not include any direction to staff regarding the level of supervision needed to keep other residents safe until after the incident on 04/30/2025. RI #21 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include: Adjustment Disorder with Depressed Mood, Vascular Dementia, and Major Depressive Disorder. RI #21's annual MDS assessment with an ARD of 03/04/2025 documented a BIMS score of 15 of 15, which indicated no impaired cognition. On 05/20/2025 at 3:44 PM RI #21 was asked about the incident on 04/30/2025 and RI #21 stated, he/she was trying to go out of the room and RI #2 started swinging at him/her and RI #21 put up his/her hand to block RI #2 from hitting him/her. RI #21 said, RI #2 hit him/her on the wrist. RI #21 stated, he/she was not hurt. RI #21 stated, RI #2 had fits when staff try to put RI #2 in the bed. On 05/21/2025 at 8:20 AM CNA #4, who was working at the time of the incident, was asked about the incident involving RI #2 and RI #21. CNA #4 recalled she pushed RI #2 to his/her room and RI #2 did not want to go to bed. CNA #4 said, she left the resident in front of the door and went to tell the nurse that RI #2 did not want to go to bed. CNA #4 said, when she returned to RI #2's room, CNA #5 told her RI #2 hit RI #21. On 05/21/2025 at 9:55 AM, a phone interview was conducted with CNA #5 who witnessed the incident between RI #2 and RI #21. CNA #5 said she recalled CNA #4 brought RI #2 to her/his room, and RI #2 was crying and did not want to go into the room. CNA #5 said, she saw RI #21 trying to come out of the room and raising his/her hands to block the hit from RI #2. On 05/21/2025 at 8:56 AM Licensed Practical Nurse (LPN) #6 was asked about the incident on 04/30/2025 and she stated RI #2 was in the dayroom, was getting irritable, so she asked CNA #4 to take RI #2 to his/her room to be changed, and about five minutes later CNA #5 came to the nurses station and told her there had been an altercation between RI #2 and RI #21. LPN #6 stated, she immediately went to the room and RI #2 was in the doorway of the room and RI #21 was in activity room. LPN #6 said, a body audit was conducted on both residents, RI #21 did not have any injuries. On 05/21/2025 at 10:05 AM, a follow-up phone interview was conducted with CNA #4. CNA #4 was asked why she left RI #2 at the doorway of her/his room. CNA #4 said, she went to tell LPN #6 that RI #2 would not go to bed. When asked what should she have done when she could not get RI #2 to go to bed, she said she should have brought RI #2 back to the day room. On 05/21/2025 at 3:32 PM, an interview was conducted with the Social Services Director (SSD). The SSD stated, she became aware of the incident between RI #2 and RI #21 during the investigation. The SSD said, she was told RI #2 was trying to go into the room, RI #21 was coming out of the room, RI #2 held his/her hand up and RI #21 blocked RI #2 from hitting him/her. The SSD said, they were separated, and CNA #4 reported the incident to LPN #6. The SSD stated, RI #2 was sent out to the hospital for a psychiatric evaluation. When asked how a reasonable person would feel about being hit, the SSD said, bad and shocked. On 05/21/2025 at 4:50 PM the Director of Nursing (DON) was interviewed about the incident that occurred between RI #2 and RI #21 on 04/30/2025. The DON was asked about RI #2's behaviors and stated RI #2 would curse and had triggers sometimes depending on what was going on at the moment. The DON said no one would like to be hit. The facility took the immediate action to correct the non-compliance; thus, past non-compliance was cited. ********************************************************************* The facility's immediate actions included: 04/30/2025 at 1:55 PM- Resident Altercation occurred, residents separated immediately, and nurse informed. 04/30/2025 2:05 PM- Administrator (ADM)-informed and investigation began 04/30/2025 at 2:07 PM-Mental health notified 04/30/2025 at 2:14 PM- Skin assessment completed on both residents 04/30/2025 at 2:15 PM SSD and ADM began resident interviews 04/30/2025 at 2:17 PM Doctor Notified, orders received to send RI #2 to Providence ER for Evaluation and treatment 04/30/2025 at 2:20 PM- Family notified 04/30/2025 at 2:50 PM Ambulance picked RI #2, Abuse Inservice started for staff for Resident on Resident abuse 04/30/2025 3:58 PM- Care plan updated for supervision of RI #2 04/30/2025 Notified ADPH 04/30/2025 at 8:07 PM RI #2 returned to facility and room move occurred. Behavior Monitoring Continued 05/01/25-3 Day SS Follow up began ADHOC QAPI 05/02/2025 PHQA Root Cause Analysis initiated 05/05/2025-Mental Health Visit 05/06/2025-5 Day Report Sent to ADPH

Based on interviews and record review the facility failed to ensure the physician was notified when residents on the second and third floors did not receive their medications and treatments as ordered when the facility experienced an internet outage preventing access to the Electronic Health Record (EHR) system on 01/21/2025 and 01/22/2025. Nurses did not have access to pre-printed paper documentation forms such as physician orders and MARs (Medication Administration Record) to administer medications on 01/21/2025 and 01/22/2025. The facility staff failed to notify the Director of Nursing (DON), residents, and resident representatives of residents not receiving their ordered medications and treatments on 01/21/2025 and 01/22/2025. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.10 Resident Rights. On 03/25/2025 at 4:15 PM, the Administrator (ADM), the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and Executive Director of Operations were provided a copy of the IJ template and, notified of the finding of immediate jeopardy in the area of Resident Rights at F580-Notify of Changes (Injury/Decline/ Room, Etc.). The IJ began on 01/21/2025 and continued until 03/26/2025 when the facility implemented corrective action to remove the immediacy. On 03/27/2025 the immediate jeopardy was removed, F580 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice affected residents on the second and third floors at the facility who were receiving medications. This deficiency was cited as the result of the investigation of complaint/report number AL00050173. Findings Include: Cross-Reference F600, F658 and F760. Review of the facility's After Action Report for the snowstorm January 21 to 23, 2025, documented the following: Knollwood Healthcare experienced an unusual snowstorm on January 21 to January 23, 2025 . We did have the modem go out for the computer Internet . On 03/19/2025 at 3:53 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) #11, who was identified as a supervisor during the snowstorm on 01/21/2025. LPN #11 said she did remember when the facility's computer system was down during the snowstorm. LPN #11 said she was not sure if the residents received their medications or not. When asked if the DON or ADM knew the system was down, LPN #11 said she could not say yes or no whether they knew. When asked who would have been responsible for notifying them, LPN #11 said the supervisor. On 03/20/2025 at 11:00 AM, the surveyor conducted an interview with the DON. When asked what she could tell the surveyor about the medication system being down on 01/21/2025 and 01/22/2025 when there was a snowstorm, the DON said she was not at the facility during that time and did not recall anyone informing her the system was down. The DON said she was not notified the residents did not receive their medications on those days. The DON said on 01/22/2025 she sent a text to LPN #11 asking LPN #11 how things were going and LPN #11 texted back going, no issues. The DON said she did not know that the residents did not receive their medications during the snowstorm until 03/20/2025. On 03/21/2025 at 10:23 AM, the surveyor conducted an interview with the ADM. The ADM said the internet was down during the snowstorm back in January 2025. The ADM said he did not remember who informed him of this, but he told them to use the paper MARs. The ADM said he was not aware the residents did not receive their medications until he was made aware of this by the survey team. When asked if he should have been made aware that the residents did not receive their medications, the ADM said absolutely. On 03/22/2025 at 9:42 AM, a follow-up interview was conducted with the DON. The DON said she should have been notified when the residents did not receive their medications on 01/21/2025 and 01/22/2025. When asked who would have been the supervisor on 01/21/2025 and 01/22/2025, the DON said LPN #11. The DON said the physician also should have been notified. On 03/22/2025 at 10:18 AM, a telephone interview was conducted with the Physician/Medical Director (MD). The MD said back in January (2025) when there was a snowstorm in the area he was not informed that the facility's computer system was down and the residents did not receive their mediations. The MD said he would have liked to have been informed of this. When asked what were some of the things residents could potentially face when residents did not receive their medications as prescribed by their physician, the MD said it could be a blood pressure issues if the medication missed was for the blood pressure; it could be a clotting issues if the resident was on blood thinners; pain control could be an issue if the resident was on pain medication; and the blood sugar may be affected if insulin was not given as ordered. ********************************************************* On 03/26/2025, the facility submitted an acceptable removal plan, which documented: ********************************************************* 1) Process: To ensure that in the event of a power/internet outage the most updated Medical Record Administration (MAR) will be available for nurses that provide care to the residents: The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager, by the 1st of each month. The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits. The updated MAR will be located by the nursing stations. All, 100% of LPNs and RNs were in-serviced and completed on March 26th, 2025. Inservice was to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR. 2) In services On 3/20/2025 - 03/26/2025 the Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff (receptionist, Admissions Coordinator, Staffing Coordinator and Human Resources) and provided the education with 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-services included: a) the policy titled Policy on Computer or Internet Downtime and EHR, b) the standard of practice to: i) administer medication, ii) monitor blood glucose, iii) the implementation of the prescribing physicians' orders iv) the importance of documenting medication administration at the time of administration. c) Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order. d) Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy. The in-service was completed on March 26th, 2025 for 21 of 21 nurses, 9/9 PT staff, 16/16 of administrative staff. On 3/26/2025, 21 of 21 of the nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-service included that a printed MAR will be ready for the 1st of each month. A copy of the paper MAR will be kept at each nurses' station for use during downtime. Education included that RNs and LPNs who receives an order or confirms a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits. The Administrator educated the Director of Nursing and the Assistant Director of Nursing on 03/26/2025 that both of them are responsible to print the paper MAR to be ready for the 1st of each month and will be placed by each of the nurse's station. A monthly MAR print out schedule was created for clarity. The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm such as tropical depression, tropical storm, hurricane, or winter snow storm or other reason to expect downtime. A mock drill was conducted on 3/21/25 for the nursing personnel on shift. 2) Assessment Due to the failure of functionality of the router which caused the internet outage in the facility, the facility replaced the router on January 30th, 2025 through its internet provider. On 3/26/25 The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records. All residents that had the potential of being affected by this deficient practice from January 21st 2025 to January 22nd 2025. A report was generated from the electronic medical records to see which residents could have been affected during 1/21/25 - 1/22/25. There was a total of 56 of 56 residents were assessed by the medical director and completed on March 26th, 2025. No adverse effects were identified by the physician due to this deficient practice and no recommendations were made. 2) Quality Assurance An ad-hoc Quality Assurance meeting which included the entire IDT team ( Director of Nursing, Administrator, Rehab Director, Business Office Manager, Social Worker Director, Governing Body, Medical Director, Business Office Manager, Assistant Director of Nursing, Staffing Coordinator, Unit Manager, Dietary Director, Admissions Director) was conducted on March 25, 2025 in response to F600, F658, F580, and F760 to discuss the deficient practice and plan of correction. The nurses that were responsible were immediately educated about the in-proper practice that led to F600, F658, F580, and F760 and on the Policy on Computer or Internet Downtime and EHR access. The QA team discussed the needed in services/education for LPN #14, RN #15, LPN #11, RN #20, and RN #16. This plan was completed on March 26th, 2025. ******************************************************* After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 03/26/2025.

Based on interviews, record review and review of facility policies titled, Abuse Policy and Policy on Computer or Internet Downtime and EHR (Electronic Health Record) Access, the facility failed to protect the resident's right to be free from neglect when systems were not in place to ensure continuity of care and operations when the facility experienced a forecasted winter storm which caused internet outage preventing access to the EHR system on 01/21/2025 and 01/22/2025. The facility failed to ensure pre-printed paper documentation forms such as physician orders and MARs were available and accessible for the licensed nursing staff to utilize for resident care, treatment, and medication administration prior to the internet outage. The nurses and nurse supervisor on duty during that time failed to ensure residents received medications as ordered by the physician. Residents residing on the second floor and third floor did not receive their medications on 01/21/2025 and 01/22/2025 as ordered. The staff further failed to notify management staff or the residents' physician of their inability to safely administer. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 03/25/2025 at 4:15 PM, the Administrator (ADM), the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and Executive Director of Operations were provided a copy of the IJ template and notified of the finding of immediate jeopardy substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F600- Free from Abuse and Neglect. The IJ began on 01/21/2025 and continued until 03/26/2025 when the facility implemented corrective action to remove the immediacy. On 03/27/2025 the immediate jeopardy was removed, F 600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice affected all residents at the facility who received medications. This deficiency was cited as the result of the investigation of complaint/report number AL00050173. The facility further failed to protect Resident Identifier (RI) #15's right to be free from verbal abuse perpetrated by Certified Nursing Assistant (CNA) #10. Specifically, on 01/30/2025, the facility failed to ensure RI #15 was not verbally abused by CNA #10, who stated she was tired and frustrated from working a double the day before, and who called RI #15 a stupid mother fucker while providing assistance to RI #15 who needed assistance to stand. RI #15 said, he/she was shocked when CNA #10 spoke to him/her that way. This deficient practice was cited as the result of the investigation of complaint/report number AL00050214 and affected RI #15, one of three residents sampled for abuse, and did not rise to the jeopardy level. Findings Include: 1) Cross-Reference F580, F658 and F760. Review of the facility's policy titled, Abuse Policy, updated 08/2022, revealed the following: Our residents have the right to be free from . neglect . Policy Interpretation and Implementation Definitions . 9. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s) . Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Examples of individual failures include, but are not limited, to the following: . Failure to provide supervision and/or monitoring of the delivery and implementation of care; . Failure to provide orientation and/or training to staff; Failure to provide trained on . new procedures . required for the care of a specified resident or required due to changes in standards of practice; Failure to oversee the implementation of resident care policies; Failure to identify, assess, and/or contact a physician and/or prescriber for an acute change in condition, and/or a change in condition that require the plan of care to be revised to meet the resident's needs in a timely manner; Failure to implement effective communication systems across all shifts for communicating necessary care and information between staff, practitioners, and resident representatives . On 03/19/2025 at 3:09 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) #14, the licensed staff member assigned to work the Second Floor (back hall cart) on 01/21/2025 on the 2:00 PM to 10:00 PM shift. LPN #14 said one specific night the computer system at the facility was not working and was down because of a storm. When asked how she passed medications that evening, LPN #14 said she was not able to pass medications. LPN #14 said LPN #11 was the Second Floor supervisor at that time and when she informed LPN #11 that she was not able to pass medications, LPN #11 said she did not know what to do. On 03/21/2025 at 11:33 AM a follow-up interview was conducted with LPN #14 who said she was not aware the facility had paper MARs at the time of the storm on 01/21/2025. On 03/22/2025 at 1:43 PM, a follow-up telephone interview was conducted with LPN #14. LPN #14 said in addition to not being able to pass medications when the internet was down on 01/21/2025, she was not able to perform capillary blood glucose (CBG) monitoring checks because she did not know who needed them. LPN #14 said she did not feel comfortable to administer anything without the MAR. When asked about how many CBG checks she thought she had on her cart, LPN #14 said two to four. On 03/19/2025 at 9:50 AM an interview was conducted with RI #308's family member (FM). The FM said RI #308 did not receive his/her seizure medication as ordered while a resident. The FM said it was concerning because RI #308 had a very short window to take his/her seizure medications. The FM said before RI #308 was admitted to the facility he/she had received all of his/her medications for seizures except for two since his/her accident in 2019. The FM identified LPN #14 as the nurse that did not administer RI #308's medications as ordered. On 03/21/2025 at 11:58 AM, a telephone interview was conducted with Registered Nurse (RN) #15, the licensed staff member assigned to work the Second Floor (front hall cart) on 01/21/2025 on the 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM shift. RN #15 said she was able to pass medications that morning, but something happened that she could not administer medications that evening. RN #15 said she was hired in January and was not told to use the paper MARs if there was an internet outage. RN #15 said she informed LPN #11 she was not able to administer medications to residents. RN #15 said LPN #11 did not tell her what to do. RN #15 said when the snowstorm occurred back in January 2025, LPN #11 did not inform her to use the residents' paper MARs. On 03/19/2025 at 3:53 PM, a telephone interview was conducted with LPN #11, the LPN supervisor. LPN #11 said she did remember when the facility's computer system went down back in January of 2025 when a snowstorm hit. The surveyor asked LPN #11 if the system was down, how did the residents receive their scheduled medications. LPN #11 said on that shift there were new nurses and nothing could be printed out for the new nurse to use to give the medications by. When asked did the residents receive their medications, LPN #11 said she was not sure. LPN #11 said she did not recall anyone reporting to her that the residents did not get their medications. LPN #11 said there should have been a backup plan in place to ensure the residents received their medications. When asked did the DON and ADM know the system was down, LPN #11 said she could not say yes or no if they knew. On 03/21/2025 at 12:36 PM, a follow-up telephone interview was conducted with LPN #11 who said she could not get into the computer to print the paper MARs to give to the nurses and she could not find the paper MARs in the binder. LPN #11 said she did not recall telling the new nurses about the paper MARs because she could not print them. When asked who would have been responsible for ensuring the paper MARs were in the binder, LPN #11 said the unit manager. LPN #11 said it would be important to ensure the paper MARs were in the binders to make sure the nurses had something to give medications by if there was an internet outage. On 03/24/2025 at 11:16 AM, a telephone interview was conducted with RN #16, the licensed staff member working on the Third Floor on 01/21/2025 on the 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM shifts; and working on the Second Floor on 01/22/2025 on the 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM shifts. RN #16 said the paper MARs were kept on the unit near the nurses' station and during the downtime she did not see the paper MARs. When asked did she report to anyone that she could not find the paper MARs, RN #16 said she could not remember if she did or not. RN #16 said if anyone CBG required monitoring such as a sliding scale, she could not provide that because she did not have the paper MAR or eMAR to see who needed CBG checks. When asked what was the rationale for having preprinted MARs, RN #16 said in case of an emergency like the internet going down of if there was a power outage the nurses would have a place to document that the medications had been given. On 03/20/2025 at 4:49 PM an interview was conducted with LPN #18 who recalled that the DON was at home and LPN #11 was the supervisor. LPN #18 said LPN #11 told her to pass medications using the prepackaged medications that had the residents' name, medication name, dosage, and the time it was to be given. LPN #18 said she always checked those things against the MAR as well. LPN #18 said she asked LPN #11 where were the paper MARs and LPN #11 said she did not know. LPN #18 said each floor should have had a book with monthly paper MARs and she thought there should be a policy about that. LPN #18 said there should be something in place for giving medications when there was a power outage or computers go down or anything like that. On 03/22/2025 at 6:26 PM an interview was conducted with RN #17, Unit Manager for the Third Floor. RN #17 said that in preparation for the storm the ADM informed staff that everyone needed to be prepared to come to work if it was safe. RN #17 said when she left around 2 PM she thought the internet was still up. RN #17 said no one informed her that the residents did not get their medications because the internet was down. RN #17 said she did not know how nurses passed medications after the internet went down because she was not there and she did not know who the Supervisor was on those days. RN #17 said staff should have gotten the paper MAR and passed medications from it, and then once the internet was back up the staff should have transferred the information onto the eMAR (Electronic Medication Administration Record). RN #17 had no idea why that was this not implemented when there was an internet outage on 01/21/2025 and 01/22/2025. RN #17 said the Unit Manager or anybody in Administration can place the printed MARs in the binders on each floor. RN #17 said she did not know if the printed MARs were on the Second Floor at the time of the storm, and said they should have been on the Third Floor. On 03/21/2025 at 10:54 AM, an interview was conducted with the DON. The DON said the facility's computer system was run by the internet. The DON said the facility's policy indicated that staff should initiate downtime procedures when the outage is more than 30 minutes. The DON said paper documentation should occur during downtime and this would include the MAR as well. The DON said pre-printed downtime forms should be kept at the nurses' station in the binders behind the nurses station. When asked where would there be evidence these forms were used on 01/21/2025 and 01/22/2025 when the internet was down, the DON said the evidence would be on the paper MAR where the nurses signed their initials. The DON said she had not seen any paper MARs from January 2025 with initials that medications had been administered. The DON said all nurses should have had knowledge of the downtime procedure before 01/21/2025. On 03/22/2025 at 9:42 AM during a follow-up interview with the DON she said she should have been notified when residents did not receive their medications on 01/21/2025 and 01/22/2025. The DON said she would have asked them where was the paper MARs. The DON said anybody, like DON, ADON, unit managers could place the MARs in the book/binders. On 03/23/25 at 4:42 PM a follow-up interview was conducted with the DON. The DON was asked about a previous interview when she stated the ADON, the unit manager or the supervisor could print and place the printed MAR in the binders on the floors, and who would be responsible for verifying the MARs had been printed and placed in the binders. The DON said, no one in particular, it was just a team effort. On 03/21/2025 at 10:23 AM an interview was conducted with the ADM. The ADM said he first became aware during the survey that residents' medications had not been administered during the internet downtime on 01/21/2025 and 01/22/2025. ***************************************************** On 03/26/2025, the facility submitted an acceptable removal plan, which documented: ****************************************************** On January 21st, 2025 in the afternoon, we encountered a major snow storm and our modem was not functioning. Due to the impact of the storm, we were unable to get a technician into the facility to restore the internet until January 22nd, 2025 at approximately 6:00 pm. Unfortunately, the facility failed to ensure residents were free of significant medications when licensed nursing staff failed to administer medications including insulin and other significant medications. Deficiencies The facility failed to protect the resident's right to be free from neglect when systems were not in place to ensure continuity of care and operations when the facility experienced a forecasted winter storm which caused internet outage preventing access to EHR system on 01/21/2025 and 01/22/2025. The facility failed to ensure pre-printed paper documentation forms such as physician orders and MARs were available and accessible for the Licensed Nursing Staff to utilize for resident care, treatment, and medication administration prior to the internet outage. This affected all residents in the facility. The nurses and nurse supervisor on duty during that time failed to ensure residents received medications and treatments as ordered by physician. Residents residing on the second floor and third floor did not receive their medications and treatments on 01/21/2025 and 01/22/2025 as ordered. The staff further failed to notify management staff or the residents' physician of their inability to safely administer medication which contributed to medications and other resident care not being performed for greater than 24 hours. All the residents had the potential to be affected by this deficient practice. 1) Process: To ensure that in the event of a power/internet outage the most updated Medical Record Administration (MAR) will be available for nurses that provide care to the residents: The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager, by the 1st of each month. The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits. The updated MAR will be located by the nursing stations. All, 100% of LPNs and RNs were in-serviced and completed on March 26th, 2025. Inservice was to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR. 2) In services On 3/20/2025 - 03/26/2025 the Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff (receptionist, Admissions Coordinator, Staffing Coordinator and Human Resources) and provided the education with 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-services included: a) the policy titled Policy on Computer or Internet Downtime and EHR, b) the standard of practice to: i) administer medication, ii) monitor blood glucose, iii) the implementation of the prescribing physicians' orders iv) the importance of documenting medication administration at the time of administration. c) Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order. d) Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy. The in-service was completed on March 26th, 2025 for 21 of 21 nurses, 9/9 PT staff, 16/16 of administrative staff. On 3/26/2025, 21 of 21 of the nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-service included that a printed MAR will be ready for the 1st of each month. A copy of the paper MAR will be kept at each nurses' station for use during downtime. Education included that RNs and LPNs who receives an order or confirms a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits. The Administrator educated the Director of Nursing and the Assistant Director of Nursing on 03/26/2025 that both of them are responsible to print the paper MAR to be ready for the 1st of each month and will be placed by each of the nurse's station. A monthly MAR print out schedule was created for clarity. The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm such as tropical depression, tropical storm, hurricane, or winter snow storm or other reason to expect downtime. A mock drill was conducted on 3/21/25 for the nursing personnel on shift. 2) Assessment Due to the failure of functionality of the router which caused the internet outage in the facility, the facility replaced the router on January 30th, 2025 through its internet provider. On 3/26/25 The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records. All residents that had the potential of being affected by this deficient practice from January 21st 2025 to January 22nd 2025. A report was generated from the electronic medical records to see which residents could have been affected during 1/21/25 - 1/22/25. There was a total of 56 of 56 residents were assessed by the medical director and completed on March 26th, 2025. No adverse effects were identified by the physician due to this deficient practice and no recommendations were made. 2) Quality Assurance An ad-hoc Quality Assurance meeting which included the entire IDT team ( Director of Nursing, Administrator, Rehab Director, Business Office Manager, Social Worker Director, Governing Body, Medical Director, Business Office Manager, Assistant Director of Nursing, Staffing Coordinator, Unit Manager, Dietary Director, Admissions Director) was conducted on March 25, 2025 in response to F600, F658, F580, and F760 to discuss the deficient practice and plan of correction. The nurses that were responsible were immediately educated about the in-proper practice that led to F600, F658, F580, and F760 and on the Policy on Computer or Internet Downtime and EHR access. The QA team discussed the needed in services/education for LPN #14, RN #15, LPN #11, RN #20, and RN #16. This plan was completed on March 26th, 2025. ******************************************************* After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 03/26/2025. ******************************************************** 47408 2.) Cross reference F609, F610, F745, F867, and F943. On 01/30/2025 at 3:04 PM, the State Agency (SA) received an Online Incident Report (FRI) from the facility alleging RI #15 was verbally abused by CNA #10 after RI #15 reported to Licensed Physical Therapy Assistant (LPTA) #7 that a CNA had been mean to him/her (RI #15) and called him/her (RI #15) a Stupid Motherfucker. The FRI documented the LPTA became aware of the incident at 10:50 AM and the ADM was made aware of the incident at 11:20 AM, more than three hours before the SA was informed. The FRI report further documented the CNA had been rough with RI #15's legs, RI #15 was not hurt, but was scared of that CNA. The FRI documented actions taken included suspending CNA #10 pending the investigation, calling the mental health nurse to review, and initiating abuse and customer service in-services. The FRI also included that RI #15 was no longer scared since the CNA was gone. Further review of the facility's Abuse Policy, revealed the following: Our residents have the right to be free from abuse . To help with recognition of incidents of abuse, the following definitions of abuse are provided: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 2. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. RI #15 was readmitted to the facility on [DATE] and had diagnoses to include: Cellulitis of Left and Right Lower Limb, Need for Assistance with Personal Care, Abnormalities of Gait and Mobility, Hemiplegia and Hemiparesis following Cerebral Infarction. RI #15's Significant Change in Status Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/24/2024 revealed a Brief Interview for Mental Status (BIMS) score of 12 of 15 which indicated moderately impaired cognition. The facility investigative file contained a summary of the incident involving RI #15 and CNA #10, dated 02/06/2025, signed by the Administrator (ADM) that documented: . (RI #15) alleged that . (CNA #10), cursed (him/her) out and was rough with (his/her) legs . After discussing the allegation . we suspended the C.N.A. pending investigation. Based on the statements and interviews with staff . we have concluded (CNA #10) did curse (RI #15) . going to substantiate the allegation of verbal abuse in this instance. We have initiated abuse in-services for all staff. We are going to terminate the C.N.A. The facility investigative file contained a form titled DIVERSICARE PERSONNEL CHANGE/TERMINATION FORM dated 02/07/2025 for CNA #10 with a reason for termination of abuse. CNA #10's facility time sheet indicated CNA #10 had not worked at the facility since she was clocked out at 12:48 PM on 01/30/2025. On 03/18/2025 at 10:25 AM, an interview was conducted with RI #15. RI #15 told the surveyor CNA #10 came into his/her room on 01/30/2025 to get him/her dressed told him/her to get up and stand up you stupid mother fucker, get up you are going to stand today. RI #15 said, he/she fell back in the bed and CNA #10 called him/her a stupid mother fucker again. RI #15 said, he/she did not care for the CNA to be in his/her room. RI #15 said, CNA #10 told him/her during the incident that she had a bad day the day before. During a follow up interview on 03/22/2025 at 12:24 PM, the surveyor asked RI #15 how it made him/her feel when CNA #10 called him/her a stupid motherfucker. RI #15 stated, stunned and shocked. Contained within the facility's investigative file was a handwritten statement signed by CNA #10 dated 01/30/2025, which documented she was tired and frustrated at the time RI #15 was verbally abused, as follows: I (CNA #10's name) went to (RI #15's) room to change (him/her) to get (him/her) up for activities . I said a few words like I was tired from . doing a double on the previous shift from the day before and I wasn't directly saying it to (RI#15) just whisper it under my breath due to the frustration . Unsuccessful attempts were made to contact CNA #10 during the survey. Contained within the facility's investigative file was a handwritten statement given by the LPTA dated 01/30/2025 at 10:50 AM, which documented the following: Entered (RI #15's room number) and asked (RI #15) how (he/she) was feeling today. (He/She) responded, I'm being abused. That lady called me a 'stupid mother fucker.' When asked who called (him/her) that, (he/she) stated that it was a CNA. On 03/19/2025 at 3:49 PM, in an interview with the LPTA she stated, on 01/30/2025 RI #15 told her that a CNA called him/her a mother fucker. The LPTA stated, RI #15 appeared to be mad. The LPTA stated, she reported to her supervisor the Therapy Director (TD) and the ADM. When asked what type of abuse this would be considered, she stated it would be verbal and emotional. During an interview on 03/19/2025 at 3:31 PM with the TD she stated, she was notified of the allegation on 01/30/2025 by the LPTA who stated RI #15 told her that a CNA used aggressive language toward him/her. The TD stated she had the LPTA to write out a statement and notified the ADM. When asked what type of abuse this would be considered the TD stated verbal. Contained within the facility's investigative file was a handwritten statement given by CNA #8 dated 12/30/25, which documented the following: Today (RI #15) said to me after I walked into (his/her) room because (CNA #10) stormed out heated that she was getting a attitude with (him/her) and calling (him/her) names because (he/she) didn't stand up . An interview was conducted on 03/19/2025 at 4:16 PM, with CNA #8. CNA #8 stated that she went into RI #15's room and he/she told her that CNA #10 called him/her a stupid mother fucker. Contained within the facility's investigative file was a written statement given by CNA #9 dated 01/30/2025, which documented the following: I walked (room number of RI #15) to help (him/her) get up and (he/she) said (CNA #10) left (him/her) and was mean to (him/her) and called (him/her) a dumb mother fucker. A telephone interview was conducted on 03/19/2025 at 04:32 PM, with CNA #9. CNA #9 stated that on 01/30/2025 that she and CNA #8 were in RI #15's room providing personal care and that he/she told her a CNA was rude, nasty and called him/her a mother fucker. CNA #9 stated this was verbal abuse. Contained within the facility's investigative file was a handwritten statement signed by the ADM dated 01/30/2025 when he interviewed RI #15, which documented the following: . I asked (RI #15) who was treating (him/her) bad and (he/she) replied (CNA #10). I asked what was said and (CNA #10) called me a stupid motherfucker . I asked (him/her) if (he/she) was scared (he/she) stated yes of her (CNA #10) . During an interview on 03/20/2025 at 11:32 AM the ADM stated he became aware of the allegation of abuse involving RI #15 on 01/30/2025 at about 11:20 AM by the TD. The ADM stated, the TD was told by the LPTA that CNA #10 called RI #15 a stupid mother fucker. The ADM stated, he initiated an investigation. The ADM stated RI #15 told him that CNA #10 called him/her a stupid mother fucker. The ADM said this allegation was substantiated and it would be considered verbal abuse.

