Every finding on record at Lakeview Manor Nursing and Rehabilitation Center

Based on observations, interviews and record reviews, the facility failed to have a system in place to provide individualized behavioral health services, which met the individualized needs of a resident by preventing and treating their mental health disorder(s) for 1 (#17) of 7 residents reviewed for behavioral health in the sample Findings: Review of the facility's undated Provision of Quality Care Policy, as of 04/15/2026 at 3:45 p.m., revealed, in part, the following: Policy Explanation and Compliance Guidelines: 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 3. Qualified persons will provide the care and treatment in accordance with the resident's choices. 6. The facility will employ on a full-time, part-time, or consultant basis those professionals necessary to carry out the provisions of the residents' care plans. Review of the facility's undated Behavioral Health Services Policy, as of 04/15/2026 at 3:45 p.m., revealed, in part, the following: Policy Explanation and Compliance Guidelines: 1. The facility will ensure each resident receives the necessary behavioral health care and services to attain or maintain highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 2. Behavioral health includes a resident's entire emotional and mental health, which includes the prevention and treatment of mental disorders. 3. The facility must have sufficient staff with the appropriate competencies and skill sets to provide services to assure resident safety and attain or maintain the highest practical, mental and psychosocial well-being of each resident determined by resident assessments and individual plans of care and considering the number, acuity, and diagnosis of the facility's resident population. 4. These competencies include, but are not limited to knowledge of and appropriate training and supervision for: B. Caring for residents with mental and psychosocial disorders identified in the facility assessment and; C. Implementing non-pharmacological interventions. 5. All residents who display or are diagnosed with mental disorders will receive appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. 6. Residents will receive care in accordance with professional standards of practice and accounting for residents' experiences and preferences.Review of Resident #17's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, Anxiety Disorder, Delusional Disorder, Depression, Psychotic Disorder; Insomnia; and Generalized Anxiety Disorder. Review of Resident #17's most recent Annual MDS, with an ARD of 04/09/2026, indicated she was assessed to be cognitively intact with a BIMS of 15. Further review revealed, in part, the following: Active Diagnoses: Anxiety Disorder, Depression, Psychotic Disorder, Delusional Disorders, Other Specified Anxiety Disorders, and Unspecified Depression.Special Treatments/Procedures/Programs: Psychological Therapy: 0 minutes; Recreational Therapy: 0 minutes; and Training and Skills Practice: 0 minutes. Medications Currently Taking:Antipsychotic, Antianxiety, and Antidepressant.Review of Resident #17's Physician Orders revealed, in part, the following active orders: 04/02/2025 - Alprazolam 0.25mg - 1 tablet twice daily as needed for Anxiety. (Stopped on 05/19/2025);04/29/2025 - Buspirone 10mg - 1 tablet three times daily for Sadness, Isolation, Depression.04/29/2025 - Fluoxetine 40mg - 1 capsule twice daily for Loneliness, Isolation, Depression;05/16/2025 - Lorazepam 0.5mg - 1 tablet twice daily as needed for Anxiety. 06/04/2025 - Risperdal 0.5mg - 1 tablet daily for Mood Swings, Agitation, and Delusional Disorder. (Stopped on 06/03/2026);05/19/2025 - Alprazolam 0.5mg - 1 tablet twice daily as needed for Anxiety; 07/02/2025 - Lorazepam 0.5mg - 1 tablet twice daily for Anxiety (Stopped on 07/22/2025);07/22/2025 - Lorazepam 1mg - 1 tablet twice daily for Anxiety (Stopped on 01/29/2025); 01/06/2026 - Hydroxyzine 50mg. 1 tablet every 8 hours as needed for Picking/Itching; 01/08/2026 - Melatonin 5mg - 1 tablet at bedtime for Insomnia (Stopped 04/02/2026);01/16/2026 - Lorazepam 1mg. One time dose to be given for increased Anxiety;01/29/2026 - Lorazepam 1mg - 1 tablet three times daily for 7 days for Anxiety then resume Lorazepam 1mg twice daily on 02/06/2026. 02/06/2026 - Lorazepam 1mg - 1 tablet three times daily for Anxiety Disorders; and04/02/2026 - Melatonin 10mg - 1 tablet at bedtime for Restlessness; and06/03/2026 - Risperdal 1mg - 1 tablet twice daily for Delusional Disorders, Agitation, Isolation.Review of Resident #17's Psychiatric Specialist Progress Notes, dated 08/13/2024 through 04/13/2026, revealed in part, she received the following 3 visits since her admission: [DATE]:Resident seen today due to staff reporting compulsive behaviors and excessive picking/scratching of her skin, which was causing sores. Has history of Delusional Disorder, Depression, and Generalized Anxiety Disorder; 05/06/2025:Resident seen today as follow up. Staff reported increased anxiety and agitation. Resident reported I'm not really great and endorsed anxiety, depression, sleep impairment and appetite impairment. Resident stated she was not adjusting well to living in the facility. New medication ordered; and 06/02/2025:Resident seen today as follow up. Resident reported I'm doing so-so and endorsed anxiety, depression and staying in her room all of the time. Resident reported increased difficulty with adjusting/coping with moving into the facility. Medication doses changed and new medications ordered. Review of Resident #17's General NP Progress Notes, dated 04/01/2025 through 04/13/2026, revealed in part, the following: 04/02/2025:Resident reported increased anxiety and having panic attacks. Xanax ordered. 04/28/2025:Resident reported anxiety was uncontrolled with current dose of Xanax and requested a dose increase or to be changed to Ativan. Will refer to Psychiatric Specialist to assume medication management. Resident intermittently compliant with attending therapy and has been progressing well when attending sessions. Reported attending sessions on Tuesdays, Wednesdays and Thursdays.05/01/2025:Resident remains intermittently compliant with attending therapy but has been progressing well when attending sessions. 05/07/2025:Resident seen by Psychiatric Specialist on 05/06/2025 who recommended increasing the dose of Xanax. Change made. 05/20/2025: Resident has now refused to leave the facility for her scheduled colonoscopy on 3 separate occasions. 06/04/2025:Resident seen by Psychiatric Specialist on 06/03/2025 who recommended discontinuing Xanax, adding Lorazepam, and increasing the dose of Risperidone. Changes made. 06/22/2025:Resident noted with multiple wounds present and reports picking at her skin. 07/22/2025:Increased anxiety during today's visit. Resident reported her anxiety was poorly controlled on her current dose of Lorazepam because she was taking a much higher dose prior to long term care admission. Lorazepam dose increased. 08/25/2025:Resident frequently lays in bed, refuses therapy and remains sedentary. 09/25/2025:Resident very anxious during visit today. 11/17/2025:Resident frequently lays in bed, refuses therapy and remains sedentary. Resident demonstrated increased anxiety during visit. 12/08/2025:Resident encouraged to get out of bed and up to wheelchair. Resident stated she may start therapy next month.01/06/2026:Resident has frequently refused therapy, to get out of bed and/or leave her room;01/09/2026:Resident reported increased difficulty sleeping. 01/12/2026:Resident lived alone in her own home and performed all ADLs independently prior to long term care admission. Currently sedentary, debilitated and has gained 14.8 pounds in 2 weeks. 01/16/2026:Resident reports increasing anxiety. Resident reports picking at skin. One time dose of anxiety medication ordered. 01/29/2026:Resident reported increasing anxiety. Appears anxious and apprehensive today. States she has been having panic attacks and reported having to breathe in a paper bag for 4 hours yesterday. Ativan dose increased x7 days to allow for improvement then resume previous dose. 02/03/2026:Depression and Anxiety Assessment/Plan: Diphenhydramine; Lorazepam; Fluoxetine; Buspirone; and Risperidone. Discussed concerns regarding chronic opiate use through scheduled Ativan. Patient prioritizes anxiety control over receiving narcotics; 03/08/2026:Primary/secondary lesions on extremities, chest and abdomen;03/11/2026:Multiple scabs noted to skin. Frequently lays in bed and refuses therapy; 03/23/2026:Multiple scabs noted to skin; 04/04/2026:Longstanding history of mental health disorders which were managed by a Psychiatrist prior to admission to the long term care facility. Multiple scabs noted to skin. Review of Resident #17's Psychoactive GDRs revealed, in part, the following: 03/25/2025:Dose decrease in Risperdal, used to treat Delusional Disorder, contraindicated due to recent relapse in symptoms; and03/16/2026:Dose decrease to all psychoactive medications contraindicated due to symptoms remaining persistent enough to warrant continuation with all psychoactive medications managed by Psychiatric Specialist.An interview was conducted on 04/15/2026 at 9:55 a.m. with Resident #17. She confirmed she suffered from on-going issues with anxiety and depression, which were present long before she was admitted to the facility. She confirmed prior to admission, she lived alone, cared for herself independently and saw a psychiatrist who prescribed her medications and helped her manage her mental health issues. She confirmed she still experienced on-going issues with adjusting to not living independently anymore and all that comes with living in a long term care facility. She stated she also experienced extreme anxiety with having so many health issues and being fearful of what that will mean for her in the future. She stated she knew worrying won't change it, but she could not make herself stop all of the time. She confirmed she experienced panic attacks at times, which had become more frequent since the beginning of the year, and thought it may be because of some new health issues she'd developed. She stated when her anxiety was bad, she picked at her skin and either caused new sores or worsened ones she already had but she just couldn't make herself stop. She confirmed when she first entered the facility, she was comfortable leaving her room to participate in therapy sessions, activities, and to interact with other residents throughout the facility during meals or other events. She confirmed at some point after admission, she no longer left her room and no longer felt comfortable being around other people outside of her own space but could not express why. She confirmed in the past year, she'd missed multiple specialist appointments/testing/procedures, which would have required her to leave the facility. She stated none of the nursing staff or S6SSD had asked her why she no longer left her room and it was probably best because she wouldn't know how to answer. She confirmed a year or so back, S6SSD offered her an opportunity to participate in an intensive outpatient treatment program, but she declined due to having to leave her room and the facility in order to participate. She confirmed she used to see the facility's Psychiatric Specialist, but had not seen her in almost a year and was not sure why she quit coming. She confirmed the facility's nurse practitioners saw her and ordered her medications now. She confirmed she was never offered any sort of behavioral health counseling or therapy services to be provided in her room. She confirmed she never even realized that was a service a nursing home could provide or she would have requested it when she moved in. She confirmed if the facility provided a behavioral health counselor or therapist that came to her room, she would not only participate, she felt it would also greatly benefit her to talk through the things that were concerning her at the time.An interview was conducted on 04/15/2026 at 9:20 a.m. with S15LPN. S15LPN confirmed she was familiar with Resident #17 and provided her care frequently. S15LPN confirmed Resident #17 had on-going issues with uncontrolled anxiety and depression. S15LPN stated she could tell when Resident #17's anxiety was getting bad because she would pick at her skin and cause sores. S15LPN confirmed Resident #17 took medications several times a day to manage her signs and symptoms but some days it worked and other days weren't so good. S15LPN confirmed Resident #17 refused to leave her room but could not say why. S15LPN confirmed it had never crossed her mind it could be related to her anxiety and/or depression. S15LPN confirmed if the facility offered a counselor or therapist that saw residents in their rooms, she felt Resident #17 would definitely participate. An interview was conducted on 04/15/2026 at 9:50 a.m. with S8CNA. S8CNA confirmed she was familiar with Resident #17 and provider her care frequently. S8CNA confirmed Resident #17 refused to leave her room but had never asked her why. S8CNA confirmed Resident #17 had on-going issues with anxiety and depression and some days were better than others. S8CNA stated she could tell when Resident #17's anxiety was getting bad because she would pick at her skin and cause sores. An interview was conducted on 04/15/2026 at 2:19 p.m. with S9CNA. S9CNA confirmed she was very familiar with Resident #17 and had worked with her since she was admitted to the facility. S9CNA confirmed Resident #17 had on-going issues with anxiety, depression and panic attacks since she was admitted to the facility. S9CNA stated some days were better than others. S9CNA confirmed when Resident #17 was admitted , she attended therapy, activities and other events to interact with residents outside of her room; however, at some point she began refusing to leave her room for anything. An interview was conducted on 04/15/2026 at 2:45 p.m. with S7LPN. S7LPN confirmed when she was assigned to provide care for Resident #17, the resident typically experienced large amounts of increased anxiety. S7LPN confirmed she always documented Resident #17's anxiety in her chart so she would not inform S2DON, S3ADON or S6SSD because they reviewed documentation and discussed it then would ask questions if there were any. Review of Resident #17's Social Services Quarterly Assessment Notes revealed, in part, she was assessed quarterly by S6SSD to not have any changes or issues present regarding cognitive status, social interactions, mood status, behavioral status, and/or the presence of any rejection of care from August 2024 through April 2026. An interview was conducted on 04/15/2026 at 11:14 a.m. with S6SSD. S6SSD confirmed she was responsible for performing and documenting each resident's Quarterly SSD Assessment Note. S6SSD confirmed if a resident were capable of answering questions, she only asked them questions to complete the assessment. S6SSD confirmed if the resident couldn't answer her questions, she would check in with direct care staff. S6SSD confirmed the assessment included the entire quarter prior to the date of the assessment, not just a 7 day lookback period. S6SSD confirmed the assessment should include the presence of anything social services related that was observed by and/or reported to anyone in the facility, not just herself. S6SSD reviewed Resident #17's SSD Quarterly Assessments for 10/31/2024, 07/14/2025, 10/14/2025, 01/08/2026 and 04/09/2026 then confirmed she completed them. S6SSD confirmed each of the assessments indicated Resident #17 remained stable, did not have any changes and/or did not demonstrate any signs or symptoms related to her cognitive status, social interactions, mood status, behavioral status, and had not rejected any care from 08/2024 through 04/09/2026. S6SSD confirmed she was unaware Resident #17 experienced on-going issues with anxiety, depression and intermittent panic attacks since she was admitted to the facility and should have been. S6SSD confirmed she was unaware Resident #17 had been picking at her skin causing sores due to her anxiety and should have been. S6SSD confirmed she was unaware changes had been made to Resident #17's psychoactive medication regimen in order to better manage the onset of signs and symptoms and should have been so she could have followed up. S6SSD stated she attended a daily morning meeting with the directors of all the facility's departments and she would be notified of the presence of any behavioral and/or mental health signs and symptoms during that meeting so she could follow up with the resident. S6SSD confirmed she was not made aware of anything social services related involving Resident #17 during the daily morning meetings. S6SSD confirmed the direct care staff should also came to her if a resident was having any behavioral/mental health issues so she could follow up with the resident and see what was going on. S6SSD confirmed she was aware Resident #17 now refused to get out of bed and/or leave her room and she had been willing to do so when she was initially admitted to the facility. S6SSD confirmed Resident #17 was independent and lived at home alone prior to moving into the facility. S6SSD confirmed Resident #17 used to leave her room to participate in activities and interact with others but stopped doing so a while back. S6SSD stated she did not know when the change took place because she had not paid much attention to it and never thought it could have been related to her mental health. S6SSD confirmed she'd offered Resident #17 an opportunity to attend an intensive outpatient program in the past but confirmed she could not say when she had done so. S6SSD confirmed Resident #17 refused to participate due to not wanting to leave the facility and she did not offer or attempt to find additional options to accommodate for her unwillingness to leave her room. S6SSD confirmed she could not recall or provide documentation to indicate Resident #17 was offered any sort of counseling or therapy services to be provided in her room. S6SSD stated she only offered services to residents when there was an order present to do so or it was specifically listed on their recommended services. S6SSD confirmed she was responsible for arranging behavioral health services for the facility's residents and working with all the members of the interdisciplinary team to create an individualized plan of care which met the resident's specific needs. S6SSD confirmed this had not occurred for Resident #17 and should have. An interview was conducted on 04/15/2026 at 10:05 a.m. with S2DON. S2DON confirmed the facility's interdisciplinary team was responsible for identifying the behavioral health needs of their residents, educating the resident on what services were available, making arrangements for the services to be provided then ensuring the services were being provided as they should. S2DON confirmed the team met every morning to review what was going on with all of the resident's in the facility. S2DON confirmed they reviewed a 24 hour report to see if any of the residents had any changes or anything new since the previous meeting, such as the presence of behavioral health signs and symptoms. S2DON confirmed in addition to reviewing the report, she also expected her direct care staff to keep not only the NP's but also her informed of what was going on with the residents; if any new behaviors presented or if current ones were not resolving. S2DON confirmed she utilized all of this information to ensure she had the most up to date information during their daily morning meetings. S2DON confirmed the facility offered a Psychiatric Specialist who made monthly rounds in the facility to assess and treat resident's on their list. S2DON confirmed she was responsible for maintaining the Psychiatric Specialist's list of residents to be seen during their next rounding day. S2DON confirmed the Psychiatric Specialist should see any resident experiencing current, on-going behavioral health signs and symptoms along with residents who required psychoactive medication dose changes and/or psychoactive medication changes and/or residents who were identified as needing to be seen by a Psychiatric Specialist on their Level II PASRR. S2DON confirmed if a resident was seen for uncontrolled signs and symptoms and/or had a medication dose change/new medication addition, the resident should be added to the Psychiatric Specialist's list of residents to be seen the following month so she could follow up and ensure everything resolved since the previous visit. S2DON confirmed it was her responsibility to know which residents should be added to the list for follow up the following month. S2DON confirmed the only reason the Psychiatric Nurse practitioner would see a resident less frequently than every month was if they were stable on their medication doses and were not experiencing any signs or symptoms and at that point they would be seen annually. S2DON confirmed it was her responsibility to be aware of what was going on with the residents so she could ensure everyone who needed to be seen were seen when the Psychiatric Specialist was at the facility. S2DON confirmed if one of the facility's general NP's were making changes to a resident's psychoactive medication(s), the resident should be seen by the Psychiatric Specialist the next time they round in the facility to ensure they are in agreement with the changes that were made. S2DON confirmed Resident #17's Progress Note from the Psychiatric Specialist on 06/02/2025 indicated she was seen for unresolved signs and symptoms and received medication order changes during the visit. S2DON confirmed Resident #17 should have been seen again the following month and she was not. S2DON confirmed it was her responsibility to add Resident #17 to the list and to ensure she was seen but she did not know what happened or why she was left off. S2DON confirmed in addition to providing residents with a mental health diagnosis the opportunity to see the Psychiatric Specialist, the facility also offered residents the opportunity to participate in an intensive outpatient program which was provided at another facility in a nearby town. S2DON confirmed the facility did not currently provide any in-house options for behavioral health therapy and/or counseling services. S2DON confirmed if a resident did not wish to leave the facility to receive treatment in another location, the facility should provide an in-house option to meet their needs and/or individual treatment preferences. S2DON confirmed she was unaware Resident #17 was experiencing on-going issues with anxiety, depression and intermittent panic attacks since she was admitted to the facility and should have been. S2DON confirmed she was unaware Resident #17 had been picking at her skin causing sores due to her anxiety and should have been. S2DON confirmed she was unaware changes had been made to Resident #17's psychoactive medication regimen by both the Psychiatric Specialist and the facility's NPs in order to better manage the onset of signs and symptoms and should have been so she could have ensured follow up was completed and all necessary services were provided. S2DON confirmed Resident #17's admitting diagnoses should have alerted the facility of the need to provide her with the necessary behavioral health services and it did not. S2DON confirmed the facility was required to provide their residents with individualized behavioral health services which best met their needs and included non-pharmacological interventions, not just medication management and medication side effect/behavior monitoring and they did not for Resident #17. S2DON confirmed the facility was required to provide Resident #17 with behavioral health services in a way that best met her needs and they did not. An interview was conducted on 04/15/2026 at 10:07 a.m. with S3ADON. S3ADON confirmed direct care staff had not made her aware of Resident #17 having on-going depression, anxiety, and anxiety/panic attacks and should have. An interview was conducted on 04/15/2026 at 10:07 a.m. with S5RN. S5RN confirmed the facility was required to provide their residents with individualized behavioral health services which best met their needs and included non-pharmacological interventions, not just medication management and medication side effect/behavior monitoring. S5RN reviewed Resident #17's chart and stated her non-pharmacological behavioral health interventions provided by the facility included activities providing one on one visits when they could, encouraging family to visit, monitoring for behaviors and medication side effects, and providing a calm environment when she experienced anxiety. S5RN confirmed since Resident #17 was unwilling to leave her room or the facility to participate in the intensive outpatient treatment program, the facility should have provided her with an in-house option in order to meet her needs and individual treatment preferences but they did not. S5RN confirmed the facility did not currently provide this service to any of their residents and should. S5RN confirmed Resident #17 should have been managed and seen by the Psychiatric Specialist much more frequently but she was dropped from the list and should not have been. S5RN confirmed since the facility's NPs were the providers making dose changes to Resident #17's psychoactive medications, the facility could not indicate a GDR was contraindicated due to the medications being managed by the Psychiatric Specialist because that was no longer who was managing them. S5RN confirmed S6SSD should have performed and documented accurate Quarterly Assessments which accurately reflected Resident #17's behavioral health status and the presence of her on-going signs and symptoms which would have helped ensure she received the services she required and she did not. S5RN confirmed the IDT should have a system of communication to ensure they were aware of the behavioral health signs and symptoms Resident #17 was experiencing over the past year so they could provide her with appropriate services and they did not. S5RN confirmed S6SSD should not rely on Level II PASRR recommendations as her sole source of determining what behavioral health services residents require because all residents, even those without a Level II PASRR could potentially benefit from receiving them. S5RN confirmed the facility was required to provide all residents with behavioral health services in a way that best met her needs and they did not.