Based on interviews, record review, review of facility policies titled Administering Medications, and Policy on Computer or Internet Downtime and EHR (Electronic Health Record) Access, the facility failed to ensure Licensed Practical Nurse (LPN) #14, Registered Nurse (RN) #15, RN #16, RN #20, and LPN #18 followed standards of practice and facility's policies. Specifically, LPN #14 and RN #15 failed to follow standards of practice to administer medications and perform Capillary Blood Glucose (CBG) monitoring as ordered by the physician on 01/21/2025 during the 2 PM to 10 PM shift on the Second Floor. The nurses did not notify the residents' physician, DON, or the Administrator that medications were not being administered and CBG checks were not being performed. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.21 Comprehensive Resident Centered Care Plan. On 03/25/2025 at 4:15 PM, the Administrator (ADM), the DON, the Assistant Director of Nursing (ADON), and Executive Director of Operations were provided a copy of the IJ template and notified of the finding of immediate jeopardy in the area Comprehensive Resident Centered Care Plan at F658-Services Provided Meet Professional Standards. The IJ began on 01/21/2025 and continued until 03/26/2025 when the facility implemented corrective action to remove the immediacy. On 03/27/2025 the immediate jeopardy was removed, F658 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. In addition, RN #20 and RN #16 failed to follow standards of practice when they administered medications using the pre-packaged medications without following the rights of medication administration to verify the physician's order. RN #20 and RN #16 did not document that they administered the residents' medications at the time of administration or when the EHR system was restored. Further LPN #18 failed to administer and document medication administration per standards of practice and facility's policy. This affected residents on the Second and Third Floors who were received medications at the facility, 48 of 52 residents who resided at the facility on 01/21/2025 and 01/22/2025. This deficiency was cited as the result of the investigation of complaint/report number AL00050173. Findings Include: Cross-Reference F580, F600 and F760. Review of an undated facility policy titled, Policy on Computer or Internet Downtime and EHR (Electronic Health Record) Access, revealed the following: Purpose To establish procedures for maintaining continuity of care and operations when the facility experiences a computer or internet outage that prevents access to the Electronic Health Record (EHR) system . Procedures 1. Notification Process . If the outage is expected to last more the 30 minutes, staff will initiate downtime procedures. 2. Documentation During Downtime Paper documentation will be used for all resident care activities, including but not limited to: Medication Administration Records (MARs) . 3. Medication Administration Nurses will refer to printed MARs/TARs (Treatment Administration Records) or previously printed backup records if available . 4. Restoring EHR Data Once systems are restored, all paper documentation must be entered into the EHR system as soon as possible . Nursing and administrative staff will verify that all data has been accurately transferred before discounting paper documentation . The facility policy titled, Administering Medications, with a revised date of 04/2019, revealed the following: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required time frames . 7. Medications are administered within (1) hour of their prescribed time . 10. The individual administering the medication check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication . 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration . g. The signature and title of the person administering the drug . A review of the facility's Midnight Census Report documented a facility census of 52 residents on 01/21/2025 with 27 residents on the Second Floor and 25 residents on the Third Floor. Second Floor The DAILY ASSIGNMENT SHEET indicated that LPN #14 was assigned the Second Floor back hall medication cart 01/21/2025 on the 2 PM to 10 PM shift. On 03/22/2025 at 1:43 PM, a telephone interview was conducted with LPN #14, who said on 01/21/2025 she could not pass medications because the internet was down, and she did not have the MARs to see what needed to be done. LPN #14 said she did not check residents CBG either during that time. LPN #14's assigned residents' MARs and physician orders were reviewed. The review revealed that 12 residents including RI #4, 35, 12, 38, 7, 21, 2, 52, 158, 6, 308, and 30 had scheduled medications that were not administered during the 01/21/2025 2 PM to 10 PM shift. A total of 85 doses of residents' medications were not administered, and 2 residents missed CBG checks as ordered during her shift on 01/21/2025. Medications not administered included, but not limited to, Metformin, Symbiotic Inhalation, Novolin Insulin, and Memantine Tablet. The DAILY ASSIGNMENT SHEET indicated that RN #15 was assigned the Second Floor front hall medication cart 01/21/2025 on the 2 PM to 10 PM shift. On 03/22/2025 at 2:40 PM during an interview with RN #15, she indicated she worked the Second Floor on 01/21/2025 from 6 AM to 10 PM. RN #15 said she could not administer medications during the 2 PM to 10 PM shift as ordered because the computers were not working. RN #15 said she reported that she was unable to administer medications to the Supervisor at the facility, LPN #11. RN #15 said she was unable to administer any medications except controlled pain medications upon resident's request. RN #15 said she did not check anyone's CBG because the computer was down. RN #15's assigned resident MARs and physician orders were reviewed. The review revealed 13 residents including RI #3, 56, 31, 27, 32, 17, 51, 20, 34, 46, 24, 159, and 15 had scheduled medications that were not administered during the 01/21/2025 2 PM to 10 PM shift. A total of 77 doses of residents' medications were not administered as ordered, and 2 residents missed CBG checks during RN #15's shift on 01/21/2025. Medications not administered included, but not limited to, Tamiflu Capsule, Carvedilol, Valproic Acid, Remeron, Hydralazine, Metoprolol Tartrate, Insulin Lispro, and Dilantin Capsule. On 03/19/2025 at 3:53 PM, during a telephone with LPN #11, she said on 01/21/2025 the computer system went down and there were new nurses working. LPN #11 continued to say the facility did not print MARs for the new nurses to use to administer residents' medications. LPN #11 said the physician orders were not being followed if the residents do not get their medications. The DAILY ASSIGNMENT SHEET indicated that RN #20 was assigned both medication carts on the Second Floor on 01/22/2025 on the 6 AM to 2 PM shift. On 03/22/2025 at 5:14 PM an interview was conducted with RN #20. Regarding medication administration on 01/22/2025, RN #20 said she administered medications using the prepacked medications that were labeled with resident's name, medication, dose, and time it was due. RN #20 said residents who had orders for over-the-counter (OTC) or stock medication would not have received those medications without the printed MARs because those medications were not prepackaged. RN #20 said she was able to check residents' CBG because she had a report sheet. RN #20 said she was unable to document anything in the residents' medical records. The DAILY ASSIGNMENT SHEET indicated that RN #16 was assigned to both medication carts on the Second Floor on 01/22/2025 on the 2 PM to 10 PM shift and 10 PM to 6 AM shift. On 03/22/2025 at 5:47 PM an interview was conducted with RN #16 who worked on the Third Floor on 01/21/2025 and Second Floor on 01/22/2025. RN #16 said she also used the prepackaged medications to administer medications during her shifts and was unable to document medication administration because she did not have paper MARs. RN #16 said if anyone required CBG monitoring such as a sliding scale, she could not have administered it, because the facility did not have the paper MAR or eMAR. RN #16 said she could administer residents with scheduled doses of insulin because she knew which residents were routine. Residents' who resided on the Second Floor MARs and physician's orders were reviewed. The reviews revealed 4 residents with orders for CBG monitoring and 25 residents had medications that were not documented as administered on 01/22/2025. A total 410 doses of residents' medication were not documented as administered on 01/22/2025 between all shifts. Medications not administered included, but not limited to, sliding scale insulin and OTC medications such as Aspirin, Multivitamins, Colace, and Miralax. Third Floor The DAILY ASSIGNMENT SHEET indicated that RN #16 was assigned to administer medications on the Third Floor on 01/21/2025 on the 2 PM to 10 PM shift and 10 PM to 6 AM shift. RN #16's assigned residents' MARs and physician's orders were reviewed and revealed that 21 residents including RI #36, 37, 45, 25, 39, 29, 44, 161, 48, 47, 23, 22, 19, 43, 162, 50, 33, 9, 42, 14, and 40 had scheduled medications that had not been documented as administered on 01/22/2025 during the 2 PM to 10 PM shift. A total of 68 doses of residents' medications were not documented as administered and 3 residents CBG checks were not documented as completed during RN #16's shift on 01/21/2025. Medications not documented as administered included Eliquis, Insulin Detemir, Metoprolol Succinate Extended Release, Multivitamin tablets, Docusate Sodium, and Miralax. Further review of Third Floor residents MARs and physician's orders revealed 5 residents including RI #36, 19, 2, 59, and 33 had scheduled medications that were not documented as administered on 01/22/2025 at 6:00 AM. A total of a total of 36 doses of residents' medications were not documented as administered on 01/22/2025 at 6:00 AM. Medications that were not documented as administered included, but not limited to, Amlodipine Besylate, Cymbalta, Ferrous Sulfate, Tamsulosine, and Telmisartan. The DAILY ASSIGNMENT SHEET indicated that LPN #18 was assigned to administer medications on the Third Floor on 01/22/2025 on the 6 AM to 2 PM shift and 2 PM to 10 PM shift. On 03/20/2025 at 4:49 PM, an interview was conducted with LPN #18 who said she used her cellular hotspot to connect to the internet so she could administer residents' medications and document on their eMAR (Electronic Medication Administration Record). LPN #18 said the evidence that the resident had received their medications as ordered by the physician would be the initials on eMAR. LPN #18 said the physician orders were not followed if the residents did not receive their medications. When asked why it would be important for residents to receive their medications as ordered by the physician, LPN #18 said because residents need to get their medications. LPN #18 said if residents do not get their seizure medications, they might have a seizure, if they did not get their blood pressure medication their blood pressure might go up or down. LPN #18's assigned residents' MARs and physician's orders were reviewed. The review revealed 10 residents including RI #25, 47, 22, 19, 50, 33, 9, 42, 14, and 40 had medications that were not documented as administered and 1 resident had CBG ordered, but not documented on 01/22/2025 during LPN #18's shift. Medications not documented as administered included, but not limited to, Insulin Detemir, Docusate Sodium, Lisinopril, Memantine, and Metoprolol Succinate Oral Capsule Extended Release (ER). On 03/22/2025 at 9:42 AM the DON was interviewed. The DON said she was not notified that residents' medications were not administered on 01/21/2025. The DON said she had not been able to locate the January 2025 paper MARS. The DON said the possibility of things that could have occurred when residents did not receive their medications as ordered by the physician depended on the medication. The DON said if it was a blood pressure (BP) medication not given, the BP may go up or down, if insulin was not administered hypo- or hyperglycemia may occur. On 03/25/2025 at 12:00 PM a follow-up interview was conducted with the DON who was asked, when should a nurse not administer medication as ordered and not notify the facility's DON or the person in charge that they were not able to administer medications. The DON responded never. The DON was asked, when should a nurse administer the pre-packaged medications and not document medications as administered. The DON responded, never. On 03/21/2025 at 10:23 AM an interview was conducted with the Administrator (ADM) who said he was notified the internet was not working, but not notified that staff were not administering medications as ordered. The ADM said he instructed staff to use the paper MARs. The ADM said he was not aware residents' medications had not been administered as ordered until the current survey. ********************************************************* On 03/26/2025, the facility submitted an acceptable removal plan, which documented: ********************************************************** 1) Process: To ensure that in the event of a power/internet outage the most updated Medical Record Administration (MAR) will be available for nurses that provide care to the residents: The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager, by the 1st of each month. The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits. The updated MAR will be located by the nursing stations. All, 100% of LPNs and RNs were in-serviced and completed on March 26th, 2025. Inservice was to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR. 2) In services On 3/20/2025 - 03/26/2025 the Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff (receptionist, Admissions Coordinator, Staffing Coordinator and Human Resources) and provided the education with 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-services included: a) the policy titled Policy on Computer or Internet Downtime and EHR, b) the standard of practice to: i) administer medication, ii) monitor blood glucose, iii) the implementation of the prescribing physicians' orders iv) the importance of documenting medication administration at the time of administration. c) Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order. d) Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy. The in-service was completed on March 26th, 2025 for 21 of 21 nurses, 9/9 PT staff, 16/16 of administrative staff. On 3/26/2025, 21 of 21 of the nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-service included that a printed MAR will be ready for the 1st of each month. A copy of the paper MAR will be kept at each nurses' station for use during downtime. Education included that RNs and LPNs who receives an order or confirms a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits. The Administrator educated the Director of Nursing and the Assistant Director of Nursing on 03/26/2025 that both of them are responsible to print the paper MAR to be ready for the 1st of each month and will be placed by each of the nurse's station. A monthly MAR print out schedule was created for clarity. The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm such as tropical depression, tropical storm, hurricane, or winter snow storm or other reason to expect downtime. A mock drill was conducted on 3/21/25 for the nursing personnel on shift. 2) Assessment Due to the failure of functionality of the router which caused the internet outage in the facility, the facility replaced the router on January 30th, 2025 through its internet provider. On 3/26/25 The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records. All residents that had the potential of being affected by this deficient practice from January 21st 2025 to January 22nd 2025. A report was generated from the electronic medical records to see which residents could have been affected during 1/21/25 - 1/22/25. There was a total of 56 of 56 residents were assessed by the medical director and completed on March 26th, 2025. No adverse effects were identified by the physician due to this deficient practice and no recommendations were made. 2) Quality Assurance An ad-hoc Quality Assurance meeting which included the entire IDT team ( Director of Nursing, Administrator, Rehab Director, Business Office Manager, Social Worker Director, Governing Body, Medical Director, Business Office Manager, Assistant Director of Nursing, Staffing Coordinator, Unit Manager, Dietary Director, Admissions Director) was conducted on March 25, 2025 in response to F600, F658, F580, and F760 to discuss the deficient practice and plan of correction. The nurses that were responsible were immediately educated about the in-proper practice that led to F600, F658, F580, and F760 and on the Policy on Computer or Internet Downtime and EHR access. The QA team discussed the needed in services/education for LPN #14, RN #15, LPN #11, RN #20, and RN #16. This plan was completed on March 26th, 2025. ******************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 03/26/2025.

Based on interviews, record review, and review of a facility policy titled Administering Medications the facility failed to ensure residents were free of significant medication errors when licensed nursing staff failed to administer medications including insulin and other significant medications. Specifically, on 01/21/2025 during a forecasted snowstorm the facility lost internet connection sometime after lunch which resulted in inability to access residents Electronic Health Record (EHR)/Electronic Medication Administration Record (eMAR) until the evening of 01/22/2025. Resident Identifier (RI) #12, RI #15, RI #30, and RI #308 were not administered significant medications from 01/21/2025 at 5:00 PM until 01/22/2025 at 9:00 PM. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.45 Pharmacy Services. On 03/25/2025 at 4:15 PM, the Administrator (ADM), the DON, the Assistant Director of Nursing (ADON), and Executive Director of Operations were provided a copy of the IJ template and notified of the finding of immediate jeopardy substandard quality of care in the area of Pharmacy Services at F 760-Residents are Free of Significant Med Errors. The IJ began on 01/21/2025 and continued until 03/26/2025 when the facility implemented corrective action to remove the immediacy. On 03/27/2025 the immediate jeopardy was removed, F760 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice affected RI #12, 15, 30 and 308, four of four residents reviewed for significant medication errors. This deficiency was cited as the result of the investigation of complaint/report number AL00050173. Findings Include: Cross-Reference F580, F600, and F658. Review of the facility's policy titled, Administering Medications, with a revised date of 04/2019, revealed the following: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 7. Medications are administered within one (1) hour of their prescribed time . 22. The individual administering the medication initials the resident's MAR . after giving each medication . RI #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hyperglycemia. RI #12 resided on the Third Flood of the facility. RI #12's January 2025 Order Summary Report (Physicians Orders) revealed RI #12 had orders for: sliding scale Insulin Aspart Injection Solution subcutaneous four times a for hyperglycemia related to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease; and 6 units of Novolin N FlexPen Subcutaneous Suspension Pen-Injection subcutaneously at bedtime related to Type 2 Diabetes Mellitus with Other Specific Complication. A review of RI #12's January 2025 eMAR revealed RI #12's Insulin Aspart injection per sliding scale was not administered on 01/21/2025 at 5:00 PM, 01/21/2025 at 9:00 PM, 01/22/2025 at 7:30 AM, 01/22/2025 at 11:30 AM, 01/22/2025 at 5:00 PM, and 01/22/2025 at 9:00 PM. The eMAR further revealed Novolin N 6 units was not administered to RI #12 on 01/21/2025 at 9:00 PM and 01/22/2025 at 9:00 PM. On 03/22/2025 at 5:47 PM an interview was conducted with RN #16. During the interview RN #16 said she worked on the Third Floor on the 2 PM to 10 PM and 10 PM to 6 AM shift on 01/21/2025. RN #16 said if anyone required blood glucose monitoring such as a sliding scale, she could not have administered it, because the facility did not have the paper MAR or eMAR while the internet was down. RN #16 said she could administer residents with scheduled doses of insulin because she knew which residents were routine. On 03/20/2025 at 4:49 PM an interview was conducted with Licensed Practical Nurse (LPN) #18 who reported she worked on the Third Floor on the 6 AM to 2 PM and 2 PM to 10 PM shifts on 01/22/2025. She reported when the facility lost internet that she connected to a hotspot and passed medications as ordered. RI #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Type 2 Diabetes Mellitus, Localization-Related (Focal) (Partial) Symptomatic Epilepsy, and Essential (Primary) Hypertension. RI #15 resided on the Second Floor of the facility. RI #15's January 2025 Physicians Orders revealed RI #15 had orders for Carvedilol 25 mg two times a day related to Hypertension, Hydralazine 50 mg two times a day related to Hypertension, Insulin Glargine 30 units subcutaneous in the evening related to Diabetes, Lacosamide 50 mg two times a day related to Seizures, and Insulin Lispro per sliding scale before meals related to Diabetes. A review of RI #15's January 2025 eMAR revealed RI #15's was not administered: Hydralazine 50 milligram (mg) 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Lacosamide 50 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Carvedilol 25 mg on 01/21/2025 at 8:00 PM, 01/22/2025 at 8:00, and 01/22/2025 at 8:00 PM; Glargine Insulin 30 units on 01/21/2025 at 5:00 PM and 01/22/2205 at 5:00 PM; and Insulin Lispro sliding scale on 01/21/2025 at 4:00 PM, 01/22/2025 at 7:30 AM, 01/22/2025 at 11:00 AM and 01/22/2025 at 4:00 PM. RI #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Diastolic (Congestive) Heart Failure, Essential Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery, and Long Term (Current) Use of Insulin. RI #30 resided on the Second Floor. RI #30's January 2025 Physicians Orders revealed RI #30 had orders for blood glucose monitoring twice a day related to Type 2 Diabetes, Carvedilol 12.5 mg every morning and at bedtime for Beta Blockers, Furosemide 40 mg two times a day for Diuretics, Novolog 8 units before meals related to Type 2 Diabetes, and Rivaroxaban 2.5 mg two times a day for Anticoagulants. A review of RI #30's January 2025 eMAR revealed RI #30 was not administered: Lasix 40 mg 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, 01/22/2025 at 5:00 PM; Rivaroxaban 2.5 mg 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, 01/22/2025 at 5:00 PM; Coreg 12.5 mg 01/21/2025 at 8:00 PM, 01/22/2025 at 8:00 AM, 01/22/2025 at 8:00 PM; Novolog 8 units on 01/21/2025 at 4:00 PM, 01/21/2025 at 9:00 PM, 01/22/2025 at 7:30 AM, 01/22/2025 at 11:00 AM, 01/22/2025 at 4:00 PM, and 01/22/2025 at 9:00 PM. RI #30's January 2025 eMAR also indicated his/her blood glucose was not monitored on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, or on 01/22/2025 at 5:00 PM. RI #308 was admitted to the facility on [DATE] and discharged on [DATE]. RI #308 had diagnoses that included Epilepsy, Unspecified, Conversion Disorder with Seizures or Convulsions and Localization-Related (Focal) (Partial) Symptomatic Epilepsy and Epileptic Syndrome with Complex Partial Seizures. RI #308 resided on the Second Floor. RI #308's January 2025 Physicians Orders revealed RI #308 had orders for Clobazam 10 mg two times a day for Anticonvulsants, Lacosamide 50 mg two times a day for Anticonvulsants, Lamotrigine 100 mg two times a day for Anticonvulsants, Oxcarbazepine 300 mg two times a day for Anticonvulsant, and Topiramate 300 mg two times a day for Anticonvulsant. A review of RI #308's January 2025 eMAR revealed RI #308 was not administered his/her: Clobazam 10 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Lacosamide 50 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Lamotrigine 100 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Oxcarbazepine 300 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Topiramate 300 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM. On 03/25/2025 at 11:05 AM an interview was conducted with RI #308 who said he/she was scheduled to receive medications for seizures twice a day. RI #308 said there was a few shifts that he/she did not receive any of his/her medications. On 03/21/2025 at 11:58 AM an interview was conducted with Registered Nurse (RN) #15. RN #15 reported she worked a double shift from 6 AM to 10 PM on 01/21/2025 on the Second Floor. RN #15 said something happened during the evening shift on 01/21/2025 and she was unable to pass any medications because she did not have access to residents' eMAR. On 03/22/2025 at 1:43 PM an interview was conducted with LPN #14 who reported she worked a double shift from 6 AM to 10 PM on 01/21/2025 on the Second Floor and was assigned to RI #15's rooms for medication passes. LPN #14 reported that RN #15 was assigned to RI #30 and RI #308's medication passes. LPN #14 said the facility's internet stopped functioning around 2 PM on 01/21/2025. LPN #14 said she was unable to access residents' eMAR. RN #15 said she did not administer medications or monitor resident blood glucose because the internet was down. LPN #14 said she did not know who needed their blood glucose checked off the top of her head, so she did not check. On 03/25/2025 at 1:32 PM, a telephone interview was conducted with the Medical Director (MD) and RI #12, 308, 40 and 15's physician. Regarding RI #12's missed medications the MD said, the likelihood of harm was that resident's blood sugars could go up if a resident did not receive their scheduled insulin and their blood sugars were not monitored as ordered. The MD said other things that could result from a person not receiving their insulin and not having their blood sugars checked as ordered would be short term DKA (Diabetic Ketoacidosis) and being placed on an insulin drip if blood sugars were too high. Regarding RI #308's missed medications, the MD said there was a likelihood of reoccurrence of seizures if a resident did not receive their seizure medications as ordered. Regarding RI #40's missed medications, the MD said a person with a history of diabetes, hypertension and stroke, and congestive heart failure not receiving their scheduled medications as ordered could cause their blood sugars to go up, fluid retention, and reoccurrence of heart failure. Regarding RI #15's missed medications the MD was asked, what was likely to occur if a resident did not receive their insulin, blood pressure, and seizure medications as ordered. The MD said there could be a reoccurrence of seizures, elevated blood pressures, and a person's blood sugars could go up. ******************************************************* On 03/26/2025, the facility submitted an acceptable removal plan, which documented: ****************************************************** 1) Process: To ensure that in the event of a power/internet outage the most updated Medical Record Administration (MAR) will be available for nurses that provide care to the residents: The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager, by the 1st of each month. The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits. The updated MAR will be located by the nursing stations. All, 100% of LPNs and RNs were in-serviced and completed on March 26th, 2025. Inservice was to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR. 2) In services On 3/20/2025 - 03/26/2025 the Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff (receptionist, Admissions Coordinator, Staffing Coordinator and Human Resources) and provided the education with 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-services included: a) the policy titled Policy on Computer or Internet Downtime and EHR, b) the standard of practice to: i) administer medication, ii) monitor blood glucose, iii) the implementation of the prescribing physicians' orders iv) the importance of documenting medication administration at the time of administration. c) Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order. d) Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy. The in-service was completed on March 26th, 2025 for 21 of 21 nurses, 9/9 PT staff, 16/16 of administrative staff. On 3/26/2025, 21 of 21 of the nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-service included that a printed MAR will be ready for the 1st of each month. A copy of the paper MAR will be kept at each nurses' station for use during downtime. Education included that RNs and LPNs who receives an order or confirms a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits. The Administrator educated the Director of Nursing and the Assistant Director of Nursing on 03/26/2025 that both of them are responsible to print the paper MAR to be ready for the 1st of each month and will be placed by each of the nurse's station. A monthly MAR print out schedule was created for clarity. The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm such as tropical depression, tropical storm, hurricane, or winter snow storm or other reason to expect downtime. A mock drill was conducted on 3/21/25 for the nursing personnel on shift. 2) Assessment Due to the failure of functionality of the router which caused the internet outage in the facility, the facility replaced the router on January 30th, 2025 through its internet provider. On 3/26/25 The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records. All residents that had the potential of being affected by this deficient practice from January 21st 2025 to January 22nd 2025. A report was generated from the electronic medical records to see which residents could have been affected during 1/21/25 - 1/22/25. There was a total of 56 of 56 residents were assessed by the medical director and completed on March 26th, 2025. No adverse effects were identified by the physician due to this deficient practice and no recommendations were made. 2) Quality Assurance An ad-hoc Quality Assurance meeting which included the entire IDT team ( Director of Nursing, Administrator, Rehab Director, Business Office Manager, Social Worker Director, Governing Body, Medical Director, Business Office Manager, Assistant Director of Nursing, Staffing Coordinator, Unit Manager, Dietary Director, Admissions Director) was conducted on March 25, 2025 in response to F600, F658, F580, and F760 to discuss the deficient practice and plan of correction. The nurses that were responsible were immediately educated about the in-proper practice that led to F600, F658, F580, and F760 and on the Policy on Computer or Internet Downtime and EHR access. The QA team discussed the needed in services/education for LPN #14, RN #15, LPN #11, RN #20, and RN #16. This plan was completed on March 26th, 2025. ******************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 03/26/2025.

Based on observations, interviews and a review of the facility policie's titled, DATING AND LABELING POLICY, ICE MACHINE SANITATION POLICY, And HAND WASHING POLICY. The facility failed to ensure: 1) food items in the freezer and cooler was labeled and dated; 2) the ice machine was free of a black substance; 3) a staff did not work on the dirty and clean side of the dish room without changing gloves and aprons. This had the potential to affect 53 of 53 residents who received meals from the kitchen. Finding Includes: 1) A review of a policy titled, DATING AND LABELING POLICY, with no date revealed: POLICY: All foods are to be labeled and dated appropriately to ensure food safety regulations are followed. PROCEDURE: . Once opened, the label must be updated with the current date and a use by date . (including date opened) . On 03/18/2025 at 8:39 AM, an during the initial tour of a large clear bag of okra and about six chicken fingers in a bag were observed in the freezer with no open or use by the date. Corn beef was observed in the cooler with no open or use by date. On 03/20/2025 at 12:43 PM, an interview was conducted with the Food Service Director (FSD). The FSD stated that corn beef in the cooler did not have an open and a use by date on it. She stated that the chicken tenders and okra in the freezer did not have an open or use by date on it. She stated staff should label and date food items before putting them back in the freezer or cooler. She continued to say it should be labeled with an opened and use by date on the item. She stated that the food items should have the name of the item on it. On the label it should be the date, the name of the item, the opened date or prepared date, the use by date, and the initial of the person who put it in the freezer. The FSD stated that food should be labeled and dated to keep in within the time line of safe food. She stated that the person who opened the food was responsible for dating and labeling it. The FSD stated that food that was not dated and label could cause food borne illness. The FSD stated that food was supposed to be labeled and dated. 2) A review of a facility's policy titled, ICE MACHINE SANITATION POLICY, with no date revealed: POLICY: kitchen staff will wash, rinse and sanitize the ice making machine . On 03/18/2025 at 8:39 AM, black substance was observed on the ice guard and lid on the inside of the ice machine in the kitchen. On 03/20/2025 at 12:52 PM, an interview was conducted with the FSD. The FSD was asked what was on the lid and guard on the inside of the ice machine. She stated that it was dirty with debris. She was asked why was it there and she said the machine had not been serviced. The FSD said she was responsible for making sure the ice machine was clean on the inside. The FSD stated that it was important that the ice machine was clean on the inside to make sure no bacteria or infection disease got into the ice that was served to the residents. The FSD said the ice machine lid and guard was cleaned monthly. 3) A review of an undated facility policy titled, HAND WASHING POLICY . revealed: . When to Wash Hands . Before and in between switching tasks. On 03/20/2025 at 8:59 AM, during an observation in dishware washing in the kitchen, one staff taking dirty trays and plates out of a cart and another staff was at the dish machine rinsing dishes. Dietary Aide (DA) #23 was on the dirty side of the dish room wearing gloves and an apron. She was rinsing off dishes, washing plates, trays, and plates covers. Her apron was touching dirty trays. She pulled dish ware out of the dish machine on the clean side of the dish room without changing the dirty apron or gloves. She removed dish ware on the clean side from the dish machine with the same gloves she used on the dirty side of the dish room. She was touching clean dishes, cups, plate covers, trays. She did not change her gloves or apron when she moved from the dirty side to the clean side to put clean items up. She was working both sides of the dish room. At the same time, DA #24 was observed not wearing gloves. He was on the dirty side washing out glasses to be placed in the dish machine. He left the dirty side with the same apron on and began putting up dishes on the clean side. DA #24 carried plate covers and plates out of the clean side of the dish room. The clean dishes were touching his apron as he put up the dishes. On 03/20/2025 at 9:12 AM, an interview was conducted with DA #23 who said she did she use the same gloves on the dirty and clean side of the dish room. She was asked why did she use the same gloves on the dirty side and clean side of the dish room. She stated she was a new employee. She stated that she worked both side of the dish room when someone was out. DA #23 said she did not change her apron from the dirty side to the clean side of the dish room. DA #23 stated that when she finished washing the dishes she should have changed her gloves. DA #23 was asked why should kitchen staff not work on the clean and dirty side of the dish room with the same gloves and apron. DA #23 stated because of cross-contamination 03/20/2025 at 12:31 PM, an interview was conducted with DA #24 who said he did not change his apron before went to the clean side after he rinsed out dishes on the dirty side. DA #24 stated he did not change the apron because he was so busy he did not think about it. On 03/20/2025 at 12:52 PM, an interview was conducted with the FSD. The FSD was asked why did the dietary aide work on the clean side and dirty side of the dish room. The FSD stated the person on the dirty side work both side because the new people were slow. The FSD said she was responsible for training kitchen staff on infection control in the kitchen. The FSD said it was cross-contamination when staff was worked on the clean and dirty side of the dish room with the same gloves and apron. The FSD said residents could get sick from the cross-contamination.

Based on observations, interview, record review and review of a facility policy titled, Answering the Call Light, the facility failed to ensure Resident Identifier (RI) #43's call light was in reach on 03/18/2025 and 03/19/2025 for RI #43 to be able to summon staff as needed. This deficient practice affected RI #43, one of 18 sampled residents. Findings Include: Review of a facility policy titled, Answering the Call Light, with a revised date of 10/2010, revealed the following: . The purpose of this procedure is to respond to the resident's request and needs. General Guidelines . 5. When the resident is in bed . be sure the call light is within easy reach of the resident . RI #43 was admitted to the facility on [DATE] and had a diagnosis of Vascular Dementia. RI #43's care plan with a need of potential for alteration in communication and impaired thought process related to vascular dementia, had an approach dated 02/18/2024, guiding staff to ensure/provide a safe environment with the call light in reach. On 03/18/2025 at 10:46 AM, the surveyor observed RI #43's call light on the floor behind the head of RI #43's bed, not accessible to RI #43 at this time. On 03/18/2025 at 12:16 PM, RI #43's call light remained on the floor behind the head of the bed out of RI #43's reach. On 03/19/2025 at 8:35 AM, RI #43's call light remained on the floor out of reach of RI #43. On 03/19/2025 at 2:40 PM, RI #43's call light remained on the floor behind the head of the bed out of RI #43's reach. On 03/19/2025 at 2:42 PM, the surveyor conducted an interview with the Registered Nurse (RN) Unit Manager/RN #17. RN #17 said RI #43 was able to use his/her call light. When asked how should RI #43's call light be positioned, RN #17 said on the bed where RI #43 could reach it. RN #17 said RI #43's call light was behind the bed on the floor and RI #43 could not reach it from that position. When asked why it would be important to ensure RI #43's call light was in easy reach, RN #17 said so if RI #43 needed anything like the aide or the nurse RI #43 could call and staff could get to RI #43 in a timely manner. RN #17 said it would be the responsibility of all staff to ensure RI #43's call light was in easy reach.

Based on interviews, record review, and review of a facility policy titled, Confidentiality of Information and Personal Privacy, the facility failed to ensure personal privacy and confidentiality were maintained for Resident Identifier (RI) #52. Specifically, on 01/29/2025, licensed staff provided medication, belonging to RI #52 and labeled with RI #52's information, to RI #308 upon discharge home from the facility. This deficient practice affected RI #52, one of 18 sampled residents. This deficient was cited as a result of the investigation or complaint/report number AL00050173. Findings Include: Review of a facility policy titled, Confidentiality of Information and Personal Privacy, with a revised date of 10/2017, revealed the following: Policy Statement Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation . 2. The facility will strive to protect the resident's privacy regarding his or her: . b. medical treatment . RI #308 was admitted to the facility 01/09/2025 and discharged on [DATE]. RI #52 was admitted to the facility on [DATE]. RI #52's Order Summary Report (Physician Orders) revealed RI #52 was prescribed Cyclobenzaprine (Flexeril) HCL (Hydrochloric Acid) Oral Tablet 5 MG (milligrams) by mouth three times a day for muscle spasms for 14 days. This order had a start date of 01/16/2025. On 03/19/2025 at 9:54 AM, a telephone interview was conducted with the RI #308's family member (FM). When asked about RI #308 being discharged home with someone's else medications, the FM said, her concern was someone not getting their medications because they went home with RI #308. The surveyor asked the complainant whose medications were sent home with RI #308. The complainant said, RI #52's name was the resident's name and the name of the medication in her possession was Cyclobenzaprine. On 03/19/2025 at 8:45 PM, a telephone interview was conducted with Registered Nurse (RN) #13, the nurse who discharged RI #308 home. When asked how did RI #52's Flexeril medication get sent home with RI #308, RN #13 said, she had RI #308's medications put to the side and had RI #308's things ready to go home. RN #13 said when the ambulance service came to pick up RI #308, she must have unintentionally placed RI #52's medication card into RI #308's bag of medications. On 03/20/2025 at 11:00 AM, an interview was conducted with the Director of Nursing (DON). When asked should a resident be sent home with another resident's medications, the DON said never. The DON said it would also be a privacy concern when someone, besides nursing staff, had information concerning the medications a resident was receiving. On 03/26/2025 at 3:42 PM, a telephone interview was conducted with the Pharmacist. When asked what type of concern it would be if a resident's medications were sent home with another resident being discharged from the facility, the Pharmacist said, that would be privacy for the resident whose medications were sent home. When asked what guidance she would give to the facility if a resident's medications were accidentally sent home with another resident, the Pharmacist said, she would have informed the facility to try and retrieve the medicine from the family and bring it back to the facility.

Based on interview, record review, review of a facility policy titled Abuse Policy, and review of a Facility Reported Incident (FRI), the facility failed to report to the State Agency an allegation of verbal abuse within two hours after the allegation was reported to the Administrator at approximately 11:20 AM on 01/30/2025. The State Agency did not receive the FRI alleging Certified Nursing Assistant (CNA) #10 verbally abused Resident Identifier (RI) RI #15, calling RI #15 a stupid mother fucker, until after 3:00 PM on 01/30/2025. This deficient practice affected RI #15; one of three residents sampled for Abuse. Findings Include: A facility policy titled Abuse Policy, updated 8/2022, documented: . The following table describes the different reporting requirements. What is to be reported. All alleged violations of abuse, neglect, . When . All alleged violations- 1) Immediately but no later than 2 hours if the allegation involves abuse . On 01/30/2025 at 3:04 PM, the State Agency (SA) received an Online Incident Report (FRI) from the facility alleging RI #15 was verbally abused by CNA #10 who called RI #15 a Stupid Motherfucker. The FRI documented the Licensed Physical Therapy Assistant (LPTA) became aware of the incident at 10:50 AM and the ADM was made aware of the incident at 11:20 AM. Contained within the facility's investigative file was a handwritten statement signed by the LPTA dated 01/30/2025 at 10:50 AM, which documented the following: Entered (RI #15's room number) and asked (RI #15) how (he/she) was feeling today. (He/she) responded, I'm being abused. That lady called me a 'stupid mother fucker.' When asked who called (him/her) that, (he/she) stated that it was a CNA. On 03/19/2025 at 3:49 PM an interview was conducted with LPTA. The LPTA stated RI #15 told her a CNA called him/her a motherfucker. The LPTA stated she reported the allegation of abuse to her supervisor and the Administrator (ADM). The LPTA stated abuse was to be reported immediately and the incident was verbal abuse. An interview was conducted with the ADM on 03/20/2025 at 11:32 AM. The ADM said he became aware of the abuse allegation involving RI #15 on 01/30/2025 at 11:20 AM and submitted the initial report to the SA on 01/30/2025 at 3:04 PM. A follow-up interview was conducted on 03/21/2025 at 5:38 PM with ADM who said the timeframe for reporting abuse to the SA was no later than two hours after the abuse.

Based on interviews, resident record review, review of a facility policy titled Abuse Policy, Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to conduct a thorough investigation for an incident of verbal abuse and take appropriate corrective actions to prevent recurrence. On 01/30/2025 during resident care Resident Identifier (RI) #15 was verbally abused by Certified Nursing Assistant (CNA) #10 who at the time of the verbal abuse, voiced being frustrated and tired from working double shifts the day prior. Because the facility's investigation failed to identify potential contributing factors of the verbal abuse, the facility was unable to develop and implement any new measures or actions to prevent recurrence. Further, handwritten statements in the investigative file failed to clearly and accurately reflect from whom the statements were obtained; and the facility failed to have any evidence in the investigative file or interviews to ensure other residents had not been verbally abused by CNA #10. This deficient practice was cited as a result of the investigation of complaint/report number AL00050214 and affected RI #15, one of three residents sampled for abuse. Findings Include: A facility policy titled Abuse Policy updated 08/2022 documented: Our residents have the right to be free from abuse, neglect . Prevention: . 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: 4. Allowing staff to express frustrations with their job; or in working with difficult residents; 8. Helping staff to deal appropriately with stress and emotions; 17. Identifying areas within the facility that may make abuse and/or neglect more likely to occur . 18. Striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met . Screening: 1. Monitoring staff on all shifts to identify inappropriate behaviors towards residents (e.g., using derogatory language, rough handling of residents .) 5. Identifying areas within the facility that may make abuse and/or neglect more likely to occur . Protection/Investigation: The facility protects individuals from abuse during investigation of any allegation of abuse. 1. Allegation must be reported to the Administrator and other officials. 2. Investigation will be initiated immediately. 3. Steps will be taken to prevent further potential abuse, and should include: Immediate suspension of the employee pending outcome of the investigation Potential staffing changes Potential increased supervision, Protection from retaliation, and Follow-up counseling for the resident(s). if warranted Corrective measures will be implemented to prevent recurrence. Response: The facility must ensure that any incidents of substantiated abuse are reported and analyzed and the appropriate corrective, remedial, disciplinary action occurs . 11. Upon receiving information concerning a report of abuse, the Director of Nursing Services will request that a representative of the Social Services Department monitor the resident's reactions to and statements regarding the incident and his/her involvement in the investigation. 12. Unless the resident requests otherwise, the social service representative will give the Administrator and the Director of Nursing Services a written report of his/her findings. 13. All phases of the investigation will be kept confidential . medical records. Administrative policies . notification of the resident's representative(sponsor) and Attending Physician . 15. Report to the State nurse aide registry . any knowledge it has of actions .an employee, which would indicate unfitness for service as a nurse aide . Assessment: The nurse will assess the individual and document related findings. Assessment data will include: . q. The physician and staff will help identify risk factors for abuse within the facility . Cause Identification 1. The staff . will investigate alleged occurrences of abuse . to clarify what happened and identify possible causes. Monitoring and Follow-Up 1. The staff . will monitor individuals who have been abused at least until their . mood, and function have stabilized, and periodically thereafter. On 01/30/2025 the State Agency received an Online Incident Report (FRI) from the facility alleging RI #15 was verbally abused by CNA #10, who called RI #15 a Stupid Motherfucker. The FRI documented actions taken included suspending CNA #10 pending the investigation, calling the Mental Health Nurse to review, initiating abuse and customer service in-services, and skin assessments were to be done on all residents with a Brief Interview for Mental Status (BIMS) score less than 12. RI #15 was admitted to the facility on [DATE] and readmitted on [DATE]. Contained within the facility's investigative file was a handwritten statement signed by the Administrator (ADM) dated 01/30/2025 which documented his interview with RI #15 as follows: . I was asked by a staff member to go see (RI #15) (He/she) was asking for me. I had just been made aware of the allegation of verbal abuse. (RI #15) and I discussed (his/her) issue. (RI #15) discussed with me that some people were treating (him/her) bad. (RI #15) said, (CNA #10s name). I asked (him/her) what was said She called me a stupid motherfucker and was rough with my legs when I was in bed. I told (him/her) that we would take care of (him/her) and (he/she) would not have to worry about that CNA. The handwritten interview also included that RI #15 denied pain and said CNA #10 was the only one who had been mean. The facility investigative file contained a summary of the incident involving RI #15 and CNA #10, signed by the ADM and dated 02/06/2025, documenting that after discussion of the allegation with RI #15, CNA #10 was suspended pending the investigation. The summary documented that discussions were had with the resident, roommate, and staff; statements were taken from each. Based on statements and interviews the facility concluded CNA #10 did curse RI #15 and was inappropriate in her handling of RI #15. The incident of verbal abuse was substantiated by the facility, abuse in-services for all staff were initiated, and they were going to terminate CNA #10. During an interview with the ADM on 03/20/2025 at 11:32 AM he stated, he became aware of RI #15 being verbally abused on 01/30/2025 at 11:20 AM. The ADM said, he went to talk to RI #15 who said the CNA called him/her a stupid motherfucker and was rough with his/her legs. The ADM said, actions taken to protect the alleged victim and other residents from abuse while the investigation was in process included suspension of CNA #10, and statements were obtained from the alleged abuser and witnesses (staff to whom RI #15 reported). When asked about the Mental Health Evaluation performed on RI #15, the ADM said, the psychiatric nurse practitioner was to see RI #15 on her next visit. The facility did not have evidence of a Mental Health visit conducted with RI #15 since the verbal abuse incident had occurred. Contained within the facility's investigative file was a handwritten statement titled Roommate Statement dated 1/30/29 signed by RI #15 and CNA #12 which documented the following: Upon getting the patient ready for lunch (he/she) stated to me that the other CNA that had (him/her) was very mean . and called (him/her) a stupid mother-fucker and (he/she) state that she said she is (tired) of you all acting like yall can't do anything. and (He/she) said, that the CNA was (also) upset because (his/her) clothes was dirty . During a follow up interview with ADM on 03/21/2025 at 5:38 PM the ADM was asked about the handwritten statement titled Roommate Statement since the statement was confusing as to who wrote it and who it was about. The ADM said, it appeared to be what RI #15 told one of the CNAs, it was a statement from the Restorative CNA #12. The ADM said, he did not take a statement from RI #15's roommate who was unable to give a statement, and Roommate Statement was written on the statement in error. When asked what discussions were held with the resident, roommate, and staff, as mentioned in the summary, the ADM said, there were not any discussions other than the handwritten witness statements from staff to whom RI #15 had initially reported to that he/she had been verbally abused. The ADM was asked about the handwritten statements in the investigative file having unclear signatures and not including job classifications because the LPTA's statement signature was not clear and there was no job classification, and CNA #12's statement was titled Roommate Statement and the signature was not clear and had no job classification. When asked how anyone reviewing the file would know who gave or wrote the statements and their job classification, the ADM said, human resources could pull the job classifications, but going forward he would ensure titles were assigned to the statements. Because the facility investigative file review revealed no interviews with other residents nor staff to determine if they had knowledge of any other instances of unreported abuse that involved CNA #10, the ADM was asked if any interviews were conducted with residents to find out if anyone else had been affected by CNA #10. The ADM said, no interviews were conducted with residents after RI #15's verbal abuse. When asked where the root cause analysis was documented, the ADM said, they had not done a root cause analysis to address RI #15's verbal abuse. When asked how the resident abuse could have been prevented, the ADM said, continuing education for abuse and they could have done some burnout training. When asked about a Quality Assurance Performance Improvement (QAPI) review or action plan, the ADM said, he did not know they were to write out a plan. Contained within the facility's investigative file was a handwritten statement signed by CNA #10 dated 01/30/2025, which documented she was tired and frustrated at the time RI #15 was verbally abused, as follows: I (CNA #10's name) went to (RI #15's) room to change (him/her) to get (him/her) up for activities . I said a few words like I was tired from . doing a double on the previous shift from the day before and I wasn't directly saying it to (RI#15) just whisper it under my breath due to the frustration . In the continued interview with the ADM on 03/21/2025 at 5:38 PM, the ADM was asked what type of supervision or monitoring was in place for staff who worked double shifts or extra hours, to make sure they were not burned out, frustrated, or too tired. The ADM, said, they did not have that. When asked what type of training the staff received specifically about burnout or frustration after working increased hours, the ADM said, there was not one being done. When asked what evidence there was that CNA #10 received training on burnout or frustration prior to her verbal abuse against RI #15, the ADM said, she had not received that type of training. When asked what type of process the facility had to encourage staff to express concerns, the ADM said, they did not have that type of process currently. When asked if Social Services or Mental Health Nurses had evaluated RI #15 after the verbal abuse, the ADM said, no. An interview was conducted on 03/22/2025 at 12:35 PM with Social Services Director (SSD). When asked about RI #15, the SSD said, she just learned of RI #15's abuse during the survey a few days ago and she had not assessed RI #15. The SSD said, she had not been informed a Mental Health Nurse was to evaluate RI #15. The SSD said, she should have been made aware. During an interview with Director of Nursing (DON) on 03/22/2025 at 5:51 PM, she was given a copy of the Facility Reported Incident (FRI) submitted on 01/30/2025 per ADM to read. The DON stated there was no notification of SSD nor the Mental Health Nurse. The DON stated that not notifying the SSD or Mental Health Nurse could have resulted in emotional distress for RI #15.