Based on observations, interviews, and policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. Food was labeled and / or dated with a preparation date; and 2. Left over food was discarded in a timely manner.This deficient practice had the potential to affect any of the 91 residents who received nourishment from the facility's kitchen.Findings: Review of the undated facility policy titled Storage: Freezer revealed the following, in part:3. Label and date all items Review of the undated facility policy titled Storage: Refrigerator revealed the following, in part:6. If raw foods must be kept in the same refrigerator keep cooked foods above raw foods. If cooked foods are kept below raw foods, they can become contaminated by drips and spills. Then, if they are not to be cooked again before serving, they may be hazardous.7. Keep refrigerated foods wrapped or covered in sanitary containers. On 04/14/2026 at 2:24 p.m., an interview was conducted with S4DM. S4DM confirmed 91 residents received food from the kitchen. On 04/13/2026 at 8:23 a.m., a tour of the kitchen was conducted with S4DM. The following observations were made and confirmed: Freezer a 1 personal cup with a lid and straw containing liquid sitting on top of the freezer;1 large Styrofoam cup with a lid containing ice with no label and no date; and1 small Styrofoam cup with a lid containing a dessert with no label and no date. Cooler a1 container of cut tomatoes with a preparation date of 04/06/2026 and a use by date of 04/12/2026;1 container labeled of mixed peanut butter jelly with no preparation date and no use by date; 3 cartons of pork chops stored on a wire shelf over a covered bowl of diced pears; and1 container of tuna salad with no label and no preparation date. On 04/13/2026 at 8:36 a.m., an interview was conducted with S4DM. S4DM confirmed the Styrofoam cups in Freezer a belonged to an employee and should not have been stored in the freezer. S4DM confirmed the personal cup with a lid and straw should not have stored on top of Freezer a. S4DM confirmed the cut tomatoes and container of beets should have been used within a week's time. S4DM confirmed the 3 cartons of pork chops should not be stored over the bowl of diced pears. S4DM confirmed all foods should be labeled and have a preparation date. On 04/14/2026 at 2:38 p.m., an interview was conducted with S1ADM. S1ADM confirmed employees should not store personal items in the freezer of the kitchen. S1ADM confirmed pork chops and meats should be stored on lower levels below other food items. S1ADM confirmed opened foods and left over food should be labeled with a preparation date.

Based on record review and interviews, the facility failed to ensure nursing staff notified the provider when staff heard Resident #89 state she did not want to live anymore for 1 (#89) of 3 residents reviewed for Dementia Care.Findings:Review of Resident #89's Clinical Record revealed she was admitted to the facility on [DATE] with the following diagnoses: Unspecified Dementia, Mood Disturbance, Anxiety, and Schizoaffective Disorder.Review of Resident #89's Quarterly MDS with an ARD of 03/03/2026 revealed the resident had a BIMS of 12, indicating the resident was moderate cognitively impaired.Review of Resident #89's Nursing Notes, dated 02/23/2026 at 5:53 a.m., revealed the following: Resident #89 was heard in her room stating I just want to die already. S16LPN asked Resident #89 why she felt that way and Resident #89 stated because people are talking about her. S16LPN asked what people and Resident #89 pointed to the empty bed in her room. S16LPN assured her no one was in the room with her. Resident #89 continued to state that she no longer wanted to live. NP and DON made aware. Review of Resident #89's NP Progress notes, dated 02/23/2026 to 03/27/2026, revealed no documentation Resident #89 stated she did not want to live anymore. An interview was conducted with S16LPN on 04/15/2026 at 10:38 a.m. She stated during the night shift of 02/23/2026, she heard Resident #89 state she just wanted to die and did not want to live any longer. She stated she left a message for the on call provider via voice message and wrote the information in the green NP communication binder found at the nurse's station. An interview was conducted with S2DON on 04/15/2026 at 10:48 a.m. She stated she was aware Resident #89 had a diagnosis of Dementia and Schizoaffective Disorder. She stated she was not aware of a green communication binder at the nurse's station and she would expect staff to contact her and the NP immediately if the resident was heard saying she did not want to live any longer. She confirmed she was not made aware of Resident #89's change of condition and should have been. An interview was conducted with S10NP on 04/15/2026 at 1:05 p.m. She stated there was a NP on call 24 hours a day 7 days a week. She stated if Resident #89 stated, I just want to die already, the on call provider should have been notified immediately and the on call provider would have sent the resident out to the hospital for an evaluation. She confirmed she rounded on Resident #89 on 02/23/2026 and was not made aware of Resident #89's statement. She stated if she was made aware it would have been in her encounter note on 02/23/2026 and she would have sent Resident #89 out to the hospital for an evaluation.

Based on observations, interviews, and record reviews, the facility failed to respect the resident's right to personal privacy for 2 (#8 and #63) of the 25 residents reviewed for privacy in the initial pool. The facility failed to ensure Residents #8 and #63 had privacy curtains around their beds.Findings: Resident #8Review of Resident #8's Clinical Record revealed an admission date of 07/03/2025. Review of Resident #8's Quarterly MDS with an ARD of 03/26/2026 revealed that the resident had a BIMS of 15, indicating the resident was cognitively intact. Resident #63Review of Resident # 63's Clinical Record revealed an admission date of 04/28/2025. Review of Resident #63's Quarterly MDS with an ARD of 02/02/2026 revealed that the resident had a BIMS of 14, indicating the resident was cognitively intact. Review of facility Census revealed Resident #8 and Resident #63 were roommates. On 04/13/2026 at 9:01 a.m., an observation was conducted of Resident #8 sitting in her room next to the window. Further observation revealed there was no privacy curtain attached to the track on the ceiling. Resident #8 stated she would like to have a curtain for privacy in her room. On 04/14/2026 at 4:20 p.m., an observation was conducted of Resident #8's and Resident #63's room which revealed there was no privacy curtain attached to the track on the ceiling. On 04/15/2026 at 7:50 a.m., an observation was conducted of Resident #8's and Resident #63's room which revealed there was no privacy curtain attached to the track on the ceiling.An interview was conducted with Resident #63 on 04/14/2026 at 4:25 p.m. Resident # 63 stated she would like a privacy curtain in her room to separate her space from Resident #8. An interview with observation was conducted with S18CNA on 04/15/2026 at 7:56 a.m. Observation of Resident #8 and Resident #63's room revealed no privacy curtain was attached to the ceiling track. S18CNA confirmed Resident #8 and Resident #63 should have a privacy curtain between the beds to ensure they each had personal space. An interview was conducted with S17CNAS on 04/15/2026 at 8:04 a.m. She confirmed all rooms should have a privacy curtain. She stated she was not aware the room did not have a privacy curtain and should have. An interview was conducted with the S2DON on 04/15/2026 at 3:35 p.m. She confirmed all resident's had the right to privacy and a privacy curtain should be in all resident's rooms.

Based on interviews and record review the facility failed to ensure a resident with a newly identified psychiatric diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 1 (#51) of 4 sampled residents reviewed for PASRR. Review of the facility's undated Policy titled Resident Assessment- Coordination with PASRR Program revealed the following, in part: Policy: The facility coordinates assessments with preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. U9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: aa. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASRR. Review of Resident #51's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #51 acquired a new psychiatric diagnosis of Schizophrenia on 03/20/2025. Review of Resident # 51's most recent PASRR Level 1 Form dated 08/08/2022 revealed no psychiatric diagnoses. Review of Resident #51's Care Plan with a revised date of 10/02/2025 revealed, in part the following: The resident had a behavioral problem related to Schizophrenia.On 04/14/2026 at 1:30 p.m., an interview was conducted with S6SSD. She confirmed she did not have a Level II PASRR for Resident #51. S6SSD confirmed Resident #51 had acquired a diagnosis of Schizophrenia on 03/20/2025. 6SSD stated she was unaware a Resident Review Form should have been submitted after acquiring diagnosis of Schizophrenia. S6SSD confirmed there was no process in place for identifying residents with any newly acquired psychiatric diagnoses. On 04/15/2026 at 2:45 p.m., an interview was conducted with S1ADM. S1ADM confirmed if a resident received a new mental health or psychiatric diagnosis the facility should submit a Resident Review Form for evaluation and determination for Level II services.