Based on interviews and review of the Administrator job description, the facility's Administrator, responsible for the day-to-day operation of the facility failed to ensure the QAPI (Quality Assurance and Performance Improvement) committee met to identify all concerns using root cause analysis to ensure corrective actions needed with plans to prevent further occurrence including ongoing monitoring after Resident Identifier (RI) #1 eloped from the facility on 02/05/2023. This failure placed all 53 residents residing in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death, due to the ongoing risk of elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, S483.70 Administration at a scope and severity of L. On 04/06/2024 at 12:44 PM, the Director of Nursing (DON), Owner, and Regional Consultant (via phone) were provided a copy of the Immediate Jeopardy Template and notified of the findings at the immediate jeopardy level in the area of F 835 - Administration. The IJ began on 02/05/2023 and continued until 04/08/2024 when survey team verified onsite that corrective actions had been implemented. On 04/08/2024 the immediate jeopardy was removed, F835 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL00043280 and AL00046465. Findings include: Cross-Reference F689, F867, and F837. A review of the Administrator job description documented: . Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and Company policies so as to maintain care for the residents while achieving the facility's business objectives . The facility policy titled Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership revised date of March 2020 documented: Policy Statement The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body. Policy Interpretation and Implementation 1. The administrator, whether a member of the QAPI committee of not, is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body. 4. The responsibilities of the QAPI committee are to: . c. identify and help resolve negative outcomes . d. utilize root cause analysis to help identify where identified problems point to underlying systematic problems; . An interview was conducted on 04/03/2024 at 7:36 PM with the Former Administrator #1, who said that she started as the administrator in January of 2022, and held the position for over a year. She said that she served as the Abuse Coordinator and was available round the clock to address any allegations, which were reported to Alabama Department of Public Health (ADPH) and the ombudsman. When asked about RI #1 leaving the premises on 02/05/2023, she stated that she did not recall the specific incident but remembered that he/she was discovered on a nearby street and brought back to the facility. Regarding the protocol for staff encountering a resident off-site, she stated that they should remain with the resident and contact the facility for assistance. When asked if the staff member followed the protocol when RI #1 was found off-site, she said that the CNA received one on one re-education. After RI #1 arrived back to the facility a body audit was conducted, and he/she was sent to the hospital. Additionally, the incident was reported to ADPH. In response to the question about how far RI #1 had gotten off-site, she replied approximately 0.5 miles. The Former Administrator said RI #1 had exited the building through a side door that had a closing issue. When asked about the measures taken to prevent RI #1 or other residents from leaving the building, she stated that the door had been changed out. She explained that when RI #1 managed to leave the building, the door became stuck when a staff member took the trash to the dumpster. Finally, when asked if this incident was taken to Quality Assurance (QA), she said that typically all reportable incidents are presented to QAPI. She was uncertain if an emergency QAPI was conducted after the incident. On 04/05/2024 at 3:02 PM, a follow-up interview was conducted with the Former Administrator #1. During the interview, she was asked about the education provided to the staff after RI #1 eloped. She said that one on one training was conducted with CNA #11, and typically elopement training would have been conducted as well, although she was uncertain if it had taken place. According to her, the training records were usually stored in the staff members' personnel files. The FA #1 was also asked about the concern regarding leaving doors unsecured when a resident expressed a desire to leave the building. She stated that it posed a general safety risk. When questioned about why QAPI did not create an action plan after RI #1 eloped from the facility, she explained that all QAPI records were maintained on the medical records computer and no formal plan was implemented. An interview was conducted with the Director of Nursing (DON) on 04/06/2024 at 11:41 AM. During the interview, the DON was questioned regarding the documentation of the incident when RI #1 eloped from the facility. She stated that there was no documentation available. The DON said that the QAPI program was overseen by the Administrator, with monthly meetings scheduled. When asked about evidence of a QAPI meeting following RI #1's elopement, she said there was no evidence. Finally, when questioned about the facility's compliance with effective administration, the DON said they were not in compliance. ******************************************************************** On 04/08/2024 at 4:44 PM, the facility submitted an acceptable Removal Plan for F835 which documented: ************************************************************************* 1. After RI #1 eloped from the facility on February 5th, 2023, the Administrator failed to ensure the QAPI committee met to identify all concerns using root cause analysis to ensure corrective actions needed with plans to prevent further occurrence including ongoing monitoring. 2. Removal plan written on April 6th, 2024, by Regional Consultant 3. The new Administrator started on April 8th, 2024, and was trained by the Regional Consultant on the QAPI Policy, Quality Assurance and Performance Improvement (QAPI) Program-Governance Leadership and their responsibility of ensuring QAPI compliance and resident safety. The NHA was also trained on the new Door Safety Assessment and Review Policy, Elopement Prevention and Response, the Elopement Response Policy. The new administrator was trained on the Administrator's job responsibilities. 4. The facility has a policy and procedure on QAPI as well as the NHA's responsibility to ensure QAPI. Policy is from med pass and is titled Quality Assurance and Performance Improvement (QAPI) Program-Governance Leadership. Administrator Training completed on April 8th, 2024. *********************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 04/08/2024 and the scope and severity was lowered to no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on record review, interviews and the facility policy Governing Body Duties and Responsibilities, the governing body failed to provide oversight to the QAPI committee. The Governing Body failed to provide guidance to the QAPI committee to use root cause analysis to determine all concerns and to make a determination of corrective actions needed with plans to prevent further occurrence after Resident Identifier (RI) #1 eloped from the facility on 02/05/2023. On 02/05/2023, RI #1 told the staff he/she wanted to leave the facility around 1:10 PM. RI #1 was given a psychotropic medication at 2:21 PM, then was not supervised. RI #1 left the facility through an unsecured door. RI #1 was seen by an off-duty staff member at approximately 3:30 PM on a busy two-lane road near the facility, but the staff member did not stay with the resident to provide supervision, and left RI #1 in unsafe environment. RI #1 was not returned to the facility until another off-duty staff member returned him/her to the facility at approximately 4:10 PM. This failure affected all 53 residents residing in the facility. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, S483.70 Administration at a scope and severity of L. On 04/06/2024 at 12:44 PM, The Owner of the company, the Corporate Consultant, and the Director of Nursing, were provided a copy of the immediate jeopardy template and notified of the immediate jeopardy finding in the area of Governing Body, F837. The IJ began on 02/05/2023 and continued until 04/08/2024 when survey team verified onsite that corrective actions had been implemented. On 04/08/2024 the immediate jeopardy was removed, F837 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. Further the Governing Body failed to ensure the facility had an acting Administrator from 03/29/2024 through 04/08/2024. This deficiency was cited as a result of the investigation of complaint/report number AL00043280. Cross-Reference F689, F835, and F867. Findings Include: Review of an undated facility policy titled Governing Body Duties and Responsibilities documented: Policy Statement/Purpose: The Company must have a Governing Body that assumes full legal responsibility for establishing and implementing policies regarding the management and operation of the facility. Policy Interpretation and Implementation: 1. GOVERNING BODY DUTIES AND RESPONSIBILITIES A. Policies and Procedures: The Governing Body is legally responsible for establishing and implementing policies regarding the management and operation of the facility. The Governing Body, in conjunction with regular reporting by the Administrator, should assess on a regular basis that services are being provided in accordance with facility policies, that policies are current and reflect an acceptable standard of care, that care is coordinated among professional staff, and that there is effective use of resources. C. Appointment of Administrator: The Governing Body is responsible for appointing an Administrator who shall: . c. Report to and be accountable to the Governing Body. i. Facility will determine a means and schedule for regular reporting to the Governing Body and how the Governing Body will respond to the Administrator. The facility policy titled Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership revised date of March 2020 documented: Policy Statement The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body. Policy Interpretation and Implementation 1. The administrator, whether a member of the QAPI committee of not, is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body. 2. The governing body is responsible for ensuring the QAPI program: a. is implemented . b. is sustained through transitions of leadership and staffing . On 04/05/2024 an interview was conducted with the Facility Owner #2. FO #2 said he only remembered that RI #1 had left the building either through the front or side door. FO #2 said when the staff were taking out the garbage or taking a break, they were leaving the door ajar. FO #2 said the staff were putting on top of the door so the door would not close when they left because they did not want to walk around to the front door. FO #2 did not recall if the incident was reviewed by the Quality Assurance, also called QAPI, team. FO #2 did not know how often the QAPI committee meet and said the Director of Nursing was currently responsible for the QAPI program. On 04/05/2024 at 5:33 PM an interview was conducted with the Facility Owner (FO) #1. He said that Facility Owner #2 and himself were the Governing Body. FO #1 said he did not remember the oversight he gave to Former Administrator #1 during the incident involving RI #1. He said he would have instructed to do a full investigation of what occurred, how it occurred, at the time, interview any staff and resident, that might have been around the area around that time. The facility would have reported it to the authorities. FO #1 said he did not remember all the details of the incident. He directed them to check all exit doors, do a head count, they evaluated any other concerns, changed the codes of doors, educated all staff on proper protocol and the necessity for ensuring all doors are properly closed and secured at all times. When he was asked where this information was documented he said that was a good question. He said he could not answer if there was a formal plan done; he said the facility had a nurse consultant that would have done one and there should have been a sign-in sheet. When asked what oversight was the governing body providing now since the facility did not have an Administrator. FO #1 said the duties of the governing body were to oversee the facility and the Administrator and to be involved in QAPI and administration. On 04/24/2024 at 4:22 PM an interview was conducted with the Regional Nurse Consultant (RNC). The RNC said it was important for the facility to have an Administrator so that they could oversee what was going on in the facility, oversee regulatory issues, develop monitor any care approaches with the deptartment heads, and to supervise the home and department heads. The RNC said from 03/29/2024 to 04/08/2024 the facility did not have an acting Administrator. ********************************************************** On 04/08/2024 at 4:44 PM, the facility submitted an acceptable Removal Plan for F 837 which documented: 1. RI #1 eloped from the facility on 2/5/2023, the Governing Body failed to provide oversight to the Administrator and QAPI committee and guide the committee to identify all concerns using root cause analysis to ensure corrective actions needed were in place with plans to prevent further occurrence including ongoing monitoring. 2. On April 6th, 2024, the F867 Removal Plan was written by Regional Consultant. 3. On April 7th, 2024, the Regional Consultant completed education with The Governing Body (Owner, Regional Director via phone, and Regional Consultant via phone) on their responsibility to provide oversight over the Administrator and ensuring the QAPI Program meets to identify all concerns using root cause analysis and developing corrective actions needed with plans to prevent further occurrence including ongoing monitoring. 4. On April 7th, 2024, the Governing Body met with the Director of Nursing to discuss ensuring an effective QAPI committee (Director of Nursing, Medical Director via phone, Facility Owner, Dietary Manager, Social Services, Activities Director, Environmental Services/Maintenance Director, Rehabilitation Director, MDS Coordinator, Staff Development/Infection Control via phone, Unit Manager 2nd Floor, Unit Manager, 3rd Floor, Business Office Manager, Staffing Coordinator, Human Resources Director, Wound Care Coordinator, Housekeeping Supervisor) takes place in the facility, that can function to identify all concerns with incidents, perform root cause analysis and determine corrective actions needed to prevent further incidents. 5. On April 7th, 2024, an emergency QAPI meeting was then held by the Governing Body. The Governing Body guided the QAPI committee in identifying root causes and corrective actions needing to take place for elopement prevention. 6. Root causes identified, on April 7th, 2024, were lack of staff education regarding elopement, staff failure to supervise the resident at risk, staff not ensuring all doors and exits were secure, and further, staff not ensuring resident safety if observed in an unsafe environment. 7. On April 7th, 2024, at 0900, The Governing Body met with the QAPI committee to review the new and updated policies and procedures Door Safety Assessment and Review Policy, Elopement Prevention and Response, and the Elopement Response Policy that will ensure staff is able to respond appropriately to residents at risk for elopement as well as to residents observed in an unsafe environment. 8. The facility has a policy and procedure on QAPI as well as the NHA's responsibility to ensure QAPI. Policy is from med pass and is titled Quality Assurance and Performance Improvement (QAPI) Program-Governance Leadership. Governing Body meetings are scheduled weekly every Thursday via Teams. 9. On April 8th, 2024, the Governing Body met with the new Administrator to ensure an effective QAPI committee takes place in the facility, that can function to identify all concerns with incidents, perform root cause analysis and determine corrective actions needed to prevent further incidents. The Governing Body also provided training to the new administrator on Quality Assurance and Performance Improvement (QAPI) Program-Governance Leadership and that the Governing Body meetings are scheduled weekly every Thursday via Teams. *********************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 04/08/2024 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on record review, the facility policy Quality Assurance and Performance Improvement (QAPI) Program, and the facility's policy Quality Assurance and Performance Improvement (QAPI) Program - Analysis and Action the facility's QAPI committee failed to thoroughly review all factors related to Resident Identifier (RI) #1's elopement on 02/05/2023. The facility further failed to develop and implement effective plans and interventions to prevent recurrence and ensure the facility was secured. On 02/05/2023 RI #1 exited the facility through an unsecured side door without staff's knowledge. RI #1 was further left by staff unsupervised in an unsafe area 2,640 feet from the facility. The failure of the QAPI committee to thoroughly review all factors and implement effective interventions following an adverse event had the potential to affect all 53 residents. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, S483.75 Quality Assurance and Performance Improvement at a scope and severity of L. On 04/06/2024 at 12:44 PM, The Facility's Owner, the Corporate Consultant, and the Director of Nursing, were provided a copy of the immediate jeopardy template and notified of the immediate jeopardy finding in the area of Quality Assurance and Performance Improvement (QAPI), F867-QAPI/Quality Assessment and Assurance (QAA). The IJ began on 02/05/2023 and continued until 04/08/2024 when survey team verified onsite that corrective actions had been implemented. On 04/08/2024 the immediate jeopardy was removed, F 867 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL00043280. Findings Include: Cross-Reference F689, F835, and F837. A review of a facility policy Quality Assurance and Performance Improvement (QAPI) Program, with a revised date of February 2020 documented Policy Statement This facility shall develop, implement, and maintain an ongoing, facility wide data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Authority 1. The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program A review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program - Analysis and Action dated March 2020 documented: .Policy Interpretation and Implementation 1. The QAPI Program, overseen by the QAPI Committee is designed to identify and address quality deficiencies through analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level. 2. The methodology for analysis and action is guided by a written QAPI plan that includes: a. definition of the problem, based on information obtained through data, self-assessments, and feedback systems. b. an analysis of the root cause of the problem from a systems perspective. c. establishing measurable goals and benchmarks for improvement. d. specific interventions aimed at correcting the problem and achieving the stated goals or benchmarks. e. methods and frequency of monitoring performance improvement objectives. 3. The QAPI committee is responsible for analyzing identified problems, establishing corrective actions, measuring progress against the established goals and benchmarks, communicating information to staff, residents, and reporting findings to the administrator and governing board . On 04/06/2024 at 11:41 the Director of Nursing said she could not find QAPI minutes from the incident of elopement that occurred on 02/05/2023. On 04/03/2024 at 7:36 PM during a phone interview with the Former Administrator, she said she did not recall much about the incident of RI #1 leaving the facility he/she was found and returned. She said staff should stay with the resident and call the facility for help if they will not come back with them. She said RI #1 left the building through a side door that had an issue with closing. She said she was not sure what was done when RI #1 expressed wanting to leave the building. The former Administrator said she did not know if there was an emergency QAPI meeting. On 04/06/2024 at 11:41 AM, during an interview with the Director of Nursing, she said there was no evidence of what was done after RI #1 eloped from the facility. She said she had been employed at that facility since January 2024. The DON said the concern of not having evidence of what was done after RI #1 eloped from the facility was the facility could not justify what was done or that staff were provided training and education. The DON said that after RI #1 eloped from the facility, the facility should have conducted proper notification, investigation, in-services, monitoring of the resident, identified the root cause of the incident, and ensured safety measures were implemented after the incident. The DON said the Administrator was over the QA/QAPI program and meetings were supposed to be held monthly. She said the QAPI team was the Administrator, DON, Social Services, MDS, Activities, basically key personal and the Medical Director. ********************************************************************************************************** On 04/08/2024 at 4:44 PM, the facility submitted an acceptable Removal Plan for F867 which documented: 1. The QAPI committee failed to develop and implement effective interventions including ongoing monitoring to prevent recurrence after the facility failed to prevent RI #1 from leaving the facility on 02/05/2023 unsupervised, through an unsecure side door exiting to the outside of the building. RI #1 was further left by staff unsupervised in an unsafe area 2640 feet from the facility crossing a two-lane road with oncoming traffic. 2. On April 6th, 2024, the F867 Removal plan was written by Regional Consultant. 3. On April 7th, 2024, the Governing Body (Owner, Regional Director, and Regional Consultant) met with the Director of Nursing to discuss ensuring an effective QAPI committee takes place in the facility, that can function to identify all concerns with incidents, perform root cause analysis and determine corrective actions needed to prevent further incidents. An emergency QAPI meeting was then held by the Governing Body. The Governing Body guided the QAPI committee in identifying root causes and corrective actions needing to take place for elopement prevention. 4. On April 7th, 2024, the Regional Consultant provided training to the QAPI committee (Director of Nursing, Medical Director via phone, Facility Owner, Dietary Manager, Social Services, Activities Director, Environmental Services/Maintenance Director, Rehabilitation Director, MDS Coordinator, Staff Development/Infection Control via phone, Unit Manager 2nd Floor, Unit Manager, 3rd Floor, Business Office Manager, Staffing Coordinator, Human Resources Director, Wound Care Coordinator, Housekeeping Supervisor) during an emergency QAPI meeting to ensure an effective QAPI committee takes place in the facility, that can function to identify all concerns with incidents, perform root cause analysis and determine corrective actions needed to prevent further incidents. The QAPI Committee was trained on the facility's QAPI Policy Quality Assurance and Performance Improvement (QAPI) Program-Governance Leadership. 5. On April 7th, 2024, root causes identified were lack of staff education regarding elopement, staff failure to supervise the resident at risk, staff not ensuring all doors and exits were secure, and further, staff not ensuring resident safety if observed in an unsafe environment. 6. On April 7th, 2024, the QAPI committee reviewed the new and updated policies and procedures The Door Safety Assessment and Review, Elopement Prevention and Response, and Elopement Response policies to ensure staff are able to respond appropriately to residents at risk for elopement as well as to residents observed in an unsafe environment. 7. On April 7th, 2024, the Door Safety Assessment and Review, Elopement Prevention and Response, and Elopement Response policies were developed and implemented to ensure staff respond appropriately to residents at risk for elopement as well as residents observed in an unsafe environment. ********************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 04/08/2024 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance. 47408 An interview was conducted on 04-24-2024 at 11:15 AM with former adminstrator. She was asked how often QAPI meetings were held and she stated monthly. When asked who attended the QAPI meetings she stated most department heads, the Administrator, Director of Nursing and maintenance. She stated the Medical Director came periodically but was updated every other week by phone or email .She was asked what was the most recent PIP (program improvement plan) the QAPI committee implemented. She stated she did not remember. She was asked if QAPI Plan included adverse event monitoring; she stated yes and that she was recording anything that was reported to the state including reportables, FRI's and emergency plans that were put in place to prevent episodes from happening and abuse plans. She was asked what direction was provided by the Governing Body regarding the QAPI Program and she stated she did not remember; only had two during the time she she was employed. The facility was unable to locate the records. During an interview conducted on 04-24-2024 at 3:00 PM with former administrator. she was asked how were results of the QAPI meeting communicated to the Governing Body. She stated usually by phone or in person and the local owner was usually present. When asked how the Governing Body provided oversight to the QAPI Program she stated meetings were held quarterly.When asked what actions were taken by the Governing Body to ensure QAPI Program was sustained during changes of leadership/administrators she stated she could not account for the other governing bodies. She was asked why it was important for QAPI to meet at least quarterly she stated so we can look at any trending areas that need addressing and find the root cause such as falls and other incidents. On 04-24-2024 at 4:22 PM an interview was conducted with the Regional Consultant who stated she has been a consultant since October 2023 and she does all the recruiting and oversees any regulatory issues. She further stated some situations can be taken care of via phone. When asked what her role was as Governing Body of the facility she stated she handles governing calls and any issues that may come up. When asked what actions were taken by the Governing Body to ensure QAPI Program was sustained during changes of leadership/administrators she stated previously they were doing QAPI but they were not scanning the data to shared drive. Going forward during our weekly governing body calls will be shared what is to be discussed in our QAPI meetings. She stated governing body calls are held weekly on Thursdays. During an interview with the adminstator on 04-25-2024 at 12:15 PM she was asked to provide QAPI meeting records for October, November and December 2023 and she replied there is no QAPI papers at all for October 2023, November sign in was blank and the material to be discussed for November 2023 was blank. She furthe stated the December QAPI document and the signature page was blank. When asked where the QAPI documentation that addressed the 10/11/2023 incident involving RI#3 was she stated she could not answer that.

Based on interviews, medical record review, review of the facility's policies titled Wandering and Elopements, and Elopement Guideline and review of a facility document summarizing the facility's investigation into Resident Identifier (RI) #1's elopement, facility failed: 1) to supervise RI #1 after he/she stated he/she had a desire to leave and was given a one-time dose of Ativan, 2) to ensure all doors in the building were secure and closed properly to prevent residents leaving the facility without staff's knowledge, and 3) to ensure RI #1 was not left by a staff member in an unsafe environment. On 02/05/2023, RI #1 told the staff he/she wanted to leave the facility around 1:10 PM. RI #1 was given Ativan, a psychotropic medication, at 2:21 PM, then was not supervised nor observed. RI #1 left the facility through an unsecured door. RI #1 was seen by an off-duty staff member at approximately 3:30 PM on a busy two-lane road near the facility. The staff member did not stay with the resident to provide supervision and left RI #1 in an unsafe environment. RI #1 was not returned to the facility until another off-duty staff member returned him/her to the facility at approximately 4:10 PM. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (d) Free of Accident Hazards/Supervision/Devises at a scope and severity of J. On 04/06/2024 at 12:44 PM, the Director of Nursing (DON), Owner, and Regional Consultant (via phone) were provided a copy of the Immediate Jeopardy Template and notified of the findings of substandard quality of care at the Immediate Jeopardy level in the area of Quality of Care, at F689-Free of Accident Hazards/Supervision/Devices. The IJ began on 02/05/2023 and continued until 04/08/2024 when survey team verified onsite that corrective actions had been implemented. On 04/08/2024 the immediate jeopardy was removed, F689 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL00043280. Findings include: A facility policy titled, Wandering and Elopements with an updated date of 07/06/2021, documented, Policy Statement The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation . 2. If an employee observes a resident leaving the premises, he/she should: . C. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident is attempting to leave or has left the premises. A facility policy titled, Elopement Guideline dated of 07/06/2021, documented, Purpose Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The facility's initial report titled Alabama Department of Public Health Online Incident Reporting System dated of 02/05/2023, documented, . Narrative summary of incident: (Certified Nursing Assistant (CNA) #11) alerted staff that (RI #1) eloped around 3:20 PM. An off duty nurse was driving to the facility and saw (RI #1) on the side of the road . She asked him/her to get in her car and he/she complied. She drove him/her to the facility. He/she told the staff that he/she saw someone go out the side door . and followed her out. He/she said he/she .was going to buy beer . Actions taken by the facility in response to the incident . Facility will be notifying the hospital in report that (RI #1) should stay at the hospital for an assessment to see if there is a medical reason for his/her agitation and some confusion noted . The facility's investigation documentation titled 5 Day Investigation Report dated 02/10/2023, documented, . It was reported on February 5, 2023, that (RI #1) had eloped from the facility . and was found . walking . (CNA #11) saw him/her when she was leaving the facility . She pulled over in an attempt to get him/her to go back to the facility with her but he/she kept refusing. She drove back to the facility and had front desk person call a code . An agency employee who was on her way to the facility . picked him/her up and brought him/her back to the facility. (RI #1) told the staff that he/she was watching staff go out the side door when he/she saw someone go out and noticed that the door wasn't shut so he/she pushed on the door and was able to get out. He/she told them he/she got his/her money ($30) Friday and was walking to get a beer. Prior to this incident, (RI #1) had been exhibiting agitation and was wanting to get out of the facility. This behavior was noted around 1:15 PM the day of the incident. The DON and Medical Director were notified and orders to give him/her a one-time dose of 1 mg Lorazepam for the agitation stemming from Altered Mental Status was obtained along with an order to send out to hospital if the symptoms continued to worsen. Before they had a chance to discharge (him/her), the resident had already eloped. RI #1 has a BIMS (Brief Interview Mental Status) score of 12 . The agitation and insistence on leaving the facility by walking has not been (his/her) norm . RI #1 was admitted to the facility on [DATE] with diagnoses to include Cerebral Infraction and Altered Mental Status. RI #1's Minimum Data Set with an Assessment Reference date of 01/02/2023, documented RI #1 had a Brief Interview Mental Status (BIMS) score of 12 of 15, which means RI #1 was moderately cognitive impaired. Section G of the MDS indicated RI #1's walking ability with or without assistive device was not steady and he/she was only able to stabilize himself/herself with staff's assistance. RI #1's Progress Notes included a Behavior Note dated of 02/05/2024 at 1:15 PM that documented, .Resident is walking around the second floor yelling and screaming (he/she) is about to leave here, and (he/she) is calling the police and will jump out the window if (he/she) has to. The note further indicated the DON and MD were contacted and an order was received for one-time dose of Ativan (lorazepam). The note indicated to contact his/her family and also if his/her behavior continued to send him/her to hospital for evaluation. The note was electronically signed by Licensed Practical Nurse (LPN) #18. A review RI #1's Medication Administration Record for February 2023 indicated lorazepam 1 (one) milligram oral tablet was administered on 02/05/2023 at 2:21 PM. A telephone interview was conducted with CNA #11 on 04/03/2024 at 12:32 PM. CNA #11 stated on 02/05/2023, around 3:30 PM, after leaving the building she saw RI #1 walking on the side of the road. CNA #11 said RI #1 was kind of stumbling which made her think he/she was getting tired. She stated she turned her car around and tried to pick up RI #1, but RI #1 refused. She stated after RI #1 refused, she went to the facility to let them know RI #1 was up the street and they needed to call a code. CNA #11 said that she should have stayed with RI #1, called the facility to let them know a resident had gotten out of the facility and waited for someone to come to assist her. CNA #11 said RI #1 had gotten hysterical, and she panicked. CNA #11 said it was a poor decision on her part. She stated RI #1 started getting loud, yelling, and cursing. An interview was conducted with CNA #13 on 04/04/2024 at 4:09 PM. CNA #13 stated after RI #1 was returned to the facility, she asked RI #1 why did he/she leave the facility. She stated, RI #1 told her the football game was on and he/she wanted some beer. CNA #13 stated that RI #1 said that he/she watched girl go out the door, and then he/she just kicked it with his/her feet and went out the door. CNA #13 said the RI #1 exited through the door used by staff. An interview was conducted with CNA #14 at 4:34 PM. CNA #14 stated on 02/05/2023, she saw RI #1 on the second floor. RI #1 told her that he/she was going to get himself/herself some cigarettes and some beer. CNA #14 said that she told RI #1 to not leave the facility. She stated she was not assigned to RI #1 on that day; however, she informed the nurse about his/her behavior. CNA #14 stated after she informed the nurse of RI #1's behavior she did not see RI #1 anymore, she assumed he/she went back upstairs. A telephone interview was conducted with CNA #15 on 04/04/2024 at 5:00 PM. CNA #15 stated RI #1 left out the facility through a side door. She stated staff had to make sure it was closed all the way or it would not be closed. CNA #15 said the door had been that way as long as she could recall and had worked at the facility two years. An interview was conducted with the Maintenance Director (MTD) on 04/04/2024 at 5:20 PM. The MTD stated the side door was not broken. He stated the CNAs would leave the door open when they took the trash out. He said the staff would make it look like the door was closed and just rest it on the latch, so they would not have to go all the way around to the front door to reenter. A telephone interview was conducted with the Former Administrator #1 on 04/03/2024 at 7:36 PM. The FA #1 said she was unsure of what interventions were put in place after RI #1 stated earlier in the day that he/she wanted to leave the building. She stated RI #1 exited the facility through the side door which was used by staff. She stated the facility had issues with that door closing. The FA #1 stated RI #1 was found a half mile from the facility. The FA #1 said the resident usually used a rolling walker and it was found at the top of the hill near the entrance to the facility. The FA #1 stated per protocol, the staff should have tried to get the resident to come back to the facility when the staff saw a resident off the premises. The FA #1 continued to say, if the resident would not return with that staff, the staff should stay with the resident and call the facility for help. The FA #1 said CNA #11 did not follow the facility's protocol. An interview was conducted with the Physical Therapy Director (PTD) on 04/24/2024 at 3:50 PM. The PTD said RI #1 was unable to walk without the use of his/her rolling walker. A follow-up interview was conducted with the FA #1 on 04/05/2024 at 3:02 PM. The FA #1 stated she was unsure why staff did not keep an eye on RI #1 when he/she told staff he/she wanted to leave the building and had been given lorazepam on 02/05/2023. She was asked what interventions were in place to prevent RI #1 from leaving the facility without staff's knowledge. The FA #1 said when she was there all of the exit doors required a code to exit. She stated the concern with staff leaving doors unsecured was residents would be able to elope from the building without anyone knowing and it was a general safety risk. She said the facility did not allowing doors to be propped open. An interview was conducted with the facility's Owner (FO) #2 on 04/05/2024 at 11:00 AM. The FO #2 stated the concern with the unsecure door was when employees taking out the garbage or taking a break, they were leaving the door ajar. They were putting something on top of the door so the door would not close when they left, because they did not want to walk around to the front door. On 04/02/2024 at 6:00 PM, surveyor observed front door to facility propped opened with a brick. ************************* On 04/08/2024 at 4:44 PM, the facility submitted an acceptable Removal Plan for F689 which documented: 1. R#1 expressed desire to leave the facility. The facility received orders to administer Ativan but failed to provide supervision of RI #1 and to ensure all exits were secure. Therefore, R#1 was able to elope from the facility. 2. On April 6th, 2024, the F689 Removal Plan was written by Regional Consultant. 3. On April 7th, 2024, the Governing Body and QAPI committee (Director of Nursing, Medical Director via phone, Facility Owner, Dietary Manager, Social Services, Activities Director, Environmental Services/Maintenance Director, Rehabilitation Director, MDS Coordinator, Staff Development/Infection Control via phone, Unit Manager 2nd Floor, Unit Manager, 3rd Floor, Business Office Manager, Staffing Coordinator, Human Resources Director, Wound Care Coordinator, Housekeeping Supervisor) reviewed the current Elopement Policy and were educated on the following new policies by the Regional Consultant: i. The Door Safety Assessment and Review Policy, ii. The Elopement Response iii. The Elopement Response and Prevention Policy During the Governing Body and QAPI meeting, the facility discussed the elopement incident and identified a root cause of what failed to ensure the residents' safety. Upon review of the facility's current policies, the above policies were developed and implemented based on the root cause and debriefing of the incident and investigation. It was discovered the facility did not have a policy and procedure on what staff should do if a resident would voice and/or express desire to leave the facility. Further, the facility did not have a policy and procedure on what staff should do if a resident is found off campus. During the meeting, The Governing Body and QAPI committee made recommendations on doing monthly elopement drills, weekly door checks on ensuring doors are secure by the Maintenance Director, as well as daily routine checks by IDT. The facility failed to ensure the door was secure when a staff member exited the facility, thus, training on ensuring doors are secure upon exiting the facility was completed. In February 2023, following this incident, an alarm was placed on this door to alert staff when the door is not fully secure. 4. On April 7th, 2024, the Governing Body (Owner, Regional Director via phone, and Regional Consultant via phone) met and discussed the policies being implemented. 5. On June 15th, 2023, RI #1 was discharged from the facility. 6. The facility does not have anyone expressing the desire to leave the facility currently based on review of the 24-hour report along with Q-shift nurse report check offs. An assessment scoring report, consisting of residents' wander risk scores, was checked to ensure an elopement binder and appropriate interventions are in place. The facility also places residents that are identified as High Risk to Wander as well as an Elopement Risk on the 3rd floor, as room availability permits, as a preventative measure for elopement. Elopement book assessed and checked on April 6th, 2024. No discrepancies were identified. SYSTEMIC CHANGES 7. On April 6th, 2024, the following policies Door Safety Assessment and Review, the Elopement Response and Resident Elopement Prevention and Response were developed and implemented. 8. A review of door security was conducted on April 6th, 2024, by the maintenance director). The maintenance director conducted a thorough assessment of all doors in the facility to ensure they were properly secured and functioning. This included checking for any breaches or issues with door securing, as well as ensuring that no doors were propped open. No other doors during the audit were identified to be a concern. 9. On April 7th, 2024, the Door Safety Assessment and Review policy was revised to include no propping of doors. 10. On April 6th, 2024, signage was placed at all exits alerting staff and guests to use certain doors for use and to not prop open doors. One sign states Do not prop door. The other sign states Attention all staff, this is an emergency exit only. Please keep this door closed. Thank you, Knollwood Healthcare. 11. On April 7th, 2024, the Door Assessment and Review policy update includes that staff are to only use the front door for entering and exiting the facility and all other exits (doors) are for emergency use only. Signage has been placed on doors/exit that are not to be used. The Elopement Prevention and Response policy advises staff on what actions to take when a resident voices that they are going to elope. Actions to include assessment, supervision if necessary, determining the appropriate plan of care/intervention, consulting with interdisciplinary team and reviewing/updating care plan. TRAINING: 12. Education was provided to the Maintenance Director by the Regional Consultant on April 6th, 2024, regarding Door Safety Assessment and Review Policy. 13. Education was provided to the Director of Nursing regarding The Elopement Response Policy by Regional Consultant on April 6th, 2024. This policy addresses what staff should do if a resident is found off campus. 14. On April 6th, 2024, the DON trained the Designee and together they began training the IDT team and all full-time staff including, CNA's, LPN's, RN's, Therapy Dept., Housekeeping, Maintenance, and Kitchen Personnel on Door Safety Assessment and Review, Resident Elopement Prevention and Response, the Elopement Response policies. Training included resident behavior management, including the identification of at-risk residents, appropriate interventions, and the updated policies and procedures related to elopement prevention. Training was completed April 6th, 2024, through April 8th, 2024. As of April 8th, 2024, ninety of 102 employees have been educated. Staff that have not yet been educated in the above policies and procedures will not be permitted to return to work prior to education being completed. All part-time, PRN staff, and contract staff will not be permitted to work prior to education being completed. *********************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 04/08/2024.

Based on observation, interview, medical record review, the facility's Spring/Summer 2024 Menu, the facility's standardized recipe for Chili - 4042, and the facility's policies for Menus, and Standardized Recipes the facility failed to ensure portion sizes listed on the menu for 07/23/2024 and 07/24/2024 were provided to residents, the portion of Sliced Ham Steak served on 07/23/2024 was at least three ounces (oz.), the portion to be served as listed on the Chili recipe was reflected on the menu for the Puree diet for 07/24/2024, and puree bread was provided to the Puree diets as listed on the menu for 07/23/2024 and 07/24/2024. This had the potential to affect 52 of 52 residents receiving meals from the kitchen including Resident Identifier (RI) #35 one of six residents receiving Puree diets. The deficient practice caused actual harm that was not immediate jeopardy to RI #35. RI #35 had significant weight loss of 10.7% (percent) over a six-month period from 01/02/2024 through 07/06/2024. This deficient practice was cited as a result of the investigation of complaint/ report #AL00048377. Cross Reference F 692. Findings include: The undated facility policy for Menus in the Dietary Service General Policies included the following: . Menus shall provide a variety of foods and indicate standard portions at each meal. All Menus shall be approved by the dietitian. The undated facility policy for Standardized Recipes in the Dietary Service General Policies included the following: . Standardized recipes, adjusted to appropriate yield, are used in the preparation of foods. The facility's standardized recipe for Chili - 4042, dated 04/14/2015, which included ground beef and red pinto beans, listed the following: . Serving size: 6 oz. ladle or #5 (number 5) scoop . The facility's Spring/Summer 2024 Menu for Week 2, Sunday through Saturday included the following for Tuesday Lunch: Ham Steak Mashed Potatoes Green Beans Dinner Roll Cake/Icing Milk, 2% Coffee/Tea This menu, provided by the facility on 07/22/2024, did not include portion sizes or diet texture/therapeutic diet extensions. On 07/23/2024 at 11:15 AM, three Dietary staff were observed preparing lunch trays for the residents. The AM [NAME] was serving the hot food from the steamtable. At 11:45 AM, the Dietary staff were asked if the Dietary Manager was present in the building. The Dietary staff all shook their heads negatively and the AM [NAME] said, No. When asked the number of Puree diets being served, the AM [NAME] said six. Upon being asked how the puree bread was being served, the AM [NAME] said the Puree diets only got meat, vegetable, and starch on the plate. When asked if any bread was added to the puree meat, the AM cook said, no. A Puree diet plate prepared at 12:13 PM for dining room service was observed to include puree meat (ham) with gravy, puree vegetable (green beans), and mashed potatoes with gravy. No puree bread was present on either the plate or the tray served. At 12:20 PM on 07/23/2024, the serving utensils used for portioning lunch were observed with the AM [NAME] and included the following: A 3-ounce spoodle (spoon-ladle) was used to serve the [NAME] Beans. A #10 scoop was used to serve the Puree [NAME] Beans. When asked about the portion size of the sliced Ham, the AM [NAME] said it was supposed to be three ounces. Upon being asked if there was a food scale to verify the portion size of the Ham, the AM [NAME] said there was no food scale available. The menu used for lunch was checked with the AM Cook. The Tuesday, Daily Menu for Week 2 was posted in the food production area and included the following: Ham Steak Mashed Potatoes Green Beans Dinner Roll Cake/Icing The Week 2 Sunday through Saturday menu was missing, but the Sunday through Saturday menus for Week 1, Week 3, and Week 4 were present on the table. None of these menus included portion sizes or diet texture/therapeutic diet extensions. The AM [NAME] said there were no other menus with portion sizes. At 12:35 PM on 07/23/2024, a portion conversion chart was observed in the kitchen's food production area on the wall above the table with the menus and to the left of the handwashing sink. The chart was plastic coated and approximately 24 inches by 18 inches in size. The portion conversion chart revealed the following: A #8 scoop equals 4 ounces or 1/2 cup measure. A #10 scoop equals 3 ounces or 3/8 cup measure. A #16 scoop equals 2 ounces or 1/4 cup measure. On 07/23/2024 at 1:30 PM, the Administrator was asked for a copy of the extended menus, to include the texture modified and therapeutic diets along with portion sizes. The facility's Spring/Summer 2024 Menu for Week 2, Tuesday, Lunch on 07/23/2024, provided by the facility on 07/23/2024 after lunch, included the following: Regular texture diet - . 3 oz Ham Steak . 4 oz [NAME] Beans . Mechanical Soft texture diet - . 4 oz [NAME] Beans . Puree texture diet - . 4 oz Pur (Puree) [NAME] Beans . 2 oz Pur Dinner Roll . On 07/23/2024 at 3:40 PM, the Dietary Manager said the extended menus were kept in the kitchen in a folder on the table next to the handwashing sink (food production area). The Dietary Manager said she did not know why the cook would not know where the extended menus were located. When asked if there was a scale in the kitchen to weigh meat portions, the Dietary manager said yes. At 4:40 PM, the Dietary Manager looked throughout the kitchen for the portion scale but could not find it. The Dietary Manager asked two Dietary staff where the portion scale was, but neither of the employees remembered seeing the scale. The Dietary Manager showed two spots where the folder with the extended menus might be kept in the food production area, but they were not there earlier. The extended menus for each week were now shown to be behind the Sunday through Saturday menus for Week 1, Week 2, Week 3, and Week 4; with each week in a plastic sleeve, for a total of four plastic sleeves. The facility's Spring/Summer 2024 Menu for Week 2, Wednesday, Lunch on 07/24/2024 included the following: Regular texture diet - . 4 oz Italian Vegetables . Mechanical Soft texture diet - . 4 oz Italian Vegetables . Puree texture diet - . 2 oz Pur Bread Sticks . On 07/24/2024 at 11:10 AM, the trayline was set up for Lunch and a 3-ounce spoodle was observed in the Italian Vegetables. The AM [NAME] was asked if she had seen the extended menu. The AM [NAME] said yes and got the menus. When asked if she had seen these extended menus before today; the AM [NAME] said she had seen this type of menu in other facilities, but not at this facility. Upon looking at the Week 2 menu for Wednesday, the AM [NAME] saw the 4-ounce portion listed for the Italian Vegetables and got the appropriate 4-ounce spoodle for service. No puree bread was prepared to be served on the trayline for the lunch service. The facility's Spring/Summer 2024 Menu for Week 2, Wednesday, Supper on 07/24/2024 included the following: Regular texture diet - . 6 oz Beef Chili w/ (with) Beans . Mechanical Soft texture diet - . 6 oz Beef Chili w/ Beans . Puree texture diet - . 3 oz Pur Beef Chili w/ Beans . 4 oz Pur Peas & (and) Carrots . 2 oz Pur Bread . On 07/24/2024 at 4:43 PM, the Supper trayline was ongoing with the PM [NAME] serving from the steamtable. The serving utensils being used for portioning Supper included the following: A 4-ounce spoodle was used to serve the Beef Chili w/ Beans. A 3-ounce spoodle was used to serve the Puree Beef Chili w/ Beans. A 3-ounce spoodle was used to serve the Puree Peas & Carrots. There was no puree bread on the trayline for the Supper service. On 07/24/2024 at 5:20 PM, the PM [NAME] was interviewed. When asked how she knew what to serve for Supper; the PM [NAME] went to the food production area and explained that she looked at the menu to determine what to prepare, indicating the Sunday through Saturday menu for Week 2 and the Daily Menu for Wednesday. Upon being asked how she knew the amount to serve; the PM [NAME] said she did not know, as there was nothing on these menus about portion size. The PM [NAME] was shown the seven days of extended menus now in the plastic sleeve behind the Sunday through Saturday menu. The PM [NAME] said she had not seen these extended menus before. The PM [NAME] also said she had not served bread to the Puree diets. On 07/24/2024 at 5:30 PM, the Dietary Manager was asked how the cooks were expected to ensure the correct portion size for sliced meats without a food portion scale. The Dietary manager said the cooks could know for sure without weighing to check it. When asked why was it important for the cooks to know the food portion to serve the residents, the Dietary Manager said it was important for the residents to receive a regular portion meal. On 07/25/2024 at 3:10 PM, the Registered Dietitian (RD) was interviewed. When asked the concern if residents were served portions less than those listed on the menu or if food items were omitted; the RD said then they are not getting enough food and the concerns would be weight loss, possible skin breakdown, and dehydration. In a follow-up call to the RD on 07/26/2024 at 12:08 PM, the RD agreed the menu for Week 2, Wednesday Supper meal was incorrect based on the Chili - 4042 recipe and that the Puree diets should receive a 6-ounce portion of pureed Beef Chili w/ Beans. The RD further said she would need to look at all the menu extensions for texture modified/therapeutic diets to make sure they were correct. RI #35 was admitted to the facility on [DATE] with diagnoses to include Dysphagia Oropharyngeal Phase, Unspecified Protein-Calorie Malnutrition, and Adult Failure to Thrive. RI #35's July 2024 Order Summary Report, dated July 25, 2024, documented the following: . Regular Diet Pureed texture, Regular consistency, for diet . Order Date 02/17/2020 . Ensure Plus three times a day . Order Date 07/11/2024 . Monthly weight every day shift starting on the 1st and ending on the 1st every month . Order Date 11/22/2023 . Weekly weights x (times) 4 (four) weeks every day shift every Mon (Monday) . Order Date 7/11/2024 . RI #35's Meal Intake records from Breakfast on 06/08/2024 through Breakfast on 07/25/2024 indicated a value of 3 (meaning 76 % to 100 % of the meal was consumed) for 128 meals and a value of 2 (meaning 51 % to 75 % of the meal was consumed) for ten meals. RI #35's Weights and Vitals Summary documented the resident weighed 197 lbs. (pounds) on 01/02/2024 and 176 lbs. on 07/06/2024. RI #35 lost 21 pounds and had a 10.7 percent weight loss over 180 days. RI #35's Progress Notes *NEW* documented the following: . 07/11/2024 . Note: July Monthly wt.(weight) reported down to 176# (pounds), loss of 10.7% (percent) or 21# from January. Recommend weekly wts. for now and increase Ensure Plus to TID (three times daily). (name of Registered Dietitian) Dietary - Registered Dietician (Dietitian) . RI #35's July 2024 Medication Administration Record (MAR) documented RI #35 received his/her Ensure Plus supplement twice daily from 07/01/2024 to 07/10/2024 and then three times daily beginning 07/11/2024 through 07/24/2024. On 07/25/2024 at 3:10 PM, the Registered Dietitian (RD) was interviewed. When asked the concern if residents were served portions less than those listed on the menu or if food items were omitted; the RD said then the residents were not getting enough food and the concerns would be weight loss, possible skin breakdown, and dehydration. Upon being asked the concern if a resident did not receive the nutritional values as approved by the RD for a Regular Puree Diet, the RD said potential for weight loss. The RD further said the facility should have been serving the portions residents were supposed to get. When asked about RI #35, the RD said the resident had weight loss over six months and it was now significant weight loss. The RD further said approaches were put in to address the weight loss; but, if not enough food was being served, the facility needed to in-service dietary staff on proper portion size and to give the staff the serving tools they need.