Based on observation, interviews, and record review, the facility failed to ensure a resident's comprehensive person-centered care plan was implemented by failing to administer enteral feeding as ordered for 1 (#53) of 2 (#53 and #71) residents reviewed with enteral feeding. Findings: Review of Resident #53's Clinical Record revealed he admitted to the facility on [DATE] and had diagnoses, which included Neurocognitive Disorder with Lewy Bodies, Gastrostomy Status, and Dysphagia. Review of Resident #53's Significant Change MDS with an ARD of 01/08/2025 revealed a BIMS interview was not conducted related to the resident was rarely/never understood. Review of Resident #53's current Care Plan revealed the following, in part: Problem: At risk for malnutrition related to PEG tube feedings; NPO (nothing by mouth) status. Goal: The resident will maintain weight through review date Interventions: 01/03/2025 - Diet changed to PEG tube feedings. Resident is now NPO. Review of Resident #53's Physician Orders dated 01/03/2025 through 03/11/2025 revealed the resident was NPO beginning 01/03/2025. Further review revealed Resident #53 was always ordered to receive more than one can of Diabetisource AC at breakfast, lunch, and dinner. An observation was made of S6RN providing tube feeding for Resident #53 on 03/11/2025 at 9:58 a.m. She administered one can of Diabetisource AC via PEG tube by gravity. An interview was conducted with S6RN on 03/11/2025 at 10:09 a.m. She confirmed the above observation. She stated she worked twelve hour shifts, on two days, off two days, and every other weekend. She reviewed Resident #53's tube feeding order after administration and confirmed Resident #53 should have received 2 cans of Diabetisource. S6RN confirmed Resident #53 should have received 2 cans of Diabetisource at breakfast, lunch, and dinner since 02/20/2025, and 1.5 cans prior to that beginning on 01/03/2025. She confirmed the first time she had administered more than one can of tube feeding to Resident #53 was this morning after reviewing the tube feeding orders with the surveyor. An interview was conducted with S2DON on 03/11/2025 at 1:00 p.m. She stated Resident #53's tube feeding orders changed frequently. She stated he was receiving 1.5 cans of Diabetisource four times a day, then it went to two cans at breakfast, lunch, and supper and one can at night. She stated, on 03/11/2025, Resident #53's tube feeding order changed to two cans at breakfast, lunch, supper, and at night. She confirmed at no point had Resident #53 been ordered one can of tube feeding formula. She stated the nurses should have administered the amount of tube feeding ordered. An interview was conducted with S13NP on 03/11/2025 at 1:22 p.m. He stated he expected the nurses to administer Resident #53's tube feeding as ordered.

Based on observation, interviews, and record review, the facility failed to ensure each resident received services as outlined in the comprehensive care plan which met professional standards of quality for 1 (#53) of 2 (#53 and #71) residents reviewed with enteral feeding. The facility failed to ensure S6RN: 1. Verified Resident #53's physician orders prior to enteral feeding administration; and 2. Accurately documented administration of Resident #53's enteral feeding. Findings: Review of the facility's undated policy titled, Enteral Tube Feeding via Gravity revealed the following, in part: Purpose: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan and provide for any special needs of the resident. General Guidelines: 3. Check the enteral nutrition label against the order before administration. Review of the facility's undated policy titled, Documentation revealed the following, in part: The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment . Purpose: 12. Personnel will be expected to document .accurately . Review of Resident #53's Clinical Record revealed he admitted to the facility on [DATE] and had diagnoses, which included Neurocognitive Disorder with Lewy Bodies, Gastrostomy Status, and Dysphagia. Review of Resident #53's Significant Change MDS with an ARD of 01/08/2025 revealed a BIMS interview was not conducted related to the resident was rarely/never understood. Review of Resident #53's current Care Plan revealed the following, in part: Problem: At risk for malnutrition related to PEG (Percutaneous Endoscopic Gastrostomy) tube feedings; NPO (nothing by mouth) status. Goal: The resident will maintain weight through review date Interventions: 01/03/2025 - Diet changed to PEG tube feedings. Resident is now NPO. Review of Resident #53's Physician Orders dated 01/03/2025 through 03/11/2025 revealed the following, in part: Beginning 01/03/2025 to current - NPO From 01/03/2025 to 01/10/2025 - Enteral Feeding 360 mL four times daily; From 01/10/2025 to 02/17/2025 - Diabetisource 1.5 cans four times daily; From 02/17/2025 to 02/18/2025 - Diabetisource 2 cans at breakfast, 2 cans at lunch, 2 cans at dinner, and 1 can at night; From 02/18/2025 to 02/20/2025 - Diabetisource 360 mL four times daily From 02/20/2025 to 03/11/2025 - Diabetisource AC 2 cans at breakfast, 2 cans at lunch, 2 cans at dinner, and 1 can at night; and From 03/11/2025 to current - Diabetisource AC 2 cans at breakfast, 2 cans at lunch, 2 cans at dinner, and 2 cans at night. Review of Resident #53's MAR dated 01/03/2025 through 03/10/2025 revealed S6RN documented administration of tube feedings as ordered on the following dates and times: From 01/03/2025 to 01/10/2025 - Enteral Feeding 360 mL four times daily: 01/03/2025 at 4:00 p.m.; 01/04/2025 at 10:00 a.m. and 4:00 p.m.; 01/08/2025 at 10:00 a.m. and 4:00 p.m.; 01/09/2025 at 10:00 a.m. and 4:00 p.m.; and 01/10/2025 at 10:00 a.m. From 01/10/2025 to 02/17/2025 - Enteral feeding Diabetisource 1.5 cans four times daily: 01/10/2025 at 4:00 p.m.; 01/13/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/14/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/17/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/18/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/19/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/23/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/27/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/28/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/01/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/02/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/05/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/06/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/10/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/14/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/15/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; and 02/16/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m. From 02/17/2025 to 02/18/2025 - Enteral Feeding Diabetisource 2 cans breakfast, 2 cans lunch, 2 cans dinner, 1 can at night: 02/18/2025 at 9:00 a.m. From 02/18/2025 to 02/20/2025 - Enteral Feeding Diabetisource 360 mL four times daily: 02/18/2025 at 1:00 p.m. and 5:00 p.m. From 02/20/2025 to 03/11/2025 - Enteral Feeding Diabetisource AC 2 cans at breakfast, 2 cans at Lunch, 2 cans at dinner, and 1 can at night: 02/24/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/25/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/26/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 03/01/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 03/02/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 03/05/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 03/06/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; and 03/10/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m. Review of the Diabetisource AC (1.2 kilocalories/mL) can used by the facility revealed it contained 250 mL. An observation was made of S6RN providing tube feeding for Resident #53 on 03/11/2025 at 9:58 a.m. She administered one can of Diabetisource AC via PEG tube by gravity. An interview was conducted with S6RN on 03/11/2025 at 10:09 a.m. She confirmed the above observation. She stated she worked twelve hour shifts, on two days, off two days, and every other weekend. She reviewed Resident #53's tube feeding order after administration and confirmed Resident #53 should have received 2 cans of Diabetisource. S6RN confirmed Resident #53 should have received 2 cans of Diabetisource at breakfast, lunch, and dinner since 02/20/2025, and 1.5 cans prior to that beginning on 01/03/2025. She confirmed the first time she had administered more than one can of tube feeding to Resident #53 was this morning after reviewing the tube feeding orders with the surveyor. An interview was conducted with S6RN on 03/11/2025 at 4:48 p.m. She reviewed Resident #53's MARs dated January, February, and March 2025. She confirmed all of the above listed documentation for administering tube feeding to Resident #53 was inaccurate. She confirmed, since Resident #53 began receiving tube feeding, she had never administered more than one can of tube feeding at a feeding. She confirmed she should have verified the tube feeding order prior to administration of the tube feeding. An interview was conducted with S2DON on 03/11/2025 at 1:00 p.m. She confirmed Resident #53 was always ordered to receive more than one can of Diabetisource at breakfast, lunch, and dinner. She stated the nurses should have administered the amount of tube feeding ordered. She confirmed S6RN should have verified the tube feeding order prior to administration. She reviewed Resident #53's January, February, and March 2025 MARs and confirmed S6RN should not have documented administration of the tube feeding as ordered if she did not administer the tube feeding as ordered.

Based on observation, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered to maintain acceptable parameters of nutritional status for 1 (#53) of 4 (#37, #53, #65, and #71) residents reviewed for nutrition and/or enteral feeding. Findings: Review of Resident #53's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Neurocognitive Disorder with Lewy Bodies, Gastrostomy Status, and Dysphagia. Further review of the Clinical Record revealed Resident #53's ideal body weight was 166 pounds. Review of Resident #53's Significant Change MDS with an ARD of 01/08/2025 revealed a BIMS interview was not conducted related to resident was rarely/never understood. Further review of the MDS revealed Resident #53 had lost 5% or more in the last month or 10% or more in the last six months of body weight and was not on a physician-prescribed weight loss regimen. Resident #53 received 51% or more of nutrition through tube feeding. Review of Resident #53's Physician Orders dated 01/03/2025 through 03/11/2025 revealed he was always prescribed more than one can of Diabetisource per PEG tube at breakfast, lunch, and dinner. Review of Resident #53's current Care Plan revealed the following, in part: Problem: At risk for malnutrition related to PEG (Percutaneous Endoscopic Gastrostomy) tube feedings; NPO status. Goal: The resident will maintain weight through review date. Interventions: 01/03/2025 - Diet changed to PEG tube feedings. Resident is now NPO 01/03/2025 - Triggered in 10% for a loss. Further review revealed weekly interventions beginning on 01/17/2025 through 02/27/2025 noted the resident triggered in 7.5/10% for a loss Review of Resident #53's Weight History dated January 2025 through March 2025 revealed the following, in part: 01/03/2025 - 203.5 pounds; 01/08/2025 - 204.7 pounds; 01/10/2025 - 204.7 pounds; 01/17/2025 - 190.5 pounds; 01/24/2025 - 188.4 pounds; 01/31/2025 - 189.5 pounds; 02/07/2025 - 185.6 pounds; 02/14/2025 - 184.6 pounds; 02/27/2025 - 180.5 pounds; 03/07/2025 - 184.8 pounds; and 03/11/2025 - 184.7 pounds. An observation was made of S6RN providing tube feeding for Resident #53 on 03/11/2025 at 9:58 a.m. She administered one can of Diabetisource AC via PEG tube by gravity. An interview was conducted with S6RN on 03/11/2025 at 10:09 a.m. She confirmed the above observation. She stated she worked twelve hour shifts, on two days, off two days, and every other weekend. She reviewed Resident #53's tube feeding order after administration and confirmed Resident #53 should have received 2 cans of Diabetisource. S6RN confirmed Resident #53 should have received 2 cans of Diabetisource at breakfast, lunch, and dinner since 02/20/2025, and 1.5 cans prior to that beginning on 01/03/2025. She confirmed the first time she had administered more than one can of tube feeding to Resident #53 was this morning after reviewing the tube feeding orders with surveyor. An interview was conducted with S12RD on 03/11/2025 at 12:38 p.m. She stated Resident #53 had significant weight loss since his PEG tube placement in January 2024. She stated Resident #53 was initially on 1.5 cans of Diabetisource at breakfast, lunch, and dinner. She stated, on 02/20/2025, his PEG tube feedings were increased to two cans at breakfast, lunch, and dinner. She stated, on 03/06/2025, she recommended increasing his feeding to 2 cans of Diabetisource AC at breakfast, lunch, supper, and at night, which was implemented by the Nurse Practitioner on 03/11/2025. She confirmed Resident #53 had never been ordered to receive one can of Diabetisource at breakfast, lunch, or dinner. She confirmed since Resident #53 returned with the PEG tube in January 2025, all of her recommendations were due to his continued weight loss. She stated she intended for the resident to receive tube feedings as recommended and ordered by the Physician to maintain his nutritional status. She stated incorrect feeding amounts could have contributed to increased weight loss. She stated Resident #53 received 900 kilocalories less than recommended if he only received one can per feeding of Diabetisource AC for three feedings in a 24 hour period. She confirmed his current weight loss could have been from not receiving the ordered amount of tube feeding. An interview was conducted with S2DON on 03/11/2025 at 1:00 p.m. She stated Resident #53's tube feeding orders had changed frequently. She confirmed at no point had Resident #53 been ordered only one can of tube feeding formula at breakfast, lunch, or dinner. She stated the nurses should have administered the amount of tube feeding ordered. She stated if Resident #53 did not receive his ordered tube feedings, it could have contributed to further weight loss. A telephone interview was conducted with S13NP on 03/11/2025 at 1:22 p.m. He stated Resident #53 returned to the facility on [DATE] with a PEG tube. He stated he had been working with facility staff and S12RD to get Resident #53's weights stable. He stated Resident #53's tube feeding volume had to be changed multiple times. He stated he expected the nurses to administer Resident #53's tube feeding as ordered. He stated if Resident #53 had not received the correct amount of feeding, or calories, it could have contributed to his weight loss.

Based on observations, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. Medication rooms were free of expired supplements for 1 (MR3) of 2 (MR2 and MR3) medication rooms reviewed; 2. Medication carts were free of expired supplements for 1 (MC3) of 2 (MC1 and MC3) medication carts reviewed; 3. Medication carts were free of loose pills for 1 (MC1) of 2 (MC1 and MC3) medication carts reviewed; and 4. Insulin pens were labeled with an opened date on 1 (MC1) of 2 (MC1 and MC3) medication carts reviewed. This deficient practice had the potential to affect all of the 97 residents residing in the facility. Findings: Review of the undated facility policy titled Medications - Storage revealed the following, in part: The facility shall store drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. The facility shall not use discontinues, outdated, or deteriorated drugs or biologicals. 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. On [DATE] at 12:29 p.m., an observation was made of MR3 with S8LPN, which revealed the following: 8 containers of liquid supplements with an expiration date of [DATE]. On [DATE] at 12:29 p.m., an interview was conducted with S8LPN. S8LPN confirmed the liquid supplements was expired and should have been discarded. On [DATE] at 12:39 p.m., an observation was made of the MC3 cart with S8LPN, which revealed the following: 1 bottle Thiamin Vitamin B-1 100 milligram (mg) with an expiration date of ,d+[DATE]; 1 bottle Aspirin Regular Strength Enteric Coated 325 mg with an expiration date of ,d+[DATE]; 1 bottle Melatonin 3 mg with an expiration date of ,d+[DATE]; 1 bottle Magnesium Oxide 400 mg with an expiration date of ,d+[DATE]; and 2 containers/bottles of liquid supplements with an expiration date of [DATE]. On [DATE] at 12:39 p.m., an interview was conducted with S8LPN. S8LPN confirmed the above listed items were expired and should not be on the medication cart. On [DATE] at 12:58 p.m., an observation was made of the MC1 cart with S6RN, which revealed the following: Resident #46's multi dose Insulin Aspart bottle was open and had no open date; Resident #295's Lantus Solostar 100 pen and Insulin Lispro pen were open and had no open date; Resident #39's Tresiba Flextouch pen was open and had no open date. The drawers of the cart revealed the following: 2 loose round white pills; 5 loose oblong white tablets; 1 loose oblong green tablet; and 1 loose round gold pill. On [DATE] at 12:58 p.m., an interview was conducted with S6RN. S6RN confirmed the multi dose Insulin Aspart vial, Lantus Solostar pen, Insulin Lispro pen, and Tresiba Flextouch pens had no open date. S6RN confirmed she could not tell what date they were opened. S6RN confirmed when insulins are opened they should be marked with an opened date. S6RN confirmed there should not be loose pills on the medication cart. On [DATE] at 11:58 a.m., an interview was conducted with S2DON. S2DON stated she expected nurses to put an open date or a discard date on insulin pens and multi dose vials. S2DON confirmed expired supplements should be discarded. SS2DON confirmed over the counter drugs/vitamins should be discarded by the expiration date. S2DON confirmed there should be no loose pills on the medication cart.

Based on observations, interviews, and policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. food was dated after opening; 2. food was properly sealed and stored; and 3. staff with facial hair wore a beard restraint. This deficient practice had the potential to affect any of the 97 residents who received nourishment from the facility's kitchen. Findings: Review of the undated facility policy titled Storage: Dry Food revealed the following, in part: Procedure: 2. Keep all containers tightly closed from insects, rodents, and dust. Dry foods can be contaminated, even if they do not need refrigeration. Review of the undated facility policy titled Storage: Freezer revealed the following, in part: 2. Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. 3. Label and date all items Review of the undated facility policy titled Storage: Refrigerator revealed the following, in part: 5. Store raw items separately if possible. 6. If raw foods must be kept in the same refrigerator keep cooked foods above raw foods. If cooked foods are kept below raw foods, they can become contaminated by drips and spills. Then, if they are not to be cooked again before serving, they may be hazardous. 7. Keep refrigerated foods wrapped or covered in sanitary containers. On 03/10/2025 at 8:37 a.m., an initial tour of the kitchen was conducted with S17CK. S17CK confirmed the following observations: Small reach in freezer -1 Ziplock bag of hot dogs with no opened date. Large dietary cooler - 1 opened gallon container of mustard with no opened date; - 1 opened gallon container of mayonnaise with no opened date; - 1 opened gallon container of sliced dill pickles with no opened date; - 1 opened gallon container of sweet relish with no opened date; - 1 opened gallon container of ranch with no opened date; - 1 container of sandwiches partially covered by torn aluminum foil; and - 8 cups of beverages with lids dated 03/02/2025. On 03/10/2025 at 8:37 a.m., an interview was conducted with S17CK. S17CK confirmed there was no opened date on the hotdogs, mustard, mayonnaise, sweet dill pickles, sweet relish, and ranch. S17CK confirmed the aluminum foil on the container of sandwiches was torn and was not sealed. S17CK confirmed the 8 drink cups were labeled for 03/02/2025 and should have been discarded after 3 days. On 03/10/2025 at 8:49 a.m., an observation was made of the Walk-in cooler and freezer with S4DM. S4DM confirmed the following observations: Walk-In cooler - 3 cases of 15 dozen raw eggs were stored on a wire shelf above 5 cases of 1 pound butter and 2 cases of heavy whipping cream. Walk-In freezer -1 case of chicken stored on the floor; -1 case of pork loin was stored on the floor; -1 bag of mixed vegetables opened/unsealed, with no opened date and stored in an open unsealed box; -1 bag of crinkled sliced yellow squash opened/unsealed, with no opened date and stored in an open unsealed box; and -1 bag of mixed vegetables opened/unsealed, with no opened date and stored in an open unsealed box. On 03/10/2025 at 9:00 a.m., an observation was made of the dry storage area with S4DM. S4DM confirmed the following observations: -3 Bulk plastic containers with no identification labels or opened dates; -1 partially used bag of spaghetti noodles with no opened date; -1 partially used bag of macaroni noodles with no opened date; -1 partially used gallon of sweet and sour sauce with no opened date; -1 partially used gallon of vanilla with no opened date; and -1 opened box of Thickening Powder with the internal bag opened, unsealed and with no opened date. On 03/10/2025 at 9:03 a.m., an interview was conducted with S4DM. S4DM confirmed there were 97 residents who ate out of the kitchen. S4DM confirmed lidded drinks should only be held in the refrigerator for one day. S4DM confirmed the lidded drinks should have been thrown away. S4DM confirmed the bulk containers should have been labeled. S4DM confirmed all opened items should be sealed in a ziplock bag and labeled with an opened date. S4DM confirmed the raw eggs could bust or leak on the butter and contaminate it. On 03/10/2025 at 10:54 a.m., an observation was made S4DM walking past the food preparation area and serving line to the dishwasher without a facial hair restraint over his beard. S4DM confirmed he was not wearing a facial hair restraint over his beard and should have. On 03/11/25 at 1:04 p.m., an interview was conducted with S1ADM. S1ADM confirmed open containers of food should be dated with the date it was opened. S1ADM confirmed when a box was opened it should contain the date the box is open. S1ADM confirmed food should not be stored on the floor of the walk-in freezer. S1ADM confirmed lidded beverages should be held no longer than a day in the refrigerator. S1ADM confirmed facial hair restraints should be worn by everyone with a beard in the kitchen.

Based on record reviews and interviews, the facility failed to report allegations of verbal abuse to the State Survey Agency immediately, but no later than 2 hours, for 1 (#195) of 3 (#5, #36 and #195) residents reviewed for abuse. Findings: Review of the undated facility policy titled, Abuse Prevention and Investigation revealed the following: Definitions: Verbal Abuse: means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Alleged Violation: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Identification of Abuse B. Possible indicators of abuse include, but are not limited to: 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. Reporting/Response 1. Reporting of all alleged violations to the administrator, state agency . within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Resident #195 Review of Resident #195's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Unspecified Mood Disorder and Cognitive Communication Deficit. Review of Resident #195's Admission MDS assessment, with an Assessment Reference Date (ARD) of 02/25/2025, indicated the resident was assessed by the facility to have a Brief Interview of Mental Status (BIMS) of 15, which indicated she was cognitively intact. Resident #5 Review of Resident #5's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cognitive Communication Deficit and Major Depressive Disorder. Review of Resident #5's MDS, with an ARD of 12/19/2024, indicated the resident was assessed by the facility to have a BIMS of 11, which indicated moderate cognitive impairment. Review of Resident #5's most recent Care Plan revealed Resident #5 had a history of physical and verbal aggressive behaviors with interventions implemented on 05/13/2020. On 03/10/2025 at 1:10 p.m., an interview was conducted with Resident #195. She stated Resident #5, her current roommate, scared her. She reported Resident #5 told her, I'll shoot you with a gun. Resident #195 stated because of this, she slept in the hallway. On 03/10/2025 at 4:15 p.m., an interview was conducted with S14LPN. She stated Resident #5 was confused at times and had a history of cursing at other residents and staff. She stated Resident #195 did not tell her she was afraid of Resident #5. She stated during the day shift, Resident #5 sat outside the nurse's station with other residents, and told other residents and staff, I will cut you with a knife. She confirmed it was not reported to administration because Resident #5 could not physically harm any other residents. On 03/11/2025 at 10:05 a.m., an interview was conducted with S15CNA. She stated when Resident #5 got upset she talked to herself, cursed, and said I will kill you. She stated she did not report the behaviors because the nurse was aware of the behaviors. She stated she was assigned to Resident #195 and she did not tell her she was afraid of Resident #5. On 03/11/2025 at 11:17 a.m., an interview was conducted with S16CNA. She stated Resident #5 told her, they don't know me but I will cut her neck off. She stated she did not report the behaviors because the nurse was aware of the behaviors. She stated she was assigned to Resident #195 and she did not tell her she was afraid of Resident #5. On 03/12/2025 at 2:03 p.m., an interview was conducted with S1ADM. He confirmed cursing and making threats at another resident would be considered abuse. He stated he was not aware of Resident #5 making threats to any other residents. He confirmed he was made aware on 03/11/2025 at 2:04 p.m., Resident #195 was fearful of Resident #5. He stated on 03/11/2025 at 2:30 p.m., he spoke with Resident #195 and Resident #195 reported she was scared of Resident #5 because of the way she talked and cursed. He stated in this case, Resident #5 did not know what she was doing and therefore it was not abuse, and he did not report to the state agency.

Based on record reviews and interviews, the facility failed to ensure that each resident's comprehensive Minimum Data Set (MDS) assessments were completed in a timely manner for 1 (#195) of 5 (#9, #31, #65, #195, and #295) newly admitted residents reviewed for comprehensive assessments. The facility failed to ensure that the resident admission assessment was completed within the 14-day requirement. Findings: Review of Resident #195's admission MDS assessment with an Assessment Reference Date (ARD) of 02/25/2025, revealed an admitted [DATE]. Further review of the Admit MDS revealed the MDS had a status of in progress. On 03/12/2025 at 8:58 a.m., an interview was conducted with S3MDS. S3MDS reviewed Resident #195's admission MDS and confirmed Resident #195 was admitted to the facility on [DATE]. She further confirmed Resident #195's admission MDS was still in progress on 03/10/2025, and was not completed in the required timeframe. On 03/12/2025 at 4:42 p.m., an interview was conducted with S2DON. S2DON confirmed the MDS should be completed in the required timeframe.

52097 Based on observations, interviews and record review, the facility failed to ensure resident assessments accurately reflected the residents' status. The facility failed to ensure staff accurately coded: 1. The discharge status for 1 (#94) of 2 (#93 and #94) residents reviewed for discharge; and 2. The ostomy status for 1 (#22) of 2 (#22 and #81) residents reviewed for appliances. Findings: 1. Resident #94 Review of Resident #94's clinical record revealed he was admitted to the facility on [DATE] and discharged from the facility on 02/15/2025. Review of Resident #94's MDS Discharge Assessment with an ARD of 02/15/2025, revealed resident was discharged to an acute hospital. Review of Resident #94's Nurses Notes revealed the following, in part: 02/15/2025 at 9:48 a.m., Resident #94 discharged home with family. On 03/11/2025 at 3:20 p.m., an interview was conducted with S7MDS. She reviewed Resident #94's MDS Discharge Assessment with an ARD of 02/15/2025, and confirmed it indicated Resident #94 discharged to an acute hospital. She further reviewed Resident #94's medical record and confirmed the resident was discharged home. She confirmed Resident #94's MDS Discharge Assessment was not coded accurately and should have been coded discharge to home. 2. Resident #22 Review of Resident #22's clinical record revealed she was admitted to the facility on [DATE] with a medical diagnoses of Colostomy Status. Review of Resident #22's MDS Quarterly Assessment with an ARD of 01/15/2025, revealed Resident #22 was coded as none of the above under section H0100 for bowel and bladder appliances, which pertained to Ostomy, including Colostomy. On 03/11/2025 at 12:44 p.m., an observation was made of Colostomy care for Resident #22. On 03/11/2025 at 3:15 p.m., an interview was conducted with S7MDS. She reviewed Resident #22's MDS Quarterly Assessment with an ARD of 01/15/2025, and confirmed it indicated none of the above under section H0100 for bowel and bladder, which pertained to Colostomy. She confirmed Resident #22 had a Colostomy. She confirmed Resident #22's MDS Quarterly Assessment was not coded correctly and should have been coded as present for ostomy. On 03/11/2025 at 4:33 p.m., an interview was conducted with S2DON. She confirmed all MDS assessments should have been coded accurately.

Based on record reviews and interviews, the facility failed to ensure the residents care plan was reviewed and revised for 1(#5) of 4 (#5, #12, #47, and #195) residents reviewed for accidents. The facility failed to update Resident #5's care plan when she exhibited new aggressive behaviors. This deficient practice had the potential to affect a current census of 96 residents. Findings: Review of Resident #5's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cognitive Communication Deficit and Major Depressive Disorder. Review of Resident #5's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, indicated the resident was assessed by the facility to have a Brief Interview of Mental Status (BIMS) of 11, which indicated she was moderately cognitively impaired. Further review revealed the resident did not have any behaviors. Review of Resident #5's most recent Care Plan revealed Resident #5 had a history of physical and verbal aggressive behaviors with interventions implemented on 05/13/2020. Further review revealed no documented evidence of any current aggressive behaviors. Review of Resident #5's Nurses Notes from January 2025 to March 2025 revealed no documented evidence Resident #5 had any aggressive behaviors. On 03/10/2025 at 4:15 p.m., an interview was conducted with S14LPN. She stated Resident #5 was confused at times and cursed at other residents and staff. She stated during the day shift, Resident #5 sat outside the nurse's station with other residents. She stated Resident #5 told other residents and staff, I will cut you with a knife. She confirmed it was not reported to administration or documented in the nurse's notes. On 03/11/2025 at 10:05 a.m., an interview was conducted with S15CNA. She stated when Resident #5 got upset she talked to herself, cursed, and said I will kill you. She stated Resident #5 was easily redirected when she had behaviors. She stated she did not report the behaviors because the nurse was aware of the behaviors. On 03/11/2025 at 11:17 a.m., an interview was conducted with S16CNA. She stated Resident #5 told her, they don't know me but I will cut her neck off. She stated she did not report the behaviors because the nurse was aware of the behaviors. On 03/12/2025 at 10:14 a.m., an interview was conducted with Resident #14. He stated he sat outside of the nurse's station during the day. He stated Resident # 5 cursed and made threats of using a gun or knife but he knew Resident #5 could not physically do those things. On 03/12/2025 at 10:16 a.m., an interview was conducted with Resident #19. He stated he sat outside of the nurse's station during the day. He stated Resident # 5 cursed and made threats of using a gun or knife but he knew Resident #5 could not physically do those things. On 03/12/2025 at 9:17 a.m., an interview was conducted with S3MDS. She stated they were notified of new behaviors or incidents by the 24 hour report, incident reports, nurse's notes or verbal notification. She stated once notified, the care plan was updated with new interventions. She confirmed she was not aware Resident #5 threatened staff or other residents by stating she would use a gun or knife, this was a new behavior, and the care plan should have been updated. On 03/12/2025 at 2:23 p.m., an interview was conducted with S2DON. She stated Resident #5 had verbal outburst and cursed but was easily redirected. She confirmed she was not aware Resident #5 made threats of using a gun or knife, this was a new behavior, and staff should have reported the new behavior and her care plan should have been updated.