Based on observation, interview, medical record review, the facility's Spring/Summer 2024 Menu, the facility's standardized recipe for Chili - 4042, and the facility's policies for Menus, and Standardized Recipes the facility failed to ensure portion sizes listed on the menu for 07/23/2024 and 07/24/2024 were provided to residents, the portion of Sliced Ham Steak served on 07/23/2024 was at least three ounces (oz.), the portion to be served as listed on the Chili recipe was reflected on the menu for the Puree diet for 07/24/2024, and puree bread was provided to the Puree diets as listed on the menu for 07/23/2024 and 07/24/2024. This had the potential to affect 52 of 52 residents receiving meals from the kitchen including Resident Identifier (RI) #35 one of six residents receiving Puree diets. The deficient practice caused actual harm that was not immediate jeopardy to RI #35. RI #35 had significant weight loss of 10.7% (percent) over a six-month period from 01/02/2024 through 07/06/2024. This deficient practice was cited as a result of the investigation of complaint/ report #AL00048377. Cross Reference F 692. Findings include: The undated facility policy for Menus in the Dietary Service General Policies included the following: . Menus shall provide a variety of foods and indicate standard portions at each meal. All Menus shall be approved by the dietitian. The undated facility policy for Standardized Recipes in the Dietary Service General Policies included the following: . Standardized recipes, adjusted to appropriate yield, are used in the preparation of foods. The facility's standardized recipe for Chili - 4042, dated 04/14/2015, which included ground beef and red pinto beans, listed the following: . Serving size: 6 oz. ladle or #5 (number 5) scoop . The facility's Spring/Summer 2024 Menu for Week 2, Sunday through Saturday included the following for Tuesday Lunch: Ham Steak Mashed Potatoes Green Beans Dinner Roll Cake/Icing Milk, 2% Coffee/Tea This menu, provided by the facility on 07/22/2024, did not include portion sizes or diet texture/therapeutic diet extensions. On 07/23/2024 at 11:15 AM, three Dietary staff were observed preparing lunch trays for the residents. The AM [NAME] was serving the hot food from the steamtable. At 11:45 AM, the Dietary staff were asked if the Dietary Manager was present in the building. The Dietary staff all shook their heads negatively and the AM [NAME] said, No. When asked the number of Puree diets being served, the AM [NAME] said six. Upon being asked how the puree bread was being served, the AM [NAME] said the Puree diets only got meat, vegetable, and starch on the plate. When asked if any bread was added to the puree meat, the AM cook said, no. A Puree diet plate prepared at 12:13 PM for dining room service was observed to include puree meat (ham) with gravy, puree vegetable (green beans), and mashed potatoes with gravy. No puree bread was present on either the plate or the tray served. At 12:20 PM on 07/23/2024, the serving utensils used for portioning lunch were observed with the AM [NAME] and included the following: A 3-ounce spoodle (spoon-ladle) was used to serve the [NAME] Beans. A #10 scoop was used to serve the Puree [NAME] Beans. When asked about the portion size of the sliced Ham, the AM [NAME] said it was supposed to be three ounces. Upon being asked if there was a food scale to verify the portion size of the Ham, the AM [NAME] said there was no food scale available. The menu used for lunch was checked with the AM Cook. The Tuesday, Daily Menu for Week 2 was posted in the food production area and included the following: Ham Steak Mashed Potatoes Green Beans Dinner Roll Cake/Icing The Week 2 Sunday through Saturday menu was missing, but the Sunday through Saturday menus for Week 1, Week 3, and Week 4 were present on the table. None of these menus included portion sizes or diet texture/therapeutic diet extensions. The AM [NAME] said there were no other menus with portion sizes. At 12:35 PM on 07/23/2024, a portion conversion chart was observed in the kitchen's food production area on the wall above the table with the menus and to the left of the handwashing sink. The chart was plastic coated and approximately 24 inches by 18 inches in size. The portion conversion chart revealed the following: A #8 scoop equals 4 ounces or 1/2 cup measure. A #10 scoop equals 3 ounces or 3/8 cup measure. A #16 scoop equals 2 ounces or 1/4 cup measure. On 07/23/2024 at 1:30 PM, the Administrator was asked for a copy of the extended menus, to include the texture modified and therapeutic diets along with portion sizes. The facility's Spring/Summer 2024 Menu for Week 2, Tuesday, Lunch on 07/23/2024, provided by the facility on 07/23/2024 after lunch, included the following: Regular texture diet - . 3 oz Ham Steak . 4 oz [NAME] Beans . Mechanical Soft texture diet - . 4 oz [NAME] Beans . Puree texture diet - . 4 oz Pur (Puree) [NAME] Beans . 2 oz Pur Dinner Roll . On 07/23/2024 at 3:40 PM, the Dietary Manager said the extended menus were kept in the kitchen in a folder on the table next to the handwashing sink (food production area). The Dietary Manager said she did not know why the cook would not know where the extended menus were located. When asked if there was a scale in the kitchen to weigh meat portions, the Dietary manager said yes. At 4:40 PM, the Dietary Manager looked throughout the kitchen for the portion scale but could not find it. The Dietary Manager asked two Dietary staff where the portion scale was, but neither of the employees remembered seeing the scale. The Dietary Manager showed two spots where the folder with the extended menus might be kept in the food production area, but they were not there earlier. The extended menus for each week were now shown to be behind the Sunday through Saturday menus for Week 1, Week 2, Week 3, and Week 4; with each week in a plastic sleeve, for a total of four plastic sleeves. The facility's Spring/Summer 2024 Menu for Week 2, Wednesday, Lunch on 07/24/2024 included the following: Regular texture diet - . 4 oz Italian Vegetables . Mechanical Soft texture diet - . 4 oz Italian Vegetables . Puree texture diet - . 2 oz Pur Bread Sticks . On 07/24/2024 at 11:10 AM, the trayline was set up for Lunch and a 3-ounce spoodle was observed in the Italian Vegetables. The AM [NAME] was asked if she had seen the extended menu. The AM [NAME] said yes and got the menus. When asked if she had seen these extended menus before today; the AM [NAME] said she had seen this type of menu in other facilities, but not at this facility. Upon looking at the Week 2 menu for Wednesday, the AM [NAME] saw the 4-ounce portion listed for the Italian Vegetables and got the appropriate 4-ounce spoodle for service. No puree bread was prepared to be served on the trayline for the lunch service. The facility's Spring/Summer 2024 Menu for Week 2, Wednesday, Supper on 07/24/2024 included the following: Regular texture diet - . 6 oz Beef Chili w/ (with) Beans . Mechanical Soft texture diet - . 6 oz Beef Chili w/ Beans . Puree texture diet - . 3 oz Pur Beef Chili w/ Beans . 4 oz Pur Peas & (and) Carrots . 2 oz Pur Bread . On 07/24/2024 at 4:43 PM, the Supper trayline was ongoing with the PM [NAME] serving from the steamtable. The serving utensils being used for portioning Supper included the following: A 4-ounce spoodle was used to serve the Beef Chili w/ Beans. A 3-ounce spoodle was used to serve the Puree Beef Chili w/ Beans. A 3-ounce spoodle was used to serve the Puree Peas & Carrots. There was no puree bread on the trayline for the Supper service. On 07/24/2024 at 5:20 PM, the PM [NAME] was interviewed. When asked how she knew what to serve for Supper; the PM [NAME] went to the food production area and explained that she looked at the menu to determine what to prepare, indicating the Sunday through Saturday menu for Week 2 and the Daily Menu for Wednesday. Upon being asked how she knew the amount to serve; the PM [NAME] said she did not know, as there was nothing on these menus about portion size. The PM [NAME] was shown the seven days of extended menus now in the plastic sleeve behind the Sunday through Saturday menu. The PM [NAME] said she had not seen these extended menus before. The PM [NAME] also said she had not served bread to the Puree diets. On 07/24/2024 at 5:30 PM, the Dietary Manager was asked how the cooks were expected to ensure the correct portion size for sliced meats without a food portion scale. The Dietary manager said the cooks could know for sure without weighing to check it. When asked why was it important for the cooks to know the food portion to serve the residents, the Dietary Manager said it was important for the residents to receive a regular portion meal. On 07/25/2024 at 3:10 PM, the Registered Dietitian (RD) was interviewed. When asked the concern if residents were served portions less than those listed on the menu or if food items were omitted; the RD said then they are not getting enough food and the concerns would be weight loss, possible skin breakdown, and dehydration. In a follow-up call to the RD on 07/26/2024 at 12:08 PM, the RD agreed the menu for Week 2, Wednesday Supper meal was incorrect based on the Chili - 4042 recipe and that the Puree diets should receive a 6-ounce portion of pureed Beef Chili w/ Beans. The RD further said she would need to look at all the menu extensions for texture modified/therapeutic diets to make sure they were correct. RI #35 was admitted to the facility on [DATE] with diagnoses to include Dysphagia Oropharyngeal Phase, Unspecified Protein-Calorie Malnutrition, and Adult Failure to Thrive. RI #35's July 2024 Order Summary Report, dated July 25, 2024, documented the following: . Regular Diet Pureed texture, Regular consistency, for diet . Order Date 02/17/2020 . Ensure Plus three times a day . Order Date 07/11/2024 . Monthly weight every day shift starting on the 1st and ending on the 1st every month . Order Date 11/22/2023 . Weekly weights x (times) 4 (four) weeks every day shift every Mon (Monday) . Order Date 7/11/2024 . RI #35's Meal Intake records from Breakfast on 06/08/2024 through Breakfast on 07/25/2024 indicated a value of 3 (meaning 76 % to 100 % of the meal was consumed) for 128 meals and a value of 2 (meaning 51 % to 75 % of the meal was consumed) for ten meals. RI #35's Weights and Vitals Summary documented the resident weighed 197 lbs. (pounds) on 01/02/2024 and 176 lbs. on 07/06/2024. RI #35 lost 21 pounds and had a 10.7 percent weight loss over 180 days. RI #35's Progress Notes *NEW* documented the following: . 07/11/2024 . Note: July Monthly wt.(weight) reported down to 176# (pounds), loss of 10.7% (percent) or 21# from January. Recommend weekly wts. for now and increase Ensure Plus to TID (three times daily). (name of Registered Dietitian) Dietary - Registered Dietician (Dietitian) . RI #35's July 2024 Medication Administration Record (MAR) documented RI #35 received his/her Ensure Plus supplement twice daily from 07/01/2024 to 07/10/2024 and then three times daily beginning 07/11/2024 through 07/24/2024. On 07/25/2024 at 3:10 PM, the Registered Dietitian (RD) was interviewed. When asked the concern if residents were served portions less than those listed on the menu or if food items were omitted; the RD said then the residents were not getting enough food and the concerns would be weight loss, possible skin breakdown, and dehydration. Upon being asked the concern if a resident did not receive the nutritional values as approved by the RD for a Regular Puree Diet, the RD said potential for weight loss. The RD further said the facility should have been serving the portions residents were supposed to get. When asked about RI #35, the RD said the resident had weight loss over six months and it was now significant weight loss. The RD further said approaches were put in to address the weight loss; but, if not enough food was being served, the facility needed to in-service dietary staff on proper portion size and to give the staff the serving tools they need.

Based on interviews, record review, review of a facility policy titled GHC Abuse Policy, review of the Facility Reported Incident(FRI) received by the Alabama State Survey Agency, and review of the facility's investigative file, the facility failed to protect the Resident Identifier (RI) #3's right to be free from verbal abuse by Certified Nursing Assistant (CNA) #16 and CNA #17. On 10/11/2023, at approximately 4:27 PM, RI #3's daughter was visiting and requested assistance from staff. RI #3's daughter left her cellphone on record in the room as CNA #16 and CNA #17 entered the room to provide care. After CNA #16 and CNA #17 finished providing care, the daughter returned to the room and stopped the recording. RI #3's daughter listened to the recording and heard both CNA's making multiple derogatory statements and threats of punishment toward RI #3. The daughter heard swearing and noises that sounded like the resident was being hit. RI #3's daughter stated she was so upset that she left the facility without reporting it to anyone. At approximately 5:40 PM RI #3's daughter returned to the facility and reported the incident to the Infection Control Nurse (ICN), Licensed Practical Nurse (LPN) #8. These deficient practices affected RI #3. This deficiency was cited as a result of the investigation of complaint/report number AL00045846 The survey team applied the Reasonable Person Concept in determining the psychosocial outcome related to the deficient practice. Findings include: The facility's policy titled GHC Abuse Policy dated 08/2022 revealed: Our residents have the right to be free from abuse . Policy Interpretation and Implementation Definitions To help with recognition of abuse, the following definitions of abuse are provided: 1. Abuse is defined as the willful infliction of injury . intimidation or punishment with resulting physical harm, pain or mental anguish . 2. Verbal Abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. 5. Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services . Prevention . 11. Monitoring staff on all shifts to identify inappropriate behavior towards residents (e.g. using derogatory language, rough handling of residents .) . Response . 1. Our facility does not condone resident abuse by anyone including staff members . RI #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Hemiplegia following Cerebral Infarction, Acute Respiratory Failure, and Vascular Dementia. RI #3's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/09/2023, indicated RI #3's Brief Interview Mental Status (BIMS) was 00, which indicated the resident was cognitively impaired. Section E of the MDS indicated RI #3 did not have any behaviors directed toward others. The Alabama Department of Public Health Online Incident Reporting System form, dated 10/11/2023, documented that CNA #16 and CNA #17 were in RI #3's room to provide care. RI #3's daughter recorded the conversation of the CNA's after she left the room. Both CNA's could be heard verbally abusing the resident. RI #3's daughter provided a copy of the recording on 04/25/2024 at 3:00 PM from RI #3's daughter, and the playback of the recording revealed: Voice one asking someone to step out so they could perform care on resident. Voice one said, .You got everything (CNA #17's name)? Voice two said, I was coming in here to change (his/her) shirt. Voice one said, (He/She) wants to show out. Voice two said, I don't want to do this shit. Voice one said, You know you don't want to do that, so don't even play like that. Voice two said, (He/She) done wet the bed .like what the fuck. Voice one said, He/She already know, he/she already know. Voice one screamed, Put your leg back in the bed! Voice one said, Can you put your leg back in the bed? .uh huh, now you want somebody to help . play with me, play with me, play with me, play with me, play with me. I want you to do it. I'm gonna call the police. You want me to call the police? . You want this brief off or not? . You done soaked this fucking bed up . play with me . crazy ass . crazy ass . you crazy . I'm crazy too . you can't even help yourself! . I don't play with (his/her) ass . I don't care . I don't play with (his/her) ass . they better give (him/her) (his/her) medicine or something . lay back so I can put this on you bruh. You can't do nothing for yourself and come up here act a fucking fool. Don't grab me, bruh don't grab me, grab me one more time, do it again! (laughter) . Voice two said, Just flip (his/her) ass over . come here motherfucker .bitch . motherfucker . Voice one said, Can't do nothing for yourself, come on, uh huh, uh huh, uh huh, what you do, uh huh try it . police gonna kick (his/her) ass . that's why they gonna beat (his/her) ass in jail. Resident's voice said, It's all wrong. Voice one said, It's all wrong. Voice two said, Look at this shit . it's the last time I'm coming in here today. Voice two said, Turn (his/her) ass over . fuck you . Voice two said, Let's just sell him/her to sex traffickers . crazy ass. Voice one said, I'm gonna call the police . done scratched my motherfucking hand up, I'm fixing to report your ass. Voice two said, Your the lying king, lying. Voice one said, Fuck (him/her), (he/she) don't mean shit . (he/she) scratched the fuck out of me . (he/she) don't want the shirt on fuck it . The facility's Investigative Summary dated 10/13/2023 and signed by Former Administrator (FA) #2, documented, . (RI #3) . who resides in (named room) at (name of facility) is A&O x2, has limited speech and has a BIMS of 0 . is being seen by . hospice . (RI #3's daughter) requested assistance from (CNA #17) to provide care to . (RI #3). (RI #3's daughter's) cellphone was left in the room and on record while (CNA #17) and another CNA (CNA #16) were in the room providing care to the resident. When (CNA #17) and (CNA #16) were finished with providing care, (RI #3's daughter) returned to the room and turned on the recording . heard both (CNA #17) and (CNA #16) making derogatory comments toward resident. Threatening comments were made and . noises that sounded like resident being hit. (RI #3's daughter) played the recording to this writer (FA #2). Most of the recording was audible and based on what was said by (CNA #16) and (CNA #17) it was substantiated that the resident was verbally and mentally abused by both (CNA #16 and CNA #17). This writer heard what sounded like slaps; someone hitting another person and heard one of the CNAs say, Don't hit him bitch . turn over after this it sounded as though someone was hit. The resident could be heard telling the CNA(s) . get away from me, to which one of the CNA's responded, Fuck you, I'm going to call the police and have you arrested. (He/She) done scratched my damn hand. Fuck it. Today (10/13/2023) the resident was found to have swelling in his right hand . This writer cannot say if the swelling was due to the incident with the CNA's though the swelling was not noted before the incident. Other comments made to the resident included the CNA's yelling at resident telling (him/her) to put his/her leg back in the bed. Don't play with me. (He/She) already know. (He/She) just wants to show out. I'm going to call the police. Where you tryin' to go? Want me to call the police? Ain't nobody going to play with you, Acting a fucking fool. I'm about to punch the fuck out of (him/her). I'll kill your ass; bitch mother fucker . (CNA #16) and (CNA #17) were interviewed . They denied the allegations. (CNA #16) admitted hearing (CNA #17 curse the resident . (CNA #17) denied the allegation, but state the resident called her a bitch, so she said called (him/her) a bitch back. During an interview on 04/04/2024 at 9:22 AM, Infection Control Nurse, Licensed Practical Nurse (LPN) #8 stated she was working a double shift on 10/11/2023, and a family member brought a recording that was on her phone of CNA #16 and CNA #17 providing care for their family member and being verbally abusive. LPN #8 stated that she listened to about thirty seconds of the recording, and it was so bad she stopped listening to the recording. She stated that she immediately reported the abuse to the Administrator (Former Administrator #2). On 04/04/2024 at 1:40 PM and interview was conducted with FA #2. The FA #2 said the family member recorded the CNAs changing RI #3. The FA #2 said CNA #17 was cursing and inappropriate. FA #2 said the other CNA was being aggressive. She said she substantiated the allegation by listening to the recording. On 04/25/2024 at 9:22 AM an interview was conducted with RI #3's daughter. RI #3's daughter stated it would have made RI #3 very upset and angry if he/she had not did not have decreased cognition because it was very disrespectful. An interview was conducted on 04/25/2024 at 11:20 AM with the Administrator. The Administrator said it could cause psychological or emotional distress to a reasonable person in a similar situation as the incident on 10/11/2023 involving RI #3 and CNA #16 and CNA #17. The Administrator said if there was cursing at resident it would be considered verbal abuse. An interview was conducted on 04/25/2024 at 11:35 AM with Social Services Director (SSD) in reference to 10/11/2023 incident. The SSD said a reasonable person in a similar would probably be afraid of any CNA that would take care of them. The SSD said that situation was verbal abuse. A follow-up interview was conducted with RI #3's daughter on 04/25/2024 at 3:00 PM. RI #3's daughter stated she heard the recording and that they talked very mean and ugly to him/her. RI #3's daughter stated she visited RI #3 one day prior to the incident and RI #3 told her that staff did not treat him/her right so she left her phone on record while staff provided care on 10/11/2023. On 04/24/2024 at 3:15 PM CNA #17 was called via telephone. The number was no longer in-service. On 04/24/2024 at 3:20 PM CNA #16 was contacted via telephone. A male answered and hung up when the surveyor requested to speak with CNA #16.

Based on interviews, resident record review, review of a facility policy titled, Resident-to-Resident Altercations, review of a Facility Reported Incident (FRI) received by the State Agency, and review of the facility's investigative file, the facility failed to ensure the abuse policy was implemented to take steps to protect Resident Identifier (RI) #2 from further abuse on 05/15/2024 when RI #2 was being physically abused by RI #1. Certified Nursing Assistant (CNA) #3 heard RI #2 yelling and saw RI #1 sitting on RI #2's arm and slapping RI #2 in the face. Instead of providing immediate protection and supervision for the residents, CNA #3 left the room, leaving RI #1 alone in the room with RI #2, who according to interview may have been afraid or in pain, while the CNA went to the nurses' station to get the nurse. This deficient practice affected RI #2, one of six sampled residents. This deficiency was cited as a result of the investigation of complaint/report number AL00047877. Findings include: On 05/15/2024 the State Agency received an Online Incident Report alleging a witness, CNA #3 heard RI #2 howling, saw RI #1 in RI #2's room sitting on and slapping RI #2. CNA #3 ran and got the nurse, Licensed Practical Nurse (LPN) #4, who was able to separate the residents. A facility policy titled Abuse Policy, updated 08/2022, documented: Our residents have the right to be free from abuse . Protection . The facility protects individuals from abuse during investigation of any allegations of abuse. 3. Steps will be taken to prevent further potential abuse, and should include: . Potential increased supervision . Review of a facility policy titled, Resident-to-Resident Altercations, with a revised date of 12/2007, revealed the following: . Policy Interpretation and implementation . 2. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation . RI #2 was admitted to the facility on [DATE]. RI #1 was admitted to the facility on [DATE]. The facility's investigative file was reviewed and a handwritten Witness Statement dated 05/15/2024, signed by CNA #3 documented: . Time of Incident: 4:30 (4:30 PM) . I was coming down the hall I heard (RI #2) howlling (howling) when i went in the room (RI #1) was sitting on (RI #2) and slapping (RI #2) and i was begging (RI #1) to get off of (RI #2) . (RI #1) started fighting me and i ran and got the nurse and she got (RI #1) out of there . On 06/15/2024 at 11:51 AM, a telephone interview was conducted with CNA #3 and she was asked why she left RI #2 in the room with RI #1. CNA #3 said RI #1 was fighting her so she ran out of the room to get help. CNA #3 said after the incident she was told she could have used the call light to get help. CNA #3 said RI #1 was not protected from further potential abuse when she left RI #1 in the room with RI #2. CNA #3 said when she witnessed the altercation between RI #1 and RI #2, she should have separated them immediately. CNA #3 said after the incident occurred she was told by the DON (Director of Nursing) that she should have never left RI #2 in the room alone with RI #1. When asked how she thought RI #2 was feeling based on a reasonable person's response to what she had witnessed, CNA #3 answered, like RI #2 was in pain and felt bad and RI #2 was probably scared. On 06/13/2024 at 5:28 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4 and she said, she was at the nurses station when the CNA came to tell her RI #1 was hitting RI #2. LPN #4 said, when the CNA witnessed the incident between RI #2 and RI #1, she should have stayed in the room and yelled for someone to come to the room so RI #2 would not have been in harms way. LPN #4 said, when RI #1 was left alone in the room with RI #2, RI #2 was not protected from further potential abuse by RI #1, and it took her about ten seconds to get to the room after she was informed. On 06/15/2024 at 4:05 PM, a telephone interview was conducted with the DON. The DON said, when the CNA witnessed RI #1 hitting RI #2, she should have stayed with RI #2 to keep RI #2 safe. The DON said, the CNA told her she went to get the nurse when she witnessed the incident. The DON said, RI #2 was not protected when he/she was left alone in the room with RI #1. On 06/14/2024 at 12:05 PM, an interview was conducted with the Social Service Designee (SSD). The SSD said when the CNA left RI #2 in the room with RI #1, RI #2 was not protected from further potential abuse by RI #1. The SSD said, when the CNA observed RI #1 hitting RI #2, the CNA should have made sure both residents were separated and ensured their safety before she left the room. The SSD said, the facility's policy says to protect the victim/resident, you must separate them immediately. On 06/14/2024 at 5:06 PM, an interview was conducted with the Administrator (ADM). The ADM said, when RI #1 was left in the room alone with RI #2, RI #2 was not adequately protected. The ADM said, the facility's policy says the resident was to be protected, and should be separated immediately to ensure safety of the resident. The ADM said the CNA could have removed either resident from the scene of the incident.