Based on interviews and record review, the facility failed to ensure each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene by failing to ensure each resident received scheduled bed baths for 1 (#47) of 3 (#22, #45, and #47) residents reviewed for ADLs. Findings: Review of Resident #47's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction, Hemiplegia and Hemiparesis on Left Non-Dominant Side. Review of Resident #47's Quarterly MDS with ARD of 12/10/2024 revealed a BIMS of 14, which indicated she was cognitively intact. Further review of the MDS Section GG revealed she was dependent upon staff for showering/bathing. Review of Resident #47's Current Care Plan revealed the following, in part: Focus: The resident has an ADL self-care performance deficit. Interventions: Assist with all ADLs as ordered. Review of Resident #47's ADL Documentation revealed she was scheduled to receive bed baths every day. Further review of ADL Documentation dated March 2025 revealed she did not receive her scheduled bed bath on 03/04/2025, 03/05/2025, 03/06/2025, and 03/07/2025. Review of Women Shower List located within the Facility's Nursing Assignment Binder revealed the following: Resident #47 was scheduled for daily, morning bed baths. On 03/10/25 at 10:35 a.m., an interview was conducted with Resident #47. She stated she did not receive consistent bed baths. On 03/11/2024 at 10:45 a.m., an interview was conducted with S10CNA. She stated she was assigned to Resident #47's care on day shift. She stated Resident #47 was dependent on staff for ADLs. She stated Resident #47 received bed baths. She stated night shift CNAs were responsible for completing bed baths. On 03/12/2025 at 8:08 a.m., an interview was conducted with S9CNA. She stated she was consistently assigned to Resident #47's care on night shift. She stated she was not responsible for providing bed baths to Resident #47 since she was scheduled for daily, morning bed baths. She stated CNAs referenced the Nursing Assignment binder for each resident's shower/bath schedule. She stated S5CS was responsible for creating the shower/bed bath schedules. On 03/12/2025 at 8:20 a.m., an interview was conducted with S11CNA. She stated she was assigned to Resident #47's care on day shift. She stated day shift CNAs were responsible for completing showers, and night shift CNAs were responsible for completing bed baths. She stated Resident #47 should be provided bed baths every evening by night shift staff. She confirmed she did not provide Resident #47 with baths. On 03/12/2025 at 9:00 a.m., an interview was conducted with S5CS. She stated CNAs were notified of each resident's shower/bed bath schedule through the Nursing Assignment Binder located at each nurses' station. She referenced the document titled Women's shower list within the Nursing Assignment Binder, and confirmed Resident #47 was scheduled to receive a daily, morning bed bath. She stated she expected all CNAs to check the shower/bath schedule before their shift. She confirmed S10CNA and S11CNA were responsible for Resident #47's baths. On 03/12/2025 at 10:30 a.m., an interview was conducted with S2DON. She stated CNAs utilized the shower/bath schedule within the Nursing Assignment Binder to know which residents should be bathed/showered on their shift. She reviewed the document titled Women Shower List, and confirmed Resident #47 should have received daily, morning bed baths. She reviewed Resident #47's ADL documentation dated March 2025, and confirmed a bed bath was not provided from 03/04/2025 through 03/07/2025 and should have been.

Based on observations, interviews and record review, the facility failed to implement effective fall interventions for 1 (#47) of 4 (#5, #12, #47, and #195) residents reviewed for accident hazards. Findings: Review of Resident #47's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction, Hemiplegia and Hemiparesis Affecting Left Non-Dominant Side. Review of Resident #47's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/10/2024, revealed Resident #47 had a BIMS of 14, which indicated she was cognitively intact. Further review of MDS Section GG revealed Resident #47 required max assistance for bed mobility. Review of Resident #47's Care Plan revealed in part, the following: Focus: The resident is at risk for falls. Interventions: Resident had fall from bed on 02/04/2025. Staff educated on fall interventions that are in place. New, firmer wedge to be placed to left side of bed. Review of Resident #47's current Physician Orders revealed in part, the following: 08/29/2024: Place wedge on left side of bed due to recent fall. Review of Resident #47's Incident Report dated 02/04/2025 revealed in part, the following: Nursing Description: Resident #47 found on all fours between bed and wall. Resident Description: Resident #47 stated she was on her side, and felt herself slipping off the bed. She attempted to put her arm out to stop from slipping, but fell on to the floor and hit her head. Review of Resident #47's Fall Root Cause Analysis Report completed by S2DON revealed the following: Date of Fall: 02/04/2025 Time: 5:00 a.m. Possible reasons for fall: Rolled out of bed. Interventions: New, firmer wedge placed. On 03/11/2025 at 8:02 a.m., an observation was made of Resident #47's room. Resident #47's bed was observed in a diagonal position in the corner of the room with a space on the right side between the wall and bed. On 03/11/2024 at 11:05 a.m., an interview was conducted with Resident #47. She stated she fell when she was turned toward her right side. She stated she fell between her bed and the wall on the right side. She stated she was fearful of falling into the space between the wall and bed again. On 03/11/2025 at 2:50 p.m., an observation was made of Resident #47 in her room. Resident #47 was lying in bed. There was a wedge in place under Resident #47's left side. Resident #47's bed remained in a diagonal position with a space on right side between the wall and the bed. An interview was conducted with Resident #47, and she stated the current position of the bed was how the bed was positioned when she fell on [DATE]. On 03/11/2024 at 10:45 a.m., an interview was conducted with S10CNA. She stated Resident #47 had a history of falls. She stated during Resident #47's fall on 02/04/2025, she fell off the right side in between the wall and bed. She stated Resident #47's bed was diagonal to the corner in the room. She explained there was a bar behind the headboard of the bed, which prevented it from fitting against the wall. She stated alternate bed positions had not been attempted. On 03/11/2025 at 1:38 p.m., an interview was conducted with S8LPN. She stated Resident #47 had a history of falls. She stated fall interventions in place included a fall mat and 30 minute checks. She confirmed that the bed's current, diagonal, position was an accident hazard. On 03/11/2025 at 3:22 p.m., an interview was conducted with S2DON. She stated she was responsible for investigating falls and establishing appropriate interventions. She stated she investigated Resident #47's fall that occurred on 02/04/2025. She stated Resident #47 fell out the right side of the bed between the bed and the wall. She stated, as a result of the fall on 02/04/2025, the new intervention was to place a firm wedge under Resident #47's left side. She confirmed placing a wedge under Resident #47's left side would cause her to roll to the right, which was not an appropriate intervention to prevent Resident #47 from falling out the right side of the bed. On 03/11/2025 at 3:30 p.m., an interview was conducted with S1ADM. He stated he was unaware of Resident #47's current bed position. He confirmed Resident #47's fall intervention would not prevent future falls out of the right side of bed. He further confirmed an appropriate fall intervention should have been put into place after her fall on 02/04/2025.

Based on observations, interviews, and record review, the facility failed to ensure S6RN had the specific competencies and skill sets necessary to care for residents' needs as identified in the plan of care. The facility failed to ensure S6RN was competent to: 1. Verify and administer enteral feedings as ordered by the Physician for 1 (#53) of 2 (#53 and #71) residents reviewed with enteral feeding; and 2. Identify Enhanced Barrier Precautions and don necessary PPE to provide care for 1 (#53) of 5 (#22, #53, #71, #81, and #195) residents reviewed on Enhanced Barrier Precautions. Findings: Review of the facility's undated policy titled, Sufficient and Competent Staff revealed the following, in part: Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain and maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Policy Explanation and Compliance Guidelines: 4. The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessment and described in the plan of care. Review of S6RN's Personnel File revealed a hire date of 09/03/2024. Review of S6RN's Nurse Competency Checklist dated 09/09/2024 revealed the following, in part: Infection Control: Standard and Transmission Based Precautions/PPE with assessment method with no checks and dated 09/09/2024 with initials by S2DON. Nursing Skills: Documentation with assessment method with no checks and dated 09/09/2024 with initials by S2DON. Nutrition/Hydration Management (dietary orders/therapeutic diets; snack/supplement administration) with no checks, assessment method with no checks, and dated 09/09/2024 with initials by S2DON. 1. Review of Resident #53's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Neurocognitive Disorder with Lewy Bodies, Gastrostomy Status, and Dysphagia. Review of Resident #53's current Care Plan revealed the following, in part: Problem: At risk for malnutrition related to PEG (Percutaneous Endoscopic Gastrostomy) tube feedings; NPO status. Review of Resident #53's Physician Orders dated 01/03/2025 through 03/11/2025 revealed he was always prescribed more than one can of Diabetisource per PEG tube at breakfast, lunch, and dinner. Review of Resident #53's MAR dated 01/03/2025 through 03/10/2025 revealed S6RN documented administration of tube feedings as ordered on the following dates and times: From 01/03/2025 to 01/10/2025 - Enteral Feeding 360 mL four times daily: 01/03/2025 at 4:00 p.m.; 01/04/2025 at 10:00 a.m. and 4:00 p.m.; 01/08/2025 at 10:00 a.m. and 4:00 p.m.; 01/09/2025 at 10:00 a.m. and 4:00 p.m.; and 01/10/2025 at 10:00 a.m. From 01/10/2025 to 02/17/2025 - Enteral feeding Diabetisource 1.5 cans four times daily: 01/10/2025 at 4:00 p.m.; 01/13/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/14/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/17/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/18/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/19/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/23/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/27/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 01/28/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/01/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/02/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/05/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/06/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/10/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/14/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/15/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; and 02/16/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m. From 02/17/2025 to 02/18/2025 - Enteral Feeding Diabetisource 2 cans breakfast, 2 cans lunch, 2 cans dinner, 1 can at night: 02/18/2025 at 9:00 a.m. From 02/18/2025 to 02/20/2025 - Enteral Feeding Diabetisource 360 mL four times daily: 02/18/2025 at 1:00 p.m. and 5:00 p.m. From 02/20/2025 to 03/11/2025 - Enteral Feeding Diabetisource AC 2 cans at breakfast, 2 cans at lunch, 2 cans at dinner, and 1 can at night: 02/24/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/25/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 02/26/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 03/01/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 03/02/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 03/05/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; 03/06/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; and 03/10/2025 at 9:00 a.m., 1:00 p.m., and 5:00 p.m. Review of the Diabetisource AC (1.2 kilocalorie/mL) can used by the facility revealed it contained 250 mL. An observation was made of S6RN providing tube feeding for Resident #53 on 03/11/2025 at 9:58 a.m. She administered one can of Diabetisource AC via PEG tube by gravity without verifying the tube feeding order. An interview was conducted with S6RN on 03/11/2025 at 10:09 a.m. She confirmed the above observation. She stated she worked twelve hour shifts, on two days, off two days, and every other weekend. She reviewed Resident #53's tube feeding order after administration and confirmed Resident #53 should have received 2 cans of Diabetisource. S6RN confirmed Resident #53 should have received 2 cans of Diabetisource at breakfast, lunch, and dinner since 02/20/2025, and 1.5 cans prior to that beginning on 01/03/2025. She confirmed the first time she had administered more than one can of tube feeding to Resident #53 was this morning after reviewing the tube feeding orders with the surveyor. An interview was conducted with S6RN on 03/11/2025 at 4:48 p.m. She reviewed Resident #53's MARs dated January, February, and March 2025. She confirmed all of the above listed documentation for administering tube feeding to Resident #53 was inaccurate. She confirmed, since Resident #53 began receiving tube feeding, she had never administered more than one can of tube feeding at a feeding. She confirmed she should have verified the tube feeding order prior to administration of the tube feeding. An interview was conducted with S2DON on 03/11/2025 at 1:00 p.m. She stated Resident #53's tube feeding orders changed frequently. She confirmed at no point had Resident #53 been ordered one can of tube feeding formula at breakfast, lunch, or supper. She stated nurses should have administered the amount of tube feeding ordered. She confirmed nurses should have verified the tube feeding order prior to administration. 2. Review of Resident #53's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Gastrostomy Status. Review of Resident #53's current Physician Orders revealed he was on Enhanced Barrier Precautions. An observation was made of Resident #53's door on 03/11/2025 at 8:07 a.m. He had a sign on the door, which revealed the following: STOP - Enhanced Barrier Precautions Everyone must: Clean their hands, including before entering and when the leaving the room Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities Device care or use: feeding tube An observation was made of S6RN administering tube feeding for Resident #53 on 03/11/2025 at 9:58 a.m. She did not don a gown to perform the feeding. An interview was conducted with S6RN on 03/11/2025 at 10:07 a.m. She stated Resident #53 was on Enhanced Barrier Precautions related to his PEG tube. She stated Enhanced Barrier Precautions meant to perform hand hygiene and wear gloves when necessary. She stated a gown was not required for Enhanced Barrier Precautions. She stated she did not have to don a gown to administer tube feeding or perform care of the PEG tube. An interview was conducted with S2DON on 03/12/2025 at 9:24 a.m. S2DON stated she was responsible to ensure each nurse was competent. She confirmed S6RN was not observed by anyone in the facility to ensure she was competent in performing nursing tasks. S2DON stated she performed verbal communication with S6RN but very minimal observation. She confirmed she did not ensure S6RN was competent in verifying tube feeding orders and administration of tube feedings as ordered and should have. She stated she expected the staff to wear a gown when providing a PEG tube feeding or any care of the PEG tube. She stated S6RN should have been aware of Enhanced Barrier Precautions and the appropriate PPE to don. She stated she conducted an in-service training on Enhanced Barrier Precautions, which S6RN was present. She stated she did not assess any of the staffs' knowledge or retention of the Enhanced Barrier Precautions training. She stated nine times out of ten, orientation training was verbal and there were no competency evaluations. She stated she did not currently have a process to track nursing skills she had observed and had not observed each nurse to ensure competency. Cross Reference F-656. Cross Reference F-658. Cross Reference F-692. Cross Reference F-880.

Based on observations, interviews, and record review, the facility failed to ensure staff utilized appropriate PPE during care with residents who required Enhanced Barrier Precautions for 1 (#53) of 5 (#22, #53, #71, #81, and #195) residents observed during chronic wound care and/or use of indwelling medical devices. Findings: Review of the facility's policy dated January 2025 and titled, Enhanced Barrier Precautions revealed the following, in part: Policy: It is the policy of this facility to implement Enhanced Barrier Precautions for the Prevention of transmission of multidrug-resistant organisms (MDRO). Definitions: Enhanced Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (eg. Residents with wounds or indwelling medical devices). Policy Explanation and Compliance Guidelines: 48. High-contact resident care activities include: g. Device care or use: .feeding tubes . Review of Resident #53's Clinical Record revealed he admitted to the facility on [DATE] and had diagnoses, which included Gastrostomy Status. Review of Resident #53's current Physician Orders revealed the following, in part: Enhanced Barrier Precautions Enteral Feeding Diabetisource AC 2 cans at breakfast, 2 cans at lunch, 2 cans at dinner, and 2 cans at night. An observation was made of Resident #53's door on 03/11/2025 at 8:07 a.m. He had a sign on the door, which revealed the following: STOP - Enhanced Barrier Precautions Everyone must: Clean their hands, including before entering and when the leaving the room Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities Device care or use: feeding tube An observation was made of S6RN providing tube feeding for Resident #53 on 03/11/2025 at 9:58 a.m. She did not don a gown to perform the feeding. An interview was conducted with S6RN on 03/11/2025 at 10:07 a.m. She stated Resident #53 was on Enhanced Barrier Precautions related to his PEG tube. She stated Enhanced Barrier Precautions meant to perform hand hygiene and wear gloves when necessary. She stated a gown was not required for Enhanced Barrier Precautions. She stated she did not have to don a gown to perform tube feeding or care of the PEG tube. An interview was conducted with S2DON on 03/12/2025 at 9:24 a.m. She confirmed she was the facility's Infection Preventionist. She stated Enhanced Barrier Precautions were implemented for indwelling medical devices and chronic wounds. She stated the expectation was for staff to don a gown and gloves anytime they provided care for a resident with an indwelling medical device or chronic wound. She confirmed Resident #53 was on Enhanced Barrier Precautions for his PEG tube. She stated she expected staff to wear a gown and gloves when providing a PEG tube feeding or any care of the PEG tube.

Based on record review and interviews, the facility failed to ensure nursing staff notified the resident representative when a resident had a significant change in condition for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. Findings: Review of the facility's undated policy titled, Change in a Resident's Condition or Status revealed the following, in part: Policy Statement: Our facility shall promptly notify the .representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when: b. There is a significant change in the resident's physical, mental, or psychosocial status. Review of Resident #1's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction Due To Embolism of Right Middle Cerebral Artery and Cardiomegaly. Review of Resident #1's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/29/2024 revealed the resident had a BIMS (Brief Interview for Mental Status) of 04, which indicated the resident had severe cognitive impairment. Review of Resident #1's Nurses' Notes dated August 2024 revealed no documentation the residents' representative was notified of Resident #1's change in condition on 08/27/2024. On 09/24/2024 at 1:25 p.m., an interview was conducted with S4LPN. She confirmed she was assigned to Resident #1 on 08/27/2024. She stated during her shift on 08/27/2024, Resident #1 vomited after breakfast and lunch and reported not feeling well. She stated she could not recall if she notified Resident #1's representative of the resident's change in condition on 08/27/2024. She stated she should notify the responsible party (RP) any time a resident demonstrated a change in condition. She reviewed the August 2024 Nurses' Notes for Resident #1 and confirmed there was no documentation to indicate she notified Resident #1's representative of the change in condition. On 09/24/2024 at 2:20 p.m., an interview was conducted with S5CNA. She confirmed she was assigned to Resident #1 on 08/27/2024. She stated during her shift on 08/27/2024, Resident #1 vomited after breakfast and lunch and reported her stomach was hurting. She reported Resident #1's change in condition to S4LPN. On 09/25/2024 at 8:50 a.m., a telephone interview was conducted with Resident #1's representative. The representative confirmed she was not notified of a change in Resident #1's condition on 08/27/2024. On 09/25/2024 at 9:05 a.m., a telephone interview was conducted with Resident #1's family member. The family member confirmed she was not notified of a change in Resident #1's condition on 08/27/2024. On 09/25/2024 at 10:55 a.m., an interview was conducted with S2DON. She stated S4LPN notified her on 08/27/2024 Resident #1 had a decreased appetite and had vomited. She reviewed Resident #1's Nurse's Notes and confirmed there was no documentation to indicate Resident #1's representative or family was notified of her change in condition on 08/27/2024. She stated she expected the nurses to notify a residents' representative of any changes in condition.

Based on record review and interviews, the facility failed to maintain complete and accurate records in accordance with accepted professional standards and practices for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. The facility failed to ensure nursing staff documented a resident's change in condition, provider notification of a resident's change in condition, and administration of Zofran. Findings: Review of the facility's undated policy titled, Documentation revealed the following, in part: The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., for continuity of care, treatment decisions . Procedure: 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medications, etc . 2. Document all notifications of resident status to physicians .Document all responses to notifications. 6. Document medication administration, treatments, vital signs, etc. Review of the facility's undated policy titled, Routine Standing Orders revealed the following, in part: 7. Standing orders are utilized by licensed nurses who must use professional judgement in the initiation and administration of standing orders. 10. Documentation of the situation requiring the use of standing order is placed in the Nursing Notes section of the resident's medical record prior to initiation of the order. Resident response, i.e. whether the medication was effective, is documented following the procedure for prn orders. Review of the facility's Hospital Medicine Group Nursing Home Standing Orders with a revision date of 01/10/2020, revealed the following, in part: Common Symptoms/Complaints 4. Nausea/Vomiting a. Zofran 4mg by mouth every 4 hours prn x 24 hours. Review of Resident #1's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction Due To Embolism of Right Middle Cerebral Artery and Cardiomegaly. Review of Resident #1's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/29/2024 revealed the resident had a BIMS (Brief Interview for Mental Status) of 04, which indicated the resident had severe cognitive impairment. Review of Resident #1's MAR (Medication Administration Record) dated August 2024 revealed no evidence Resident #1 received Zofran on 08/27/2024. Review of Resident #1's Nurses' Notes dated August 2024 revealed no documentation of the following: Resident #1's change in condition on 08/27/2024; the nurse practitioner was notified of Resident #1's change in condition on 08/27/2024; or evidence Resident #1 was administered Zofran on 08/27/2024. On 09/24/2024 at 1:25 p.m., an interview was conducted with S4LPN. She confirmed she was assigned to Resident #1 on 08/27/2024. She stated during her shift on 08/27/2024, Resident #1 vomited after breakfast and lunch and reported not feeling well. She stated she notified S6NP of Resident #1's change in condition who ordered a onetime dose of Zofran. She confirmed she administered a dose of Zofran to Resident #1 on 08/27/2024. She reviewed the August 2024 MAR and Nurses Notes for Resident #1 and confirmed she did not document the administration of Zofran to Resident #1 on 08/27/2024 and should have. She confirmed there was no documentation to indicate Resident #1's change in condition or notification of the resident's change in condition to S6NP and there should have been. On 09/25/2024 at 10:55 a.m., an interview was conducted with S2DON. She stated S4LPN notified her on 08/27/2024, Resident #1 had a decreased appetite and had vomited. She stated S4LPN reported she notified S6NP of Resident #1's change in condition. She stated each resident had standing orders which included Zofran. She stated when a nurse administered a onetime dose of an as needed medication on the standing orders, she expected the nurses to document the medication was administered in the nurses' notes. She stated when a resident had a change in condition the expectation was for the nurses to document the residents change in condition and notification to the provider in a nurses' note. She reviewed Resident #1's August 2024 Nurses' Notes and MAR and confirmed there was no documentation to indicate the Resident #1's change in condition, notification to the physician or nurse practitioner, or administration of Zofran to Resident #1 on 08/27/2024 and there should have been.

Based on interviews and record reviews, the facility failed to ensure the residents were free from neglect and verbal abuse by failing to ensure: 1. 1 (#77) of 6 (#7, #52, #57, #61, #65, and #77) residents reviewed for accidents received the necessary care and services to manage pain and provide timely treatment after a fall resulting in a hip fracture; and 2. S24CNA did not verbally abuse 1 (#55) of 2 (#55 and #59) residents reviewed for abuse. This deficient practice resulted in an actual harm on 03/20/2022 at 04:00 p.m. when Resident #77, a cognitively impaired resident, was found on the floor and transferred into the bed by S10LPN and S12CNA. Resident #77 exhibited signs of pain during the transfer. An order was implemented for a STAT (immediately) right hip x-ray. The x-ray was completed and a report was faxed to the facility on [DATE] at 08:20 p.m., which revealed an acute nondisplaced intertrochanteric right femur fracture. Facility staff failed to review the x-ray findings and notify the physician of the results. The facility also failed to communicate resident #77's fall with staff, which resulted in S13CNA and S14CNA transferring the resident to the commode, causing further pain. Throughout the night and early morning, Resident #77 exhibited signs of pain including moaning, facial grimacing, tearful expressions, and tensing of her body which was not addressed by nursing staff. On the morning of 03/21/2022, Resident #77 was transferred to the emergency room where she received pain medication and surgical intervention for a mildly displaced intertrochanteric fracture of her right femur. Findings: Review of the policy titled, Abuse Prevention and Investigation, revealed the following, in part: Residents have the right to be free from neglect . Neglect means 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. Review of the policy titled, Change in a Resident's Condition or Status revealed the following, in part: 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). 1. Resident #77 Review of the clinical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #77 was readmitted to the facility on [DATE] with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the admission MDS with an ARD of 03/18/2022 revealed Resident #77 was unable to complete a BIMS. This indicated she was rarely/never understood and had memory impairment. Review of the current Care Plan for Resident #77 revealed the following, in part: Difficulty communicating related to [CONDITION(S)] and [CONDITION(S)] Intervention: Provide communication board and/or binder. At risk for falls Intervention: Resident had a fall on 03/20/2022 in her room. Resident attempted to transfer self. Once assisted back into bed resident was hollering out in pain and guarding her right leg. Call was placed for mobile x-ray. Fracture was noted to Resident #77's right femur. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Incident Report dated 03/20/2022 at 04:00 p.m. for Resident #77 revealed the following, in part: Incident type: fall/no head injury Immediate action taken: Made resident comfortable in bed. Mobile x-ray ordered. Actions Taken: Pain Scale: 8 Physician notified on 03/20/2022 at 04:10 p.m. Review of the Nurses Notes for Resident #77 from 03/20/2022 to 03/21/2022 revealed the following, in part: 03/20/2022 at 05:05 p.m., Resident #77 was found sitting on the floor in her room. Resident was sitting by roommate's bed on her buttocks with her legs out in front of her. No signs/symptoms of injuries. While transferring resident, resident screamed out in pain, holding her right leg. Nurse Practitioner was notified and ordered mobile x-ray. Mobile x-ray was notified of need of x-ray and stated they would be out the same evening. S10LPN 03/21/2022 at 07:04 a.m., Note reflecting 06:20 a.m. Resident #77 moaning when entering room. Found x-ray report on fax machine which shows acute nondisplaced intertrochanteric fracture of the right femur. NP was notified and gave new order to send to local hospital. Resident transferred via ambulance at 07:00 a.m. S11LPN 03/21/2022 at 02:29 p.m., Note reflecting 11:30 a.m. Spoke with orthopedic Medical Doctor. He stated Resident #77 required surgery. He stated a rod would be placed for her right femur. S11LPN Further review of the Nurse's Notes revealed no documentation of nurses notes from 03/20/2022 at 05:11 p.m. to 03/21/2022 at 06:19 a.m. Review of the order form for Resident #77's right hip x-ray revealed the following, in part: Priority: STAT Documentation as to why patient is unable to leave facility safely and portable x-ray service is medically necessary: 1. Severe pain; cannot be transported Review of the x-ray report for Resident #77 dated 03/20/2022 at 08:20 p.m. revealed the following, in part: SIGNIFICANT FINDINGS Right hip x-ray unilateral 2-3 views: Impression: 1. Acute nondisplaced intertrochanteric right femur fracture. Electronically signed by X-ray Company's Medical Doctor on 03/20/2022 at 07:37 p.m. Review of the Neurological Observations dated 03/20/2022 for Resident #77 revealed no documentation neurological checks were completed on the 06:00 p.m. to 06:00 a.m. shift. Review of the 72 hour follow-up for falls dated 03/20/2022 for Resident #77 revealed no documentation the follow-ups were completed on the 06:00 p.m. to 06:00 a.m. shift. Review of the Hospital Records for Resident #77 revealed the following, in part: Arrival: 03/21/2022 at 08:11 a.m. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Emergency Department Provider Note dated 03/21/2022 at 08:24 a.m. revealed the following, in part: Pain details: Quality: Aching Severity: Moderate Musculoskeletal: General: Tenderness, deformity and signs of injury present. Comments: Moderate to severe tenderness upon palpation to the right hip Further review of the Hospital Records revealed Resident #77 was assessed for pain on 03/21/2022 at 08:58 a.m. with a pain score of 7. She was administered [MEDICATION(S)] (Sublimaze) injection 50mcg on 03/21/2022 at 08:58 a.m. intravenously. Review of the hospital x-ray report for Resident #77 dated 03/21/2022 revealed the following, in part: X-Ray of hip - Right Narrative: History of fall with hip pain. 3 views. There is diffuse osteopenia. There is a mildly displaced intertrochanteric fracture of the right femur. There is mild coxa vera deformity. No dislocation is noted. Impression: Traumatic right hip fracture An interview was conducted with S11LPN on 04/18/2022 at 03:24 p.m. She confirmed she was assigned to care for Resident #77 on the day shift of 03/21/2022. She stated she entered Resident #77's room and observed her to be lying in bed with her right leg turned outward and it appeared deformed. She said Resident #77 was moaning out loud, grimacing, and tensing her body. She confirmed Resident #77 was experiencing pain. She stated she found the x-ray report dated 03/20/2022 at 08:20 p.m. and it revealed Resident #77 had a right femur fracture. She stated she contacted S3NP and the resident was transferred to the emergency room . She stated Resident #77 was not able to communicate she was in pain. An interview was conducted with S12CNA on 04/19/2022 at 09:46 a.m. She confirmed she was assigned to care for Resident #77 on the evening shift of 03/20/2022. She stated on 03/20/2022 around 04:00 p.m., Resident #77 was found seated on the floor in her room. She stated she and S10LPN picked Resident #77 up off of the floor and placed her back into the bed. She explained Resident #77 was moaning, grimacing, and holding her right hip during the transfer. She stated Resident #77 experienced pain throughout her shift when she made rounds every two hours. She stated Resident #77 moaned and grimaced each time she provided care for her. She stated Resident #77 was not usually in pain prior to 03/20/2022. She stated Resident #77 could ambulate with one staff member prior to her fall. A telephone interview was conducted with S13CNA on 04/19/2022 at 10:00 a.m. She confirmed being familiar with Resident #77 and stated the resident would usually ambulate to the bathroom with assistance of one person. She stated Resident #77 did not normally complain of or show signs of pain. She confirmed she was assigned to care for Resident #77 on 03/20/2022 from 10:00 p.m. to 06:00 a.m. She stated she was not aware Resident #77 had fallen on 03/20/2022 at 04:00 p.m. She stated on the night of 03/20/2022, Resident #77 was in pain each time she made rounds, which was every two hours. She stated the resident was moaning, her body was tense, and she had tears in her eyes. She stated she and S14CNA transferred Resident #77 into the wheelchair, wheeled her to the bathroom, and then transferred her to the commode. She stated each time Resident #77 was moved during the transfer, she showed signs of increased pain such as moaning, grimacing, and grabbing her right leg. She stated she notified S15LPN Resident #77 was in pain. A telephone interview was conducted with S3NP on 04/19/2022 at 10:38 a.m. She stated S10LPN notified her of Resident #77's fall on 03/20/2022. She verified she ordered an x-ray of Resident #77's right hip to be completed on the day of the incident. She confirmed she did not receive notification from the facility staff again until the morning of 03/21/2022 when S11LPN notified her that Resident #77 sustained a right hip fracture. She stated if Resident #77 had been in pain overnight, she would have expected the nurse to call her or the on-call Nurse Practitioner so pain medication could have been ordered. She confirmed she would have given an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the staff should not have transferred Resident #77 until the x-ray report was received. She stated transferring the resident with a fracture would cause pain and the fracture could become displaced. A telephone interview was conducted with S10LPN on 04/19/2022 at 10:48 a.m. She confirmed she was assigned to care for Resident #77 on 03/20/2022 from 06:00 a.m. to 06:00 p.m. She confirmed she found Resident #77 on the floor in her room on 03/20/2022 at 04:00 p.m. She stated Resident #77 was not able to communicate well and she did not usually have any signs of pain. She explained when she and S12CNA transferred Resident #77 from the floor back into the bed, she was holding her leg, grimacing, and moaning. She confirmed Resident #77 was in pain. She stated she notified S3NP, and a mobile x-ray was ordered. She stated she implemented the order letting the x-ray company know to come to the facility immediately. She confirmed she completed the x-ray order form on 03/20/2022. She stated S15LPN relieved her and she communicated that S15LPN needed to look for Resident #77's x-ray report on the fax machine in the nurses' station. A telephone interview was conducted with S15LPN on 04/19/2022 at 12:57 p.m. She confirmed she was assigned to care for Resident #77 on 03/20/2022 from 06:00 p.m. to 06:00 a.m. She confirmed she received report from S10LPN and was aware Resident #77 fell on the day shift. She further confirmed S10LPN notified her to look for the x-ray report for Resident #77. She stated the x-ray technician completed the x-ray during her shift, but she never received the report. She stated she did not call the x-ray company to inquire about the x-ray results. She stated she was not aware she needed to assess Resident #77 more frequently after a fall. She confirmed Resident #77 should not have been transferred, and she stated she was not aware the CNAs were transferring the resident to the bathroom. A telephone interview was conducted with the Operations Manager and x-ray technician with the x-ray company on 04/19/2022 at 02:25 p.m. She confirmed the x-ray results for Resident #77 were sent to the facility on [DATE] at 08:17 p.m. She verified she had a confirmation the fax went through on 03/20/2022 at 08:17 p.m. An interview was conducted with S14CNA on 04/20/2022 at 01:55 p.m. She confirmed she assisted with transferring Resident #77 to the bathroom on the night shift of 03/20/2022. She explained she and S13CNA transferred the resident to the wheelchair, wheeled her to the bathroom, and then transferred her to the commode and back to bed. She stated she was not aware Resident #77 had a fall and should not be moved. An interview was conducted with S2DON on 04/21/2022 at 10:30 a.m. She confirmed she was aware of the incident with Resident #77 on 03/20/2022 at 04:00 p.m. when she was found on the floor. She confirmed S15LPN was responsible to care for Resident #77 from 06:00 p.m. to 06:00 a.m. on 03/20/2022. She explained after a Resident fell , the nurses were expected to complete increased assessments, which included neurological observations and a 72 hour fall follow-up. She verified S15LPN did not document increased assessments on Resident #77 after she fell and should have. She stated she would have expected S15LPN to document an assessment of Resident #77 at the start of her shift and throughout the night. She confirmed if the x-ray results had not been received by S15LPN, she should have contacted the x-ray company and the physician. She confirmed Resident #77 should not have been transferred until her x-ray results were received and communicated with the physician. She confirmed if Resident #77 experienced pain, the physician should have been notified for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Resident #77's family member on 04/21/2022 at 11:48 a.m. She stated she was with Resident #77 on 03/20/2022 between approximately 08:00 p.m. and 10:00 p.m. She stated the facility had not made her aware the resident had fallen and were waiting on results from an x-ray. She stated Resident #77 did not communicate well but would normally smile and be happy to see her. She stated Resident #77 did not usually have pain. She said Resident #77 was very uncomfortable, tense, and grimacing during the visit. She stated Resident #77 was continuously pushing her hands down on the bed trying to reposition herself and was repeatedly asked for pain medication. She stated two CNAs were in the room and were aware Resident #77 was asking for pain medication. She stated the CNAs stated they were going to tell the nurse that Resident #77 was asking for pain medication. Resident #55 Review of the clinical record revealed Resident #55 was admitted to the facility on [DATE]. Review of the annual MDS with an ARD of 03/08/2022 revealed Resident #55 had a BIMS of 15, which indicated he was cognitively intact. Review of Resident #55's Care Plan revealed no problems or interventions for any behaviors. Review of Resident #55's Grievance Form revealed the following, in part: Grievance Reported on 03/11/2022 at 02:00 p.m. Date of Incident: 03/10/2022 at 06:00 a.m. - 02:00 p.m. shift Summary: Resident #55 complained of S24CNA speaking to him in a disrespectful and unprofessional manner. Explanation: S1ADMIN met with S24CNA. S1ADMIN and S24CNA previewed the surveillance tape to see how unprofessional and disrespectful she was toward Resident #55. Action taken: S24CNA was counseled and educated on rational detachment and crisis intervention skills and re assigned to another hall in the facility. Review of Resident #55's Social Service notes revealed the following, in part: Resident #55 had a complaint today that S24CNA was disrespectful and unprofessional. An interview was conducted on 04/19/2022 at 11:30 a.m. with Resident #55. He said he was getting his coffee when S24CNA came around the corner with her cart and told him to move. He said he called her an a**hole and they argued. He said S24CNA continued to yell and did not walk away. S24CNA told Resident #55 to meet him outside. He said he felt threatened when S24CNA told him to meet her outside. He reported the argument to S1ADMIN. An interview was conducted on 04/19/2022 at 12:23 p.m. with S24CNA. She confirmed she worked at the facility on 03/10/2022 from 6 a.m. to 6 p.m. She said when she went around the corner with the linen cart Resident #55 was in her way. She explained she asked Resident #55 to move and he yelled and cursed at her. She stated she could not recall what she said back to the resident when he was cursing at her. A telephone interview was conducted on 04/19/2022 at 12:31 p.m. with S25FDON. She said Resident #55 reported an argument that occurred with S24CNA. She confirmed she watched the surveillance video with audio of the argument. She said S24CNA was coming around the corner with the linen cart and Resident #55 was sitting in his wheelchair by the coffee cart. She said S24CNA asked him to move and then they engaged in an argument. S25FDON did not remember the exact words used by S24CNA but said it was unprofessional. She said S24CNA continued to engage in the argument with Resident #55. She said S24CNA walked away and went into the linen closet but still came back out yelling at Resident #55. She said she would expect S24CNA to walk away and not engage in the argument. She confirmed S24CNA responded to Resident #55 unprofessionally. An interview was conducted on 04/20/2022 at 8:00 p.m. with Resident #47. She said S24CNA told Resident #55 to meet her in the parking lot. An interview was conducted on 04/20/2022 at 09:50 a.m. with S1ADMIN. He said Resident #55 reported to him an argument with S24CNA. He said Resident #55 admitted he cursed at S24CNA and S24CNA said she engaged in arguing and did not walk away.