Based on interviews, resident record review, review of a facility policy titled, Resident-to-Resident Altercations, review of a Facility Reported Incident (FRI) received by the State Agency, and review of the facility's investigative file, the facility failed to ensure the abuse policy was implemented to take steps to protect Resident Identifier (RI) #2 from further abuse on 05/15/2024 when RI #2 was being physically abused by RI #1. Certified Nursing Assistant (CNA) #3 heard RI #2 yelling and saw RI #1 sitting on RI #2's arm and slapping RI #2 in the face. Instead of providing immediate protection and supervision for the residents, CNA #3 left the room, leaving RI #1 alone in the room with RI #2, who according to interview may have been afraid or in pain, while the CNA went to the nurses' station to get the nurse. This deficient practice affected RI #2, one of six sampled residents. This deficiency was cited as a result of the investigation of complaint/report number AL00047877. Findings include: On 05/15/2024 the State Agency received an Online Incident Report alleging a witness, CNA #3 heard RI #2 howling, saw RI #1 in RI #2's room sitting on and slapping RI #2. CNA #3 ran and got the nurse, Licensed Practical Nurse (LPN) #4, who was able to separate the residents. A facility policy titled Abuse Policy, updated 08/2022, documented: Our residents have the right to be free from abuse . Protection . The facility protects individuals from abuse during investigation of any allegations of abuse. 3. Steps will be taken to prevent further potential abuse, and should include: . Potential increased supervision . Review of a facility policy titled, Resident-to-Resident Altercations, with a revised date of 12/2007, revealed the following: . Policy Interpretation and implementation . 2. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation . RI #2 was admitted to the facility on [DATE]. RI #1 was admitted to the facility on [DATE]. The facility's investigative file was reviewed and a handwritten Witness Statement dated 05/15/2024, signed by CNA #3 documented: . Time of Incident: 4:30 (4:30 PM) . I was coming down the hall I heard (RI #2) howlling (howling) when i went in the room (RI #1) was sitting on (RI #2) and slapping (RI #2) and i was begging (RI #1) to get off of (RI #2) . (RI #1) started fighting me and i ran and got the nurse and she got (RI #1) out of there . On 06/15/2024 at 11:51 AM, a telephone interview was conducted with CNA #3 and she was asked why she left RI #2 in the room with RI #1. CNA #3 said RI #1 was fighting her so she ran out of the room to get help. CNA #3 said after the incident she was told she could have used the call light to get help. CNA #3 said RI #1 was not protected from further potential abuse when she left RI #1 in the room with RI #2. CNA #3 said when she witnessed the altercation between RI #1 and RI #2, she should have separated them immediately. CNA #3 said after the incident occurred she was told by the DON (Director of Nursing) that she should have never left RI #2 in the room alone with RI #1. When asked how she thought RI #2 was feeling based on a reasonable person's response to what she had witnessed, CNA #3 answered, like RI #2 was in pain and felt bad and RI #2 was probably scared. On 06/13/2024 at 5:28 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4 and she said, she was at the nurses station when the CNA came to tell her RI #1 was hitting RI #2. LPN #4 said, when the CNA witnessed the incident between RI #2 and RI #1, she should have stayed in the room and yelled for someone to come to the room so RI #2 would not have been in harms way. LPN #4 said, when RI #1 was left alone in the room with RI #2, RI #2 was not protected from further potential abuse by RI #1, and it took her about ten seconds to get to the room after she was informed. On 06/15/2024 at 4:05 PM, a telephone interview was conducted with the DON. The DON said, when the CNA witnessed RI #1 hitting RI #2, she should have stayed with RI #2 to keep RI #2 safe. The DON said, the CNA told her she went to get the nurse when she witnessed the incident. The DON said, RI #2 was not protected when he/she was left alone in the room with RI #1. On 06/14/2024 at 12:05 PM, an interview was conducted with the Social Service Designee (SSD). The SSD said when the CNA left RI #2 in the room with RI #1, RI #2 was not protected from further potential abuse by RI #1. The SSD said, when the CNA observed RI #1 hitting RI #2, the CNA should have made sure both residents were separated and ensured their safety before she left the room. The SSD said, the facility's policy says to protect the victim/resident, you must separate them immediately. On 06/14/2024 at 5:06 PM, an interview was conducted with the Administrator (ADM). The ADM said, when RI #1 was left in the room alone with RI #2, RI #2 was not adequately protected. The ADM said, the facility's policy says the resident was to be protected, and should be separated immediately to ensure safety of the resident. The ADM said the CNA could have removed either resident from the scene of the incident.

Based on observation, interviews, medical record review, the facility's Spring/Summer 2024 Menu, the facility's standardized recipe for Chili - 4042, and the facility policies for Weight Assessment and Intervention, Menus, and Standardized Recipes the facility failed to ensure (RI) Resident Identifier #35 received appropriate food portions as defined by the Registered Dietitian's (RD) approved menu for Puree diets and did not suffer significant weight loss of 10.7 % (percent) over 180 days. RI #35 lost 21 pounds from 01/02/2024 to 07/09/2024. The deficient practice caused actual harm that was not immediate jeopardy to RI #35, one of six residents who received Puree diets. This deficient practice was cited as a result of the investigation of complaint/ report #AL00048377. Cross-Reference F 803. Findings Include: The facility's policy titled, Weight Assessment and Intervention, with a revised date of February 2021, documented the following: Policy Statement The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation Weight Assessment . 3. Any weight change of 5% or more since the last weight assessment will be addressed by the dietitian. 4. The Dietitian will review the resident weight record to follow individual weight trends over time. Negative trends will be evaluated by the Interdisciplinary team whether or not the criteria for significant weight change has been met. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria . c. 6 months - 10% weight loss weight loss is significant; greater than 10% is severe. Analysis 1. Assessment information shall analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range (including rationale if different from ideal body weight); b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; c. The relationship between medical condition or clinical situation and weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated. 2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss. The undated facility policy for Menus in the Dietary Service General Policies included the following: . All Menus shall be approved by the dietitian. Menus shall . indicate standard portions at each meal. The undated facility policy for Standardized Recipes in the Dietary Service General Policies included the following: . Standardized recipes, adjusted to appropriate yield, are used in the preparation of foods. The facility's standardized recipe for Chili - 4042, dated 04/14/2015, which included ground beef and red pinto beans, listed the following: . Serving size: 6 oz. ladle or #5 (number five) scoop . RI #35 was admitted to the facility on [DATE] and had diagnoses that included Dysphagia Oropharyngeal Phase, Unspecified Protein-Calorie Malnutrition, and Adult Failure to Thrive. RI #35's care plan for weight loss, initiated 03/01/2019, documented the following: . Potential for weight loss and dehydration due to lack of teeth and dentures/requiring a mechanically altered diet. Dependent on staff for food/fluid intake. Intellectual disability: unable to communicate needs and preferences. History of Failure to Thrive . Goal . No significant weight loss through next review . Approaches . ENSURE PLUS 3X'S (three times) A DAY . Provide diet as ordered. RI #35's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/2024, documented in section K0300 that the resident had not had significant weight loss and section K0520 documented the resident was on a mechanical diet. RI #35's Meal Intake records from Breakfast on 06/08/2024 through Breakfast on 07/25/2024 indicated a value of 3 (meaning 76 % to 100 % of the meal was consumed) for 128 meals and a value of 2 (meaning 51 % to 75 % of the meal was consumed) for ten meals. RI #35's Weights and Vitals Summary documented the resident weighed 197 lbs. (pounds) on 01/02/2024 and 176 lbs. on 07/06/2024. RI #35 lost 21 pounds and had a 10.7 percent weight loss over 180 days. RI #35's Progress Notes *NEW* documented the following: . 07/11/2024 . Note: July Monthly wt.(weight) reported down to 176# (pounds), loss of 10.7% (percent) or 21# from January. Recommend weekly wts. for now and increase Ensure Plus to TID (three times daily). (name of Registered Dietitian) Dietary - Registered Dietician (Dietitian) . RI #35's July 2024 Order Summary Report, dated July 25, 2024, documented the following: . Regular Diet Pureed texture, Regular consistency, for diet . Order Date 02/17/2020 . Ensure Plus three times a day . Order Date 07/11/2024 . Monthly weight every day shift starting on the 1st and ending on the 1st every month . Order Date 11/22/2023 . Weekly weights x (times) 4 (four) weeks every day shift every Mon (Monday) . Order Date 7/11/2024 . RI #35's July 2024 Medication Administration Record (MAR) documented RI #35 received his/her Ensure Plus supplement twice daily from 07/01/2024 to 07/10/2024 and then three times daily beginning 07/11/2024 through 07/24/2024. The facility's Spring/Summer 2024 Menu for Week 2, Sunday through Saturday provided by the facility on 07/22/2024, did not include portion sizes or diet texture/therapeutic diet extensions. On 07/23/2024 at 11:15 AM, three Dietary staff were observed preparing lunch trays for the residents. The AM [NAME] was serving the hot food from the steamtable. Upon being asked how the puree bread was being served, the AM [NAME] said the residents with Puree diets only got meat, vegetable, and starch on the plate. When asked if any bread was added to the puree meat, the AM cook said, no. A Puree diet plate prepared at 12:13 PM for dining room service was observed to include puree meat (ham) with gravy, puree vegetable (green beans), and mashed potatoes with gravy. No puree bread was present on either the plate or the tray served. At 12:20 PM on 07/23/2024, the serving utensils used for portioning lunch were observed with the AM Cook. A #10 (3 ounces or 3/8 cup) scoop was used to serve the Puree [NAME] Beans. The menu used for lunch was checked with the AM Cook. The Tuesday, Daily Menu for Week 2 was posted in the food production area and included the following: Ham Steak Mashed Potatoes Green Beans Dinner Roll Cake/Icing The Week 2 Sunday through Saturday menu was missing, but the Sunday through Saturday menus for Week 1, Week 3, and Week 4 were present on the table. None of these menus included portion sizes or diet texture/therapeutic diet extensions. The AM [NAME] said there were no other menus with portion sizes. At 12:35 PM on 07/23/2024, a portion conversion chart was observed in the kitchen's food production area on the wall above the table with the menus and to the left of the handwashing sink. The chart was plastic coated and approximately 24 inches by 18 inches in size. The portion conversion chart revealed the following: A #8 scoop equals 4 ounces or 1/2 cup measure. A #10 scoop equals 3 ounces or 3/8 cup measure. A #16 scoop equals 2 ounces or 1/4 cup measure. On 07/23/2024 at 1:30 PM, the Administrator was asked for a copy of the extended menus, to include the texture modified and therapeutic diets along with portion sizes. The facility's Spring/Summer 2024 Menu for Week 2, Tuesday, Lunch on 07/23/2024, provided by the facility on 07/23/2024 after lunch, included the following: Puree texture diet - . 4 oz Pur (Puree) [NAME] Beans . 2 oz Pur Dinner Roll . On 07/23/2024 at 3:40 PM, the Dietary Manager said the extended menus were kept in the kitchen in a folder on the table next to the handwashing sink (food production area). The Dietary Manager said she did not know why the cook would not know where the extended menus were located. The Dietary Manager showed two spots where the folder with the extended menus might be kept in the food production area, but they were not there earlier. The extended menus for each week were now shown to be behind the Sunday through Saturday menus for Week 1, Week 2, Week 3, and Week 4; with each week in a plastic sleeve, for a total of four plastic sleeves. The facility's Spring/Summer 2024 Menu for Week 2, Wednesday, Lunch on 07/24/2024 included the following: Puree texture diet - . 2 oz Pur (puree) Bread Sticks . On 07/24/2024 at 11:10 AM, the tray line was set up for Lunch. The AM [NAME] was asked if she had seen the extended menu. The AM [NAME] said yes and got the menus. When asked if she had seen these extended menus before today; the AM [NAME] said she had seen this type of menu in other facilities, but not at this facility. No puree bread was prepared to be served on the tray line for the lunch service. The facility's Spring/Summer 2024 Menu for Week 2, Wednesday, Supper on 07/24/2024 included the following: Regular texture diet - . 6 oz Beef Chili w/ (with) Beans . Mechanical Soft texture diet - . 6 oz Beef Chili w/ Beans . Puree texture diet - . 3 oz Pur Beef Chili w/ Beans . 4 oz Pur Peas & (and) Carrots . 2 oz Pur Bread . On 07/24/2024 at 4:43 PM, the Supper tray line was ongoing with the PM [NAME] serving from the steamtable. The serving utensils being used for portioning Supper included the following: A 3-ounce spoodle (spoon-ladle) was used to serve the Puree Beef Chili w/ Beans. A 3-ounce spoodle was used to serve the Puree Peas & Carrots. There was no puree bread on the tray line for the supper service. On 07/24/2024 at 5:20 PM, the PM [NAME] was interviewed. When asked how she knew what to serve for Supper; the PM [NAME] went to the food production area and explained that she looked at the menu to determine what to prepare, indicating the Sunday through Saturday menu for Week 2 and the Daily Menu for Wednesday. Upon being asked how she knew the amount to serve; the PM [NAME] said she did not know, as there was nothing on the menus to indicate appropriate portion sizes. The PM [NAME] was shown the seven days of extended menus now in the plastic sleeve behind the Sunday through Saturday menu. The PM [NAME] said she had not seen these extended menus before. The PM [NAME] also said she had not served bread to the residents with Puree diets. During a meal observation on 07/24/2024 at 5:16 PM, staff was assisted RI #35 up in bed. RI #35 was nonverbal but responded to call of his/her name. RI #35 fed himself/herself from the Supper tray with his/her left hand, not using the right hand/arm. RI #35 was observed independently eating puree beef chili with beans, puree peas & carrots, puree potatoes, pudding, iced tea, and water. There was no puree bread. RI #35 ate well. At 5:23 PM, the resident was still eating with almost 100% consumed. Staff then assisted RI #35 at the end of his/her meal. At 5:31 PM, CNA (Certified Nursing Assistant) #12 picked up RI #35's meal tray. When asked how much the resident consumed, CNA #12 said 100 percent. CNA #12 further said RI #35 always ate 100 percent. CNA #12 said RI #35 meal ticket on the tray said RI #35 was to recieve a puree diet, sweet tea, and water. On 07/24/2024 at 5:30 PM, the Dietary Manager was asked why it was important for the cooks to know the food portion to serve the residents. The Dietary Manager said it was important for the residents to receive a regular portion meal. On 07/25/2024 at 3:10 PM, the Registered Dietitian (RD) was interviewed. When asked the concern if residents were served portions less than those listed on the menu or if food items were omitted; the RD said then the residents were not getting enough food and the concerns would be weight loss, possible skin breakdown, and dehydration. Upon being asked the concern if a resident did not receive the nutritional values as approved by the RD for a Regular Puree Diet, the RD said potential for weight loss. The RD further said the facility should have been serving the portions residents were supposed to get. When asked about RI #35, the RD said the resident had weight loss over six months and it was now significant weight loss. The RD further said approaches were put in to address the weight loss; but, if not enough food was being served, the facility needed to in-service dietary staff on proper portion size and to give the staff the serving tools they need. In a follow-up call to the RD on 07/26/2024 at 12:08 PM, the RD agreed the menu for Week 2, Wednesday Supper meal was incorrect based on the Chili - 4042 recipe and that the Puree diets should receive a 6-ounce portion of pureed Beef Chili w/ Beans. The RD further said she would need to look at all the menu extensions for texture modified/therapeutic diets to make sure they were correct. 48195

Based on observation, interviews, medical record review, the facility's Spring/Summer 2024 Menu, the facility's standardized recipe for Chili - 4042, and the facility policies for Weight Assessment and Intervention, Menus, and Standardized Recipes the facility failed to ensure (RI) Resident Identifier #35 received appropriate food portions as defined by the Registered Dietitian's (RD) approved menu for Puree diets and did not suffer significant weight loss of 10.7 % (percent) over 180 days. RI #35 lost 21 pounds from 01/02/2024 to 07/09/2024. The deficient practice caused actual harm that was not immediate jeopardy to RI #35, one of six residents who received Puree diets. This deficient practice was cited as a result of the investigation of complaint/ report #AL00048377. Cross-Reference F 803. Findings Include: The facility's policy titled, Weight Assessment and Intervention, with a revised date of February 2021, documented the following: Policy Statement The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation Weight Assessment . 3. Any weight change of 5% or more since the last weight assessment will be addressed by the dietitian. 4. The Dietitian will review the resident weight record to follow individual weight trends over time. Negative trends will be evaluated by the Interdisciplinary team whether or not the criteria for significant weight change has been met. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria . c. 6 months - 10% weight loss weight loss is significant; greater than 10% is severe. Analysis 1. Assessment information shall analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range (including rationale if different from ideal body weight); b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; c. The relationship between medical condition or clinical situation and weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated. 2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss. The undated facility policy for Menus in the Dietary Service General Policies included the following: . All Menus shall be approved by the dietitian. Menus shall . indicate standard portions at each meal. The undated facility policy for Standardized Recipes in the Dietary Service General Policies included the following: . Standardized recipes, adjusted to appropriate yield, are used in the preparation of foods. The facility's standardized recipe for Chili - 4042, dated 04/14/2015, which included ground beef and red pinto beans, listed the following: . Serving size: 6 oz. ladle or #5 (number five) scoop . RI #35 was admitted to the facility on [DATE] and had diagnoses that included Dysphagia Oropharyngeal Phase, Unspecified Protein-Calorie Malnutrition, and Adult Failure to Thrive. RI #35's care plan for weight loss, initiated 03/01/2019, documented the following: . Potential for weight loss and dehydration due to lack of teeth and dentures/requiring a mechanically altered diet. Dependent on staff for food/fluid intake. Intellectual disability: unable to communicate needs and preferences. History of Failure to Thrive . Goal . No significant weight loss through next review . Approaches . ENSURE PLUS 3X'S (three times) A DAY . Provide diet as ordered. RI #35's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/2024, documented in section K0300 that the resident had not had significant weight loss and section K0520 documented the resident was on a mechanical diet. RI #35's Meal Intake records from Breakfast on 06/08/2024 through Breakfast on 07/25/2024 indicated a value of 3 (meaning 76 % to 100 % of the meal was consumed) for 128 meals and a value of 2 (meaning 51 % to 75 % of the meal was consumed) for ten meals. RI #35's Weights and Vitals Summary documented the resident weighed 197 lbs. (pounds) on 01/02/2024 and 176 lbs. on 07/06/2024. RI #35 lost 21 pounds and had a 10.7 percent weight loss over 180 days. RI #35's Progress Notes *NEW* documented the following: . 07/11/2024 . Note: July Monthly wt.(weight) reported down to 176# (pounds), loss of 10.7% (percent) or 21# from January. Recommend weekly wts. for now and increase Ensure Plus to TID (three times daily). (name of Registered Dietitian) Dietary - Registered Dietician (Dietitian) . RI #35's July 2024 Order Summary Report, dated July 25, 2024, documented the following: . Regular Diet Pureed texture, Regular consistency, for diet . Order Date 02/17/2020 . Ensure Plus three times a day . Order Date 07/11/2024 . Monthly weight every day shift starting on the 1st and ending on the 1st every month . Order Date 11/22/2023 . Weekly weights x (times) 4 (four) weeks every day shift every Mon (Monday) . Order Date 7/11/2024 . RI #35's July 2024 Medication Administration Record (MAR) documented RI #35 received his/her Ensure Plus supplement twice daily from 07/01/2024 to 07/10/2024 and then three times daily beginning 07/11/2024 through 07/24/2024. The facility's Spring/Summer 2024 Menu for Week 2, Sunday through Saturday provided by the facility on 07/22/2024, did not include portion sizes or diet texture/therapeutic diet extensions. On 07/23/2024 at 11:15 AM, three Dietary staff were observed preparing lunch trays for the residents. The AM [NAME] was serving the hot food from the steamtable. Upon being asked how the puree bread was being served, the AM [NAME] said the residents with Puree diets only got meat, vegetable, and starch on the plate. When asked if any bread was added to the puree meat, the AM cook said, no. A Puree diet plate prepared at 12:13 PM for dining room service was observed to include puree meat (ham) with gravy, puree vegetable (green beans), and mashed potatoes with gravy. No puree bread was present on either the plate or the tray served. At 12:20 PM on 07/23/2024, the serving utensils used for portioning lunch were observed with the AM Cook. A #10 (3 ounces or 3/8 cup) scoop was used to serve the Puree [NAME] Beans. The menu used for lunch was checked with the AM Cook. The Tuesday, Daily Menu for Week 2 was posted in the food production area and included the following: Ham Steak Mashed Potatoes Green Beans Dinner Roll Cake/Icing The Week 2 Sunday through Saturday menu was missing, but the Sunday through Saturday menus for Week 1, Week 3, and Week 4 were present on the table. None of these menus included portion sizes or diet texture/therapeutic diet extensions. The AM [NAME] said there were no other menus with portion sizes. At 12:35 PM on 07/23/2024, a portion conversion chart was observed in the kitchen's food production area on the wall above the table with the menus and to the left of the handwashing sink. The chart was plastic coated and approximately 24 inches by 18 inches in size. The portion conversion chart revealed the following: A #8 scoop equals 4 ounces or 1/2 cup measure. A #10 scoop equals 3 ounces or 3/8 cup measure. A #16 scoop equals 2 ounces or 1/4 cup measure. On 07/23/2024 at 1:30 PM, the Administrator was asked for a copy of the extended menus, to include the texture modified and therapeutic diets along with portion sizes. The facility's Spring/Summer 2024 Menu for Week 2, Tuesday, Lunch on 07/23/2024, provided by the facility on 07/23/2024 after lunch, included the following: Puree texture diet - . 4 oz Pur (Puree) [NAME] Beans . 2 oz Pur Dinner Roll . On 07/23/2024 at 3:40 PM, the Dietary Manager said the extended menus were kept in the kitchen in a folder on the table next to the handwashing sink (food production area). The Dietary Manager said she did not know why the cook would not know where the extended menus were located. The Dietary Manager showed two spots where the folder with the extended menus might be kept in the food production area, but they were not there earlier. The extended menus for each week were now shown to be behind the Sunday through Saturday menus for Week 1, Week 2, Week 3, and Week 4; with each week in a plastic sleeve, for a total of four plastic sleeves. The facility's Spring/Summer 2024 Menu for Week 2, Wednesday, Lunch on 07/24/2024 included the following: Puree texture diet - . 2 oz Pur (puree) Bread Sticks . On 07/24/2024 at 11:10 AM, the tray line was set up for Lunch. The AM [NAME] was asked if she had seen the extended menu. The AM [NAME] said yes and got the menus. When asked if she had seen these extended menus before today; the AM [NAME] said she had seen this type of menu in other facilities, but not at this facility. No puree bread was prepared to be served on the tray line for the lunch service. The facility's Spring/Summer 2024 Menu for Week 2, Wednesday, Supper on 07/24/2024 included the following: Regular texture diet - . 6 oz Beef Chili w/ (with) Beans . Mechanical Soft texture diet - . 6 oz Beef Chili w/ Beans . Puree texture diet - . 3 oz Pur Beef Chili w/ Beans . 4 oz Pur Peas & (and) Carrots . 2 oz Pur Bread . On 07/24/2024 at 4:43 PM, the Supper tray line was ongoing with the PM [NAME] serving from the steamtable. The serving utensils being used for portioning Supper included the following: A 3-ounce spoodle (spoon-ladle) was used to serve the Puree Beef Chili w/ Beans. A 3-ounce spoodle was used to serve the Puree Peas & Carrots. There was no puree bread on the tray line for the supper service. On 07/24/2024 at 5:20 PM, the PM [NAME] was interviewed. When asked how she knew what to serve for Supper; the PM [NAME] went to the food production area and explained that she looked at the menu to determine what to prepare, indicating the Sunday through Saturday menu for Week 2 and the Daily Menu for Wednesday. Upon being asked how she knew the amount to serve; the PM [NAME] said she did not know, as there was nothing on the menus to indicate appropriate portion sizes. The PM [NAME] was shown the seven days of extended menus now in the plastic sleeve behind the Sunday through Saturday menu. The PM [NAME] said she had not seen these extended menus before. The PM [NAME] also said she had not served bread to the residents with Puree diets. During a meal observation on 07/24/2024 at 5:16 PM, staff was assisted RI #35 up in bed. RI #35 was nonverbal but responded to call of his/her name. RI #35 fed himself/herself from the Supper tray with his/her left hand, not using the right hand/arm. RI #35 was observed independently eating puree beef chili with beans, puree peas & carrots, puree potatoes, pudding, iced tea, and water. There was no puree bread. RI #35 ate well. At 5:23 PM, the resident was still eating with almost 100% consumed. Staff then assisted RI #35 at the end of his/her meal. At 5:31 PM, CNA (Certified Nursing Assistant) #12 picked up RI #35's meal tray. When asked how much the resident consumed, CNA #12 said 100 percent. CNA #12 further said RI #35 always ate 100 percent. CNA #12 said RI #35 meal ticket on the tray said RI #35 was to recieve a puree diet, sweet tea, and water. On 07/24/2024 at 5:30 PM, the Dietary Manager was asked why it was important for the cooks to know the food portion to serve the residents. The Dietary Manager said it was important for the residents to receive a regular portion meal. On 07/25/2024 at 3:10 PM, the Registered Dietitian (RD) was interviewed. When asked the concern if residents were served portions less than those listed on the menu or if food items were omitted; the RD said then the residents were not getting enough food and the concerns would be weight loss, possible skin breakdown, and dehydration. Upon being asked the concern if a resident did not receive the nutritional values as approved by the RD for a Regular Puree Diet, the RD said potential for weight loss. The RD further said the facility should have been serving the portions residents were supposed to get. When asked about RI #35, the RD said the resident had weight loss over six months and it was now significant weight loss. The RD further said approaches were put in to address the weight loss; but, if not enough food was being served, the facility needed to in-service dietary staff on proper portion size and to give the staff the serving tools they need. In a follow-up call to the RD on 07/26/2024 at 12:08 PM, the RD agreed the menu for Week 2, Wednesday Supper meal was incorrect based on the Chili - 4042 recipe and that the Puree diets should receive a 6-ounce portion of pureed Beef Chili w/ Beans. The RD further said she would need to look at all the menu extensions for texture modified/therapeutic diets to make sure they were correct.