Based on record reviews, interviews, and observations the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #39) of 6 (Resident #19, #30, #39, #68, #80, #487) residents requiring 2 person assistance for transfers. The facility failed to: 1. Follow Resident #39's plan of care related to transfers, and; 2. Ensure staff follow their policy and procedure related to reporting of falls to the nurse. An actual harm occurred for Resident #39 on 11/30/2019 (time unknown) when S2CNA (Certified Nursing Assistant) transferred Resident #39, who required two-person assistance, from her bed to her wheelchair without the assistance of another staff member. The resident fell to the floor during the transfer. S2CNA asked S1CNA to help her get Resident #39 off of the floor and did not report the fall to the nurse. On 12/01/2019, the nurse noted a bluish bruise to Resident #39's anterior lower right leg when the Resident complained of pain to the leg. On 12/01/2019 an x-ray revealed Resident #39 had an acute [MEDICAL CONDITION] Tibial Plateau, and she was transferred to the local hospital. The facility implemented corrective actions prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation. Findings: A review of the facility's Moving, Transferring and Repositioning policy revealed in part .: Key points 5. Use 2 staff members when transferring residents who cannot stand without assist. Moving a resident, bed to chair/chair to bed If moving a resident bed to chair: b. If transferring the resident to a wheelchair: 1. Be sure the wheels are locked . Review of the facility policy titled Accident and Incidents revealed in part 1. Any employee witnessing an accident or incident involving a resident, employee or visitor must report such occurrence to the charge nurse as soon as possible regardless of how minor it may be, to include the following: a. Any resident fall, accident or injury . A record review revealed Resident #39 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident #39's care plan with a problem date of 03/09/2009 read in part . Potential For Falls related to impaired mobility .Provide 2 person assist for transfers. A review of Resident #39's MDS (Minimum Data Set) ARD (Assessment Reference Date) of 10/28/2019, revealed Resident #39 had a BIMS (Brief Interview For Mental Status) score of 14 (Intact Cognitive Response) and required a two person physical assistance for transfers. Record review of Resident #39's Departmental Notes dated 12/01/2019 at 11:01 a.m. stated in part .Upon assessment this nurse, S21LPN, visualized a faint bruise bluish in color to the anterior lower right leg. Leg has 2+ [MEDICAL CONDITION] and is warm to touch. Nurse questioned res (resident) about what happened. And res (resident) stated she fell on the ground. When asked when, resident stated it was recent. Yesterday. Resident stated she was dropped on the ground and stated the person who dropped her on the ground and her (Resident 39's) roommate were the only people in the room at the time of the fall. General Medicine notified and returned the call with orders to have an x-ray of the RLE (Right Lower Extremity) performed in facility. X-ray notified. On 12/1/2019 at 1:16 p.m. the facility's Departmental Notes read in part .swelling and slight discoloration, bluish in color noted to right shin. Resident c/o (complains/of) pain to this area. X-rays ordered per General Medicine. Family aware. A review of the x-ray report dated 12/01/2019 at 12:01 p.m. revealed the impression was listed as acute [MEDICAL CONDITION] plateau. A review of a local hospital's report dated 12/01/2019 at 10:15 p.m. revealed Resident #39 had an acute [MEDICAL CONDITION] plateau. A record review of the facility's Investigative Report dated 12/05/2019 at 5:14 p.m. revealed called this nurse (S14LPN) into the room stating resident leg was starting to bruise. Upon assessment res (resident) anterior RLE (Right Lower Extremity) had a light blue bruise, +2 [MEDICAL CONDITION] and hot to touch. Res (Resident) stated she fell on the ground and someone dropped her on the ground yesterday. Notified supervisor. Contacted General Medicine. New order to obtain x-ray in house. X-ray indicated fx (fracture) of the right tibial plateau. Orders to send resident to hospital. Sent via ambulance to a local hospital. Anterior RLE bruise right great toe bruised dark blue/purple in color, left heel bruised dark purple in color. Immediate Actions Taken: Notified supervisor, contacted General Medicine, notified Administrator and police was notified and obtained a statement. The resident's physician and family were notified at 1:16 p.m. A review of a witness statement to local law enforcement by S1CNA dated 12/04/2019 (no time indicated) read, On the morning of Saturday I S1CNA helped S2CNA get Resident #39 off the floor. I was at the nurse's station when she looked out the room door and asked me for help. So when I entered the room Resident #39 was on the floor so I helped her get off of the floor and put her in her wheelchair and she went to breakfast and after breakfast the nurse asked can S2CNA put her back in the bed because she was complaining about her toe was hurting so we put her back in after breakfast and that was the last time I saw Resident #39. A review of a witness statement to local law enforcement by S2CNA dated 12/06/2019 (no time indicated) revealed, When I worked with Resident #39 Saturday morning after changing her I forgot to check the wheelchair to make sure it was locked I began to transfer her from the bed to the chair and the wheelchair rolled back causing me to drop Resident #39 on the floor. She fell on her but(t) and her leg. I then asked S1CNA to help me get her up in to the chair I didn't report it because I was scared. Once we did get her in her chair. I told her I was sorry. An interview with Resident #39 on 03/10/2020 at 02:14 p.m. was conducted. The resident was alert and oriented to person, place and time. Resident #39 was sitting in her wheelchair. Resident #39 stated she may have been mistaken about how long ago she had her fall, but she thought it was around last November. When Resident #39 was asked what happened to her leg she stated she fell the day before the bruising was found but did not tell anyone. Resident #39 then stated, someone dropped me the day before. An interview with S7DON on 03/11/2020 at 10:47 a.m. was conducted. S7DON stated the incident for the resident was discovered on 12/01/2019 when a nurse was called by a CNA to the resident's room because the CNA saw the resident had a bruise just below her knee. She said the resident was given Tylenol and an x-ray was done. She said the x-ray revealed a fracture to the resident's tibial plateau. She said the investigation was done but could not find out what happened. She confirmed they got all the witness statements, and there did not seem to be anyone who was involved with an accident. She explained it wasn't until the police were called and their investigation began that S1CNA admitted to the police that she helped S2CNA get the resident up after the fall. She said S1CNA admitted she helped the resident up and was asked by S2CNA to not say anything about the resident falling. S7DON said S2CNA admitted keeping that promise not to tell until the police got involved. She explained the police told everyone that if no one said what really happened they would have to bring everyone in to the station and they could be charged with a felony. S7DON explained on 12/04/2019 the 2 CNAs (S1CNA and S2CNA) were suspended as soon as we found out what happened, and the 2 CNAs (S1CNA and S2CNA) did not work again. An interview with S15MDS/CP Coordinator on 03/11/2020 at 12:45 p.m. was conducted. S15MDS/CP confirmed the resident was a two person assist for transfers. An interview with S9ADM on 03/12/2020 at 8:44 a.m. was conducted. She stated, We had in-services and we looked at all our residents. We had fall meetings, and we had therapy demonstrate the proper techniques for transferring residents. S9ADM then stated, PT (Physical Therapy) did return demonstrations and ensured the in-services were understood by staff. An interview with S8PT on 03/12/2020 at 9:42 a.m. was conducted. She stated, We train at least quarterly. We observe to see if CNAs are doing their job. We always ask to let us know if a CNA is having trouble. I go around and make sure residents are being transferred. If it's done incorrectly I would reeducate the CNA. I will let the nurse know and they reeducate them. There is therapy communication between the staff. A review of the facility's training records revealed training for Gait Belt policy/Transfer Safety and Reporting/Lifters began on 12/04/2019. The training included transfer safety along with printed documentation of signs for residents who were to be transferred by a lifter, by 1 person assist and by 2 person assist. An interview with S13CNA was conducted on 03/12/2020 at 10:36 a.m. She stated she knew how many people were required to transfer a resident by the sign over the bed. She stated Resident #5 was a 2 person transfer. She stated she had attended an in-service with therapy a few months ago. She said the nurse observed her doing transfers in the past few months but could not remember exactly when. She voiced she could not remember the specific nurse. An interview with S5CNA was conducted on 03/12/2020 at 11:47 a.m. S5CNA stated, I do work with Resident #36. Resident #36 is transferred with the lift. She transfers well. We have a list by the nurse's station to determine how a resident is transferred. If there is a change we are told and the list is also updated. There are also signs over their beds and there are notes in their charting. We are taught how to use the lift and were watched by a nurse to ensure we did the transfer correctly. An interview with S20CNA was conducted on 03/12/2020 at 1:45 p.m. S20CNA stated if she found a resident on the floor she would immediately call for help by using the call bell and stay with the resident. S20CNA stated she would not touch the resident until the nurse had assessed them and determined it was safe to move them. An interview was conducted with S19CNA on 03/12/2020 at 1:48 p.m. She stated if she found a resident on the floor she would hit the call light to call the nurse. She said she wouldn't touch the resident until the nurse assessed them. An interview with S17CNA was conducted on 03/12/2020 at 01:55 p.m. S17CNA stated if she found a resident on the floor she would use the call bell to contact the nurse to come and assess the resident. S17CNA stated she can't touch the resident until the nurse says it is safe. An interview with S18CNA on 03/12/2020 at 2:00 p.m. was conducted. S18CNA stated if she found a resident on the floor she would call the nurse to assess her. She said she wouldn't leave her side and wouldn't touch them until the nurse deemed it safe. An interview with S10CNA on 03/12/2020 at 2:01 p.m. was conducted. S10CNA stated if she found a resident on the floor she would stay with the resident and use the call bell to ask for the nurse to come in to assess the resident. S10CNA also stated staff were instructed to never move a resident who has fallen on the floor until a nurse has been able to assess the resident. When asked if she had received recent training on transfers, she replied that they received training on lifts and gait belts by the therapy department sometime in January or February, but she could not recall the exact date. An interview was held with S16CNA on 03/12/2020 at 3:36 p.m. She said if a resident fell she would notify the nurse immediately and not move the resident until the nurse checked the resident. She said she had never had a resident fall when she was transferring and not alert the nurse. An interview with S4ADON on 03/12/2020 at 3:45 p.m. was conducted. S4ADON confirmed the above in-services included the topic of reporting included not handling a resident that has fallen until a nurse assesses the resident. An observation of Resident #78 was conducted on 03/09/2020 at 9:26 a.m. The observation was made of Resident #78 which included a transfer of Resident #78 from her bed to her chair using a Hoyer lift. S11CNA and S12CNA transferred the resident. There were no concerns with the 2 person lifter transfer An observation of a lifter transfer of Resident #39 was conducted on 03/12/2020 at 1:03 p.m. by S6CNA and S3CNA. There were no issues with the transfer. Immediately after the transfer S6CNA and S3CNA were interviewed. S6CNA stated she was trained to use the lifter and knows there should be 2 people to use the lifter. S6CNA also stated she was instructed to not touch a resident until a nurse has assessed the resident after a fall. S3CNA stated she was trained to use the lifter and knows there should be 2 people to use the lifter. S3CNA also stated she was instructed to not touch a resident until a nurse has assessed a resident after a fall. She stated she was the CNA that found the resident with bruising on her shin and immediately reported it to the weekend supervisor. An observation of Resident #39's room on 03/12/2020 at 1:03 p.m. revealed there was an image of a lifter and an image of 2 figures with the words 2 person transfer under the image. The facility has implemented the following actions to correct the deficient practice effective 01/08/2020. On Sunday Dec. (December) 1, 2020 S22RN Weekend Supervisor reports Resident #39 c/o (complained of) her leg hurting, swelling/discoloration/bruising /pain to her right leg, just below the knee, and resident initially reporting she was dropped the day before by S2CNA. This employee was not working on 12/01/2019. 1. Physician notified and orders noted to obtain x-ray, mobile x-ray taken. Results noted fracture and MD (Medical Doctor) notified then ordered to send out to ER (emergency room ). Resident was transported to a local hospital ER (emergency room ) in a nearby town. S22RN Weekend Supervisor began obtaining statements from employees who have worked on B hall, including employees in other departments-not just nursing. 2. SIMS (Statewide Incident Management System) assessment initiated r/t (related to) fracture, by a nurse on duty. 3. Local police department was contacted by facility administrator on Sunday of resident having a fracture and her reporting she was dropped. 4. S22RN Weekend Supervisor initiated resident interviews of cognitively intact residents on 12/01/2019. On Monday 12/02/2019 a list of residents on the hall was reviewed noting their BIMS (Brief Interview for Mental Status) score to determine if any other residents needed to be interviewed. Upon completion of the interviews, it is determined that no other residents were affected or identified that they felt unsafe. 5. On 12/04/2019- An ins-serviced for all C.N.A's initiated-once it is determined that S1CNA and S2CNA did not follow p/p (policy/procedure) as established by the facility. The in-service included-transfers/use of lift/gait belt/following POC (plan of care) and reporting incidents immediately. In-servicing continued to get all C.N.A.'s in-serviced. 6. On 12/06/2019- Morning QA (Quality Assurance) meeting, we discussed that we will review all falls with fall meetings to ensure residents plan of care was follow for the amount of assistance needed with transfers or use of lift D.O.N. and A.D.O.N. (Assistant Director of Nursing) initiated the check off with return demonstrations. 7. On 12/08/2019-In-services were completed, with exception of prn (as needed) staff. They were in-serviced before returning to work for a scheduled shift. 8. On 12/10/2019-The D.O.N. reviewed PIP (Performance Improvement Project) on falls with major injury indicating this resident had a fall and sustained a fracture 9. On 01/08/20 falls reviewed from over the past month, with no indications noted upon review that staff failed to follow POC with transfers. 10. The POC was implemented on 01/08/2020.