Based on observations, record reviews, and interviews, the facility failed to ensure Resident Identifier (RI) #6 and RI #8's care plans were followed. 1. Failed to ensure RI #8 was checked and changed every 2 hours as care planned, and 2. RI #6 had a fall that occurred on 10/7/15 while being transported from the shower in a wheelchair. The CNA (Certified Nursing Assistant) did not have the restraint belt in place, and the resident leaned forward and fell . RI #6 sustained a laceration to the forehead that required sutures. RI #6 was care planned to wear a restraint belt at all times while up in the wheelchair. The restraint belt was not in place during the fall on 10/7/15. RI #6 was identified as a high risk for falls. These deficiencies affected RI #6 and RI #8, two of thirteen sampled residents whose care plans were reviewed. Findings include: 1. A review of the medical record revealed RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Date Set), with an ARD (Assessment Reference Date) of 12/20/15, revealed RI #8 had a BIMS (Brief Interview for Mental Status) score of seven out of a possible fifteen points. This indicated RI #8 was severely impaired for daily decision making skills. RI #8 was always incontinent of bowel and bladder. RI #8 was non-ambulatory and required extensive assistance with ADLs (Activities of Daily Living). The review of RI #8's care plan, with a problem onset date of 04/08/15, revealed: Problem/Need Requires total assist with toileting; Always incontinent of bowel; Always incontinent of bladder. Goal & (and) Target date Resident Will be clean, dry & odor free through next review. Approaches .Check at least q (every) 2 hours for incontinent episodes. The review of RI #8's care plan for preventive skin care revealed: Problem onset date of 04/08/15; . Problem/Need Preventive skin care and potential for impaired skin integrity. Goal and Target date; Skin will remain intact through next review 04/04/16. Approaches Encourage & assist with turning at least q 2 hours. Resident usually likes to stay on (the) back, not turn. On 03/09/16, a continuous observation was made of RI #8 between 3:55 PM to 7:15 PM. During this time, RI #8 remained in bed positioned on the back. RI #8's dinner tray was served at 5:35 PM. RI #8's dinner tray was removed from the room at 6:25 PM. At 6:40 PM EI #6, a CNA (Certified Nursing Assistant), entered RI #8's room. EI #6 adjusted the bed alarm for the roommate of RI #8. EI #6 told RI #8 she would be back in a little while. At 7:15 PM, EI #6 knocked on the door and entered RI #8's room, carrying supplies. EI #6 explained to RI #8 she was going to provide perineal care. During perineal care, RI #8's brief was observed to be wet and a small amount of soft brown stool was present. The resident was tracked for 3 hours and 20 minutes. An interview was conducted with EI #6 on 03/09/15 at 7:43 PM. EI #6 was asked what was the facility's policy regarding checking/changing incontinent residents. EI #6 stated every two hours. EI #6 was asked if RI #8 was incontinent. EI #6 said RI #8 was incontinent of bowel and bladder. EI #6 was asked how often RI #8 was to be checked/changed. EI #6 stated every two hours. EI #6 was asked when was the last time RI #8 had been checked/changed. EI #6 stated she had gotten to work about 2:00 PM, so it had been 4:00 PM. EI #6 was asked if she was sure about the time and she stated, No. EI #6 was asked what RI #8's care plan indicated about how often RI #8 needed to be checked/changed. EI #6 stated every 2 hours. EI #6 was asked why the care plan was not followed. EI #6 stated she did not know. EI #6 said she was sorry, she had been waiting for RI #8 to use the call light. EI #6 was asked how the CNAs knew the content of the care plans. EI #6 stated the care plans were on the computer and the CNAs were supposed to look at them every day. EI #6 was asked what could be a potential negative outcome of not checking/changing a resident every two hours. EI #6 stated skin breakdown could occur. An interview was conducted with EI #7, the MDS/Care Plan Coordinator, on 03/10/15 at 10:25 AM. EI #7 was asked when care plans were initiated for residents. EI #7 stated on admission and a comprehensive care plan was completed on the twenty-first day. EI #7 was asked how were the needs of the residents determined. EI #7 stated by gathering information from the chart, the staff, and the resident. EI #7 was asked what were the interventions on RI #8's care plan regarding incontinence care. EI #7 stated check at least every two hours and provide incontinence care after each episode. They have a three day assessment they go by, of when the resident voids or if the resident was wet or dry. EI #7 was asked how the CNAs were made aware of their responsibilities with regard to the care of each resident. EI #7 stated the information was in the computer and also a shift-to-shift report. The surveyor shared the observation with EI #7. EI #7 was asked if the care plan for RI #8 was followed. EI #7 said it was not. EI #7 was asked what the potential negative outcome could be of not checking/changing the resident at least every two hours as indicated on the care plan. EI #7 stated skin breakdown. 2. RI #6 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 02/22/16, revealed the resident had short and long term memory problems and was severely impaired for cognition and daily decision making skills. The MDS revealed RI #6 required total assistance for all ADL (Activities of Daily Living). The MDS also revealed RI #6 had, .History of Falling . and .Unspecified abnormalities of gait and mobility . A review of a Physician order [REDACTED]. For safety remove belt for all meals, toileting, bedtime, + (and) shower/bedbath. Check Belt every 30 min (minutes) and release every 2 hrs (hours) A review of RI #6's Care Plan with the onset date of 03/16/2015, revealed, .Potential for injury Fall risk R/T (related to) Attempts to get up from wc (wheelchair) without assist, hx (history of) & (and) recent falls, antihypertensive, pain, antianxiety & antipsychotic medication, balance problems, dependent for transfers Fall risk assessment = 16 (with a line drawn through the number), 13 . Total score of 10 or above represents high risk . 10/7/15 Fall with head injury (8) sutures . Educate charge nurse on restraint, to check q (every) 2 hrs (hours) and document on MAR (Medication Administration Record) in place, on and functioning CN (Charge Nurse) 10/14/15 (RN (Registered Nurse) unit manager to educate) . A review of a facility's document titled, Resident Incident Report, for RI #6 revealed the following: .Date/Time: 10/7/15 approximately 8 pm . Incident Type: Head Injury . Incident Level: High . Narrative of incident and description of injuries: CNA reported that while bringing resident out of the shower room in a wheel chair, resident leaned forward causing (resident) to fall out of the W/C (wheel chair) landing face down. Immediate Action Taken: Resident assessed by nurse in charge, sent out to ER (emergency room ) for Tx (treatment). Type of Aid: applied pressure ti (to) fore head . Falling Star Meeting . NOTES: On 10/7/15 approximately 19:00 (7:00 PM) hrs (hours) Nurse reports that while CNA was bringing resident back to (RI #6's) room from the shower room, resident leaned forward in her w/c and fell hitting her head. Resident uses restraint belt when in w/c and the belt was not in place the time of the incident. Resident was sent out to ER for Eval (evaluation) & treat, and was returned to facility (sign for with) stitches. PLAN OF CARE: PT (Physical Therapy)- referral-Reeducate CNA regarding use of restraint seat belt in w/c all times including (sign for after) shower time . On 3/9/16 at 5:55 PM, a call was placed to EI (Employee Identifier) #10, the CNA who worked with RI #6 during the fall on 10/7/15. She no longer worked at the facility and her number was no longer in service. An interview was conducted on 03/09/16 at 6:00 PM, with EI #11, the ADON (Assistant Director of Nursing) and RN Supervisor of the unit RI #6 resided while in the facility. EI #11 was asked if she was familiar with RI #6. EI #6 stated, Oh, yes. The surveyor asked EI #11 about RI #6's fall on 10/7/15. EI #11 stated, I was not present. When I returned back to work, I was told the CNA, EI #10, was bringing (RI #6) back from the shower. The CNA did not have (RI #6's) lap belt in place. I am not sure how (RI #6) exactly fell and hit (RI #6's) head. I can see (RI #6), (RI #6) is always reaching for things. When (RI #6) had (RI #6's) lap belt on, (RI #6) was always reaching for (RI #6's) feet. (RI #6) was probably reaching down. EI #11 was asked should RI #6's lap belt been in place prior to RI #6's fall on 10/7/15. EI #11 stated, Yes. The surveyor asked EI #11 what intervention was put in place after RI #6's fall on 10/7/15. EI #11 stated, When the CNA came back to work, I in-serviced her on making sure RI #6 had the lap belt in place even when RI #6 is being transferred to and from the shower. Shortly after that put we put the lap tray in place. That is what I call it. Even when we take it off, RI #6 will grab for it. RI #6 does not want us to remove it. An interview was conducted with EI #7, the MDS Coordinator of the facility, on 3/9/16 at 6:40 PM. The surveyor asked EI #7 if she was familiar with RI #6. EI #7 stated, Yes pretty much. The surveyor asked EI #7 about RI #6's fall on 10/7/15. EI #7 looked at RI #6's care plan. EI #7 stated, The resident had a fall with sutures. I do remember RI #6 having sutures on (RI #6's) forehead. EI #7 looked at the nursing notes for RI #6. The surveyor asked EI #7 if RI #6 had the lap belt in place prior to the the fall. EI #7 stated, The notes said RI #6 was in front of the shower room door. EI #7 looked at the care plan dated 10/14/15 for RI #6. EI #7 stated, Educate the charge nurse on restraints to check Q 2 hours to check the alarms to make sure functions on resident. (On) 10/9/15 reeducate CNAs regarding use of restraint seat belt while up in w/c at all times, including after shower. I crossed it out because it was done on 10/16/15. RI #6 used to have a seat belt. RI #6 then got a lap tray which the resident has now. On 10/19/15, lap tray to w/c when up, check Q 30 minutes and release Q 2 hours. The lap belt was not working anymore. EI #7 was asked should RI #6 have had the lap belt in place prior to the fall on 10/7/15. EI #7 stated, If RI #6 was up in the w/c she should have had it on. EI #7 was asked if EI #10 followed the care plan for RI #6 to wear the lap belt on 10/7/15, since it was not place. EI #7 stated, Well the intervention says RI #6 was to wear the lap belt at all times, including after the shower. The surveyor stated, if the seat belt was not in place, did the CNA follow the care plan on 10/7/15. EI #7 stated, No. The surveyor asked EI #7 what was the concern when an intervention that was put in place to prevent a fall was not followed. EI #7 stated, That a fall could happen again. An interview was conducted with EI #13, the Director of Nursing, of the facility, on 3/10/16 at 10:25 AM. The surveyor asked EI #13 if she was familiar with RI #6. EI #13 stated, Yes ma'am. The surveyor asked EI #13 about RI #6's fall on 10/7/15. EI #13 stated, What I recall being told was, the CNA was bringing RI #6 from the shower room and the resident fell out of the chair. The surveyor asked EI #13 if RI #6 had the lap belt in place prior to the fall. EI #13 stated, The nurse who informed me said she went to the scene of the accident, she said she did not see a belt on the resident. EI #13 was asked should RI #6 have had the lap belt in place during the fall on 10/7/15. EI #13 stated, Yes, RI #6 should have, when RI #6 was being transported. The surveyor asked EI #13 what intervention was put in place after RI #6's fall on 10/7/15. EI #13 stated, The intervention was to do an in-service with the CNA who was with RI #6 at the time of the fall, to apply the lap belt when the resident is being transferred after the shower. EI #13 was asked if there was an in-service provided to the nursing staff after RI #6 fell on [DATE]. EI #13 stated, I don't recall if we did one to the rest of the staff. I recall one done with the CNA, EI #10. EI #13 was asked if RI #6 required ER visits for the falls on 10/7/15. EI #13 stated, Yes. EI #13 was asked if EI #10 followed the care plan for RI #6 to wear the lap belt on 10/7/15, since it was not place. EI #13 stated, In regards to her not applying the belt after the shower, I don't think she did. The surveyor asked EI #13 what was the concern when an intervention that was put in place to prevent a fall was not followed. EI #13 stated, If the intervention is to prevent the fall, then the fall is not going to be prevented. EI #13 was asked what should the facility have done differently to prevent RI #6 from falling on 10/7/15. EI #13 stated, I think for the 10/7/15, maybe we could have done an in-service with the CNA prior to her taking care of RI #6, to make sure she followed the care guide. The surveyor asked EI #13, by not using the seat belt as care planned, was RI #6 in harm's way, resulting in falls that required ER visit. EI #13 stated, I would not say harm's way because, what about the times RI #6 released it and nothing happened.

Based on observations, record reviews, and interviews, the facility failed to ensure: 1. Resident Identifier (RI) #6 did not sustain a fall with head injuries, requiring more than first aid treatment. The fall occurred on 10/7/15 while being transported from the shower in a wheelchair. The CNA (Certified Nursing Assistant) did not have the restraint belt in place, and the resident leaned forward and fell . RI #6 sustained a laceration to the forehead that required sutures. This deficient practice affected RI #6, one of five residents sampled for falls. 2. The facility failed to ensure doors were not observed splintered in AL (Area Locators): 2, 3, 4, 5, 8, 9, and 10. The splintered doors were observed on one of two floors, and had the potential to affect 30 residents whose mobility was via wheelchair or walker. Findings include: 1. RI #6 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's Annual Minimum Data Set (MDS), with an ARD (Assessment Reference Date) of 02/22/16, revealed RI #6 had short and long term memory problems and was severely impaired for cognition and daily decision making skills. The MDS revealed RI #6 required total assistance with all ADLs (Activities of Daily Living). The MDS also revealed RI #6 had, . History of Falling . and . Unspecified abnormalities of gait and mobility . A review of a Physician order [REDACTED]. Seat belt allowed for out of bed socialization opportunities to improve quality of life. For safety remove belt for all meals, toileting, bedtime, + (and) shower/bedbath. Check Belt every 30 min (minutes) and release every 2 hrs (hours) A review of RI #6's Fall Risk Evaluation, form dated 12/06/14 to 7/07/15, revealed RI #6 was assessed for fall risks. The assessments dated 12/06/14 and 02/8/15 both assessed RI #6 with total scores of 16. The assessments dated 04/25/15 and 7/7/15 assessed RI #6 with total scores of 18. A review of the form revealed: . Total score of 10 or above represents HIGH RISK . A review of RI #6's Care Plan with the onset date of 03/16/15 revealed, . Potential for injury Fall risk R/T (related to) Attempts to get up from wc (wheelchair) without assist, hx (history of) & (and) recent falls, antihypertensive, pain, antianxiety & antipsychotic medication, balance problems, dependent for transfers Fall risk assessment = 16 (with a line drawn through the number), 13 . Total score of 10 or above represents high risk . 10/7/15 Fall with head injury (8) sutures . Educate charge nurse on restraint, to check q (every) 2 hrs (hours) and document on MAR (Medication Administration Record) in place, on and functioning CN (Charge Nurse) 10/14/15 (RN (Registered Nurse) unit manager to educate) . A review of a facility's document titled, Resident Incident Report, for RI #6 revealed the following: . Date/Time: 10/7/15 approximately 8 PM . Incident Type: Head Injury . Incident Level: High . Narrative of incident and description of injuries: CNA reported that while bringing resident out of the shower room in a wheel chair, resident leaned forward causing (resident) to fall out of the W/C landing face down. Immediate Action Taken: Resident assessed by nurse in charge, sent out to ER (emergency room ) for Tx (treatment). Type of Aid: applied pressure ti (to) forehead . A review of the document titled, Falling Star Meeting . NOTES: On 10/7/15 approximately 1900 (7:00 PM) hrs (hours) Nurse reports that while CNA was bringing resident back to RI #6's room from the shower room, resident leaned forward in (the) w/c and fell hitting (the) head. Resident uses restraint belt when in w/c and the belt was not in place the time of the incident. Resident was sent out to ER for Eval (evaluation) & treat, and was returned to the facility (sign for with) stitches. PLAN OF CARE: PT (Physical Therapy) - referral-Re-educate CNA regarding use of restraint seat belt in (the) w/c all (at) times including (sign for after) shower time . A review of a Departmental Note on RI #6 indicated, 10/7/2015 11:49 PM Role: Charge Nurse Was call to an accident happen in front of shower room door, client lying on the floor morning (moaning) and crying bleeding from the rt (right) side of the head, first aid was given, pressure applied to head, cna stay with client until 911 was call, Dr sanders was notify and family her daughter leff mess (message) contacted DON. call ER (client remain in the ER at MIMC (signed by an LPN- Licensed Practical Nurse) A review of RI #6's Departmental Note revealed, 10/8/2015 3:28 AM Role: Charge Nurse RESIDENT RETURNED FROM MIMC PER NEWMANS AMBULANCE SERVICE. RESIDENT HAS 8 STITCHES IN RT SIDE OF FOREHEAD. ORDER WAS TO KEEP AREA CLEAN AND DRY. REMOVE STITCHES IN 10 DAYS (signed by an LPN) On 3/9/16 at 5:55 PM, a call was placed to EI (Employee Identifier) #10, the CNA who worked with RI #6, during the fall on 10/7/15. She no longer worked at the facility and her number was no longer in service. An interview was conducted on 03/09/16 at 6:00 PM, with EI #11, the ADON (Assistant Director of Nursing)/RN Supervisor of the unit where RI #6 resided in the facility. EI #11 was asked if she was familiar with RI #6. EI #11 stated, Oh, yes. The surveyor asked EI #11 about RI #6's fall on 10/7/15. EI #11 stated, I was not present. When I returned back to work, I was told the CNA, EI #10 was bringing RI #6 back from the shower. The CNA did not have (RI #6's) lap belt in place. I am not sure how (RI #6) exactly fell and hit (RI #6's) head. I can see (how) (RI #6) (fell ), (RI #6) is always reaching for things. When (RI #6) had (the) lap belt on (the resident was always reaching towards their feet). RI #6 was probably reaching down. EI# 11 was asked should RI #6 have had the lap belt in place during RI #6's fall on 10/7/15. EI #11 stated, Yes. The surveyor asked EI #11 what intervention was put in place after RI #6's fall on 10/7/15. EI #11 stated, When the CNA came back to work, I in-serviced her on making sure RI #6 had the lap belt in place even when RI #6 is being transferred to and from the shower. Shortly after that, we put the lap tray in place. That is what I call it. Even when we take it off (RI #6) will grab for it. (RI #6) does not want us to remove it. The surveyor asked EI #11 if an in-service was provided for the nursing staff after RI #6's fall on 10/7/15. EI #11 stated, Not that I can remember. Everybody else was very familiar with (RI #6). (EI #10), a CNA, was only at the facility for a month totally. The surveyor asked EI #11 who was responsible for in-servicing staff after an incident, for example, a fall with an injury. EI #11 stated, Myself, the staffing coordinator, or the DON (Director of Nursing). An interview was conducted with EI #12, the RN Staffing Coordinator of the facility, on 3/9/16 at 8:15 PM. The surveyor asked EI #12 if she was familiar with RI #6. EI #12 stated, Yes I am. The surveyor asked EI #12 about RI #6's fall on 10/7/15. EI #12 stated, I was actually out at that time. I was out from around September 2015 until after Christmas 2015, about 3 months. EI # 12 read the incident report for RI #6 on 10/7/15. The surveyor asked EI #12 if RI #6 had the lap belt in place during the fall. EI #12 stated, According to the Incident report, it says it was not in place. EI #12 was asked should RI #6's lap belt in place prior to the fall on 10/7/15. EI #12 stated, Of course. The surveyor asked EI #12 what intervention was put in place after RI #6's fall on 10/7/15. EI #12 stated, PT referral, and educate CNA regarding use of restraint, seat belt while in w/c at all times, including at shower time. EI #12 was asked if there was an in-service provided to the nursing staff after RI #6 fell on [DATE]. EI #12 stated, I don't know. I did not see it in my education book. The surveyor asked EI #12 why was EI #10 the only nursing staff member in-serviced after RI #6's fall on 10/7/15. EI #12 stated, She should not have been. All of the staff should have been in-serviced. The surveyor asked EI #12 who was responsible for in-servicing staff after an incident, for example, a fall with an injury. EI #12 stated, It depends, the nurses can educate if I am not here. The charge nurses, PT, the ADON, and the DON. EI #12 was asked if EI #10 followed the care plan for RI #6 to wear the lap belt on 10/7/15, since it was not in place. EI #12 stated, No, she did not, if it was not in place. The surveyor asked EI #12 what was the concern when an intervention that was put in place to prevent a fall, was not followed. EI #12 stated, That everybody is not educated, if only one is educated they may not follow the plan of care and it will probably cause additional falls. An interview was conducted with EI #13, the Director of Nursing of the facility, on 3/10/16 at 10:25 AM. The surveyor asked EI #13 if she was familiar with RI #6. EI #13 stated, Yes ma'am. The surveyor asked EI #13 about RI #6's fall on 10/7/15. EI #13 stated, What I recall being told was, the CNA was bringing RI #6 from the shower room and the resident fell out of the chair. The surveyor asked EI #13 if RI #6 had the lap belt in place during the fall. EI #13 stated, The nurse who informed me said she went to the scene of the accident, she said she did not see a belt on the resident. EI #13 was asked should RI #6's lap belt been in place prior to the fall on 10/7/15. EI #13 stated, Yes, (RI #6) should have, when (RI #6) was being transported. The surveyor asked EI #13 what intervention was put in place after RI #6's fall on 10/7/15. EI #13 stated, The intervention was to do an in-service with the CNA who was with (RI #6) at the time of the fall, to apply the lap belt when the resident is being transferred after the shower. EI #13 was asked if there was an in-service provided to the nursing staff after RI #6 fell on [DATE]. EI #13 stated, I don't recall if we did one to the rest of the staff. I recall one done with the CNA, EI #10. EI #13 was asked if RI #6 required ER visits for fall on 10/7/15. EI #13 stated, Yes. EI #13 was asked if EI #10 followed the care plan for RI #6 to wear the lap belt on 10/7/15, since it was not in place. EI #13 stated, In regards to her not applying the belt after the shower, I don't think she did. The surveyor asked EI #13 what was the concern when an intervention that was put in place to prevent a fall was not followed. EI #13 stated, If the intervention is to prevent the fall, then the fall is not going to be prevented. EI #13 was asked what should the facility have done differently to prevent RI #6 from falling on 10/7/15. EI #13 stated, I think for the 10/7/15, maybe we could have done an in-service with the CNA prior to her taking care of (RI #6), to make sure she followed the care guide. The surveyor asked EI #13, by not using the seat belt as care planned, was RI #6 in harm's way, resulting in falls that required two ER visits. EI #13 stated, I would not say harm's way because, what about the times (RI #6) released it and nothing happened. 2. A review of an undated facility document titled, MAINTENANCE SUPERVISOR JOB DESCRIPTION, revealed, . SUMMARY Ensure the building(s), equipment and utilities are maintained in good working order . ESSENTIAL JOB FUNCTIONS Perform minor repairs and supervise the day-to-day repair, improvement and preventative maintenance of the building, equipment . The following observations were made on 3/8/16: 11:30 AM AL #4 was observed with 3 areas of deep splintered edges. 11:34 AM AL #8 was observed with a deep scuff across the entire width of the door. 11:40 AM AL #9 was observed with the door edge splintered near the lower portion of the door. 3:45 PM AL #3 was observed with the door edge splintered in 2 places. 3:58 PM AL #2 was observed with 2 areas of broken jagged hard plastic on the kickplate/base. 4:00 PM AL #10 was observed with the door chipped on the lower portion. 5:08 PM AL #5 was observed with splintered edges in 2 areas. The following observations were made on 3/9/16: 8:25 AM AL#10 the door remained chipped. 8:30 AM AL #3 the door edges remained splintered in 2 places. 8:35 AM AL #9 the door edges were observed chipped and splintered. 11:15 AM AL #4 and AL #5 doors were found with splintered edges. 11:19 AM AL #8 the bathroom door remained with a deep scuff. 11:26 AM AL #2 the plastic remained broken and jagged. A tour/interview was conducted on 3/9/16 at 4:20 PM with EI #2, the Maintenance Supervisor. EI #2 was asked to describe what he observed at each of the Area Locators. The following remarks were his responses: AL #2 a jagged broken base in 2 places AL #3 splintered door edge AL #4 five nicks-splintered AL #5 two nicks-splintered AL #8 scrape across lower portion of the door AL #9 splintered door AL #10 door edges rough and splintered A tour/interview was conducted on 3/9/16 at 4:50 PM with EI #1, the Administrator. EI #1 was asked to describe what she observed at each of the Area Locators. The following remarks were her responses: AL #2 two broken jagged places coverplate AL #3 beat up door with rough edges AL #4 that is bad beat up-splintered AL #5 splintered AL #8 door scuffed deep all across AL #9 splintered door AL #10 door chipped with rough edges EI #1 was asked who provided maintenance to the facility and she named EI #2. EI #1 was asked how long EI #2 had been employed and she answered, One day. EI #1 was asked how long did the facility not have a person in that position. She answered, About six weeks or maybe five weeks. EI #1 was asked who fulfilled the responsibilities of maintenance staff in the absence of the previous Maintenance Supervisor. She answered, We all chipped in. I am ultimately responsible. EI #1 was asked how was the person trained. She answered, None, other than at my house. EI #1 was asked what was the facility's policy regarding maintaining the building. She answered, Kept in good repair as quickly as possible. Repair or replace it. EI #1 was asked what was the concern of splintered doors. She answered, Injuries.