Based on interviews and record reviews, the facility failed to ensure staff adequately supervised 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents diagnosed with [REDACTED]. The facility failed to: 1. Supervise a resident diagnosed with [REDACTED].#2); 2. Monitor the resident every 2 hours (#2) to ensure safety; 3. Lock and alarm the exterior doors at the designated time of 8:00 p.m. (Station "A" ); and 4. Ensure staff was available to monitor exit doors for residents going out onto the patio. This resulted in an Immediate Jeopardy situation for Resident #2 when the facility failed to ensure a system was in place to supervise each resident that was diagnosed with [REDACTED]. The Immediate Jeopardy began for Resident #2 on 3/27/14 at 9:57 p.m. when she walked out of the facility, and no staff member noticed her exiting through the door. The facility had no knowledge that Resident #2 had eloped from the facility until 3:00 a.m. on 3/28/14. S1Administrator and S2DON were notified of the Immediate Jeopardy situation on 4/2/14 at 10:12 a.m. The Immediate Jeopardy was removed on 4/2/14 at 1:37 p.m. when the facility presented an acceptable plan of removal by S1Administrator that included: On March 28, 2014, at 3:00 a.m. when Resident #2 was identified as missing from the facility, the following procedures were implemented: 1. Staff completed a thorough search of the building and surroundings areas, notified the administrator, the police and the family. 2. S2DON immediately instructed staff to ensure that all other residents were accounted for and safe. A two hour checklist for all residents was initiated immediately to be completed by each nurse at each nurses' station. This was indicated by documenting on the census by a check mark next to each resident' s name to indicate that the residents were accounted for. This census form was signed by the nurse on duty at each nurses' station at the end of each shift. 3. Staff was inserviced concerning this as well at 3 a.m. on proper elopement procedures after discovering elopement and the q 2 hr checks. On March 28, 2014 4. S2DON immediately put into place that all patients who smoked were to smoke in secure areas only. A smokers log was initiated where staff documented the time that each resident who smoked went outside and returned in the building. 5. Nurses began completing updated elopement risk assessments on all residents. Four residents were identified as possibly being at higher risk for elopement. They initially were placed on q one hour monitoring. 6. Inservices were completed on: -locking all exterior doors by 9 p.m. nightly -turning on door alarms to all exterior doors immediately after being locked -residents who smoke were to be given cigarette and have cigarette lit, and offer a smoking apron according to smoking assessments, indicating on smokers log time out and time in, and directed to smoke in a secure area. -q 2 hr. checks and documentation on census. There were to be placed each day in the door of the DON office and are to be monitored daily by the DON or her appointee. These inservices were conducted at 6 a.m., 8:30 a.m., 2 p.m., 6 p.m., 8:30 p.m., and 10 p.m. On March 29, 2014 7. Inservies were conducted on -locking all exterior doors by 9 p.m. nightly -turning on door alarms to all exterior doors immediately after being locked -residents who smoke were to be given cigarette and have cigarette lit, and offer a smoking apron according to smoking assessments, indicating on smokers log time out and time in, and directed to smoke in a secure area. -q 2 hr. checks and documentation on census. There were to be placed each day in the door of the DON office and are to be monitored daily by the DON or her appointee. These inservices were conducted at 10:45 a.m., 2 p.m., and 6 p.m. On March 30, 2014 7. DON developed and put in place a more formal form for the documentation of the q 2 hr checks. This form is to be placed in the door of the DON office after each 24 hr period. The DON or her appointee will monitor daily. An inservice on this new form was conducted. 8. Reviewed elopement policy and procedure in an inservice completed at 4:45 p.m. which included 6 a.m. - 6 p.m. nurse and nursing assistants, 2 p.m. - 10 p.m. staff and 6 p.m. -6 a.m. nurses. On March 31, 2014 9. The ID team met and re-evaluated the elopement risk assessments and decided to place the four that were on increased supervision on the secure unit until they can be re-evaluated to determine if their safety can be maintained in a less restrictive environment. 10. At 3 p.m., a mandatory meeting was held for all employees. An inservice was conducted to include all of the new procedures put in place since March 27, 2014. The inservice included: - q 2 hr checks, the documentation of this, and placing in DON's door for monitoring daily by DON or her appointee -smoking safety according to resident's smoking assessment -smoking log to sign patients in and out, and monitoring of the residents outside -elopement procedures -general safety especially at night such as reporting suspicious people on the premises -locking exterior doors and activating alarms immediately upon locking -elopement safety assessments On April 1, 2014 13. Continued inservicing employees who had not attended previous inservices on: -q 2 hr checks, the documentation of this, and placing in DON's door for monitoring daily by DON or appointee -smoking safety according to resident's smoking assessment -smoking log to sign patients in and out, and monitoring of the residents outside -elopement procedures -general safety especially at night such as reporting suspicious people on the premises -locking exterior doors and activating alarms immediately upon locking -elopement safety assessments 14. S ... Security evaluated all doors, present alarm systems and locking in order to give bid on a new system On April 2, 2014 15. Continued to evaluate new systems put in place. Made decision and policy put in place to have charge nurse at night to monitor and ensure that doors are alarmed and locked at dark. Policy states that they are to remain locked and alarmed until 5:45 a.m. Form developed for the documentation of this. Also developed form to inservice and have each nurse give return demonstration of locking doors and turning on alarms on each station. They will sign these acknowledging that they were instructed on procedure. This was started today with all nurses on duty and will continue to include all nurses. In addition, a policy was developed to include new nurses and added to employee packet on the "Nurse Orientation Sheet" for all new nurses including instruction and return demonstration. 16. All new employees will be oriented to: -elopement procedures -smoking policy -q 2 hour checks of residents -policy that doors are locked and alarmed at dark until 5:45 a.m. The deficient practice was lowered to a scope and severity of actual harm for Resident #2 when authorities found resident #2's body in a nearby river shortly before 4:00 p.m. on 3/30/14 according to local news reports. The deficient practice continues at a Level 2 for residents diagnosed with [REDACTED]. Findings: Resident #2 Review of Resident #2's clinical record revealed the following: Date of Admission - 1/23/07; Diagnosis / History - vitamin deficiency, dementia without behavior, depressive disorder, [DIAGNOSES REDACTED], reflux esophagitis, constipation, psoriasis/like disorders, pruritic disorder, insomnia, and lack of coordination. Review of the facility's video surveillance footage in the presence of S1Administrator, dated 3/27/14, revealed the following: Resident #2 on "A" station patio smoking at 21:52; Resident #2 returned inside at 21:55 and walked to her room; and walked out of her room through "A" station patio exit doors and into the parking lot at 21:57. S1Administrator said this was the last time resident #2 was seen. Review of Nurses Notes, dated 3/28/14 at 410 a.m., revealed the following: Resident was last seen at 10 p.m. when she took her last smoke. I S4LPN was approached by S5CNA that a resident needed my assistance on "B" station. I immediately went to station "B" . When arriving back to station "A" I noted that both CNAs were conducting their 10 o' clock rounds and this was at 10:25 p.m. S6CNA notified me that resident was missing and this was at 3 a.m. After I finished up in another resident room, I immediately notified S7LPN of the situation. We all began to search the facility "staff" to look for the resident. After checking the complete facility inside and out, S7LPN notified S1Administrator of the situation at 4 a.m. I S4LPN notified the husband at 4:20 a.m. N ...R ... Police department arrived at the facility at 4:10 a.m. Review of the February 2014 monthly physician's orders [REDACTED]. Review of the Nurses Notes, dated 11/17/09 at 9 a.m., revealed: nurse came to me stating housekeeper stated resident said she went across the street to see what was over there. I asked resident if she went across the street resident replied yes, I did go because I wanted to see what was over there. Nothing was there and I am not going to go back. Resident was placed on extensive supervision. Review of the Nurses Notes, dated 11/6/12 at 5 p.m., revealed Resident #2 evaluated for elopement risk. No risk found at present. New order to discontinue q 1 hour monitoring. Review of the Elopement Risk Assessment, dated 11/28/12, revealed a total score of 10 which indicated Resident #2 was at risk for elopement. Review of the Progress Notes, with assessment reference date (ARD) of 2/27/13, revealed the following in part: Staff feels she is not at risk for elopement due to the fact she must be medicated to go the doctor due to her not wanting to leave the facility. Review of the progress notes, with ARD of 1/22/14, revealed the following in part: Resident is being assessed for a quarterly review. She is awake, alert and verbal. She scored a 9 on Brief Interview for Mental Status (BIMS) = moderately impaired (cognition). She has difficulty concentrating she often talks to herself or to someone not there and answers "yep yep right, right." She paces up and down hallway to and from dining room. She has a [DIAGNOSES REDACTED]. Staff monitors her occasionally while she is smoking. She always seems to be in a hurry. She does not pay attention to her surroundings. Review of the Safe Smoking Assessment, dated 1/22/14, revealed the following in part: short term memory is ok - no; adequate memory / recall ability - no; able to make decisions regarding tasks of daily living - no; interdisciplinary team (IDT) determination - This resident is determined to be an unsafe smoker; Occasional supervision needed while smoking. Review of the Care plan revealed the following: Problem onset 1/23/2007 I have difficulty in making decisions due to (d/t) effects of [DIAGNOSES REDACTED] / Dementia Problem onset 1/23/2007 Short-term memory deficit related to (r/t) effects of [DIAGNOSES REDACTED] forgets she ate and ask for another plate or not eat forgets she just had a cigarette and ask for another 5 minutes later; Moderately impaired scored 9 on BIMS 11/6/13 Problem onset 12/17/2008 I am at risk to fall related to medications, diagnoses, and pacing. Approach - Supervise her and make her aware of her surroundings dated 3/27/13 Problem onset 1/23/2007 I am a smoker. I am on a hour smoking. Refuse to wear smokers apron. 6/23/13 I lit a cigarette in the lobby. Approaches -Occasionally monitor my smoking. Encourage to wear smoker's apron when smoking. Staff to assist with lighting cigarettes. Problem Onset 5/25/2011 Insomnia Review of the certified nurse aide (CNA's) plan of care revealed the following in part: mobility - walks independently; privileges - up and about with supervision; activities - ad lib; and attitude -repeats sentences over and over, very forgetful. An interview was held on 3/31/14 at 10:02 a.m. with S2DON. She said that S4LPN and S6CNA were assigned to Resident #2 when she was found to be missing. An interview was held on 3/31/14 at 10:30 a.m. with S4LPN. She said that she had been employed since June 6th 2013 at the facility. She said that she worked the 6 p.m. - 6 a.m. shift. She said that she had been taking care of Resident #2 since she started working here. She said she was not aware of Resident #2 leaving the facility's premises in the past. She said that Resident #2 resided on "A" station on the long hall. She said Resident #2 had a [DIAGNOSES REDACTED]. She said that Resident #2 would ask for a cigarette every hour until 10 p.m., and she would smoke her cigarette and go back to her room. She said that Resident #2 smoked independently. She said the patio area outside of "A" station was not a secured area. She said that a staff member was not always present in the patio area of "A" station. S4LPN explained that she would lock the exit doors and set the alarm on patio "A" station after Resident #2 had her 10:00 p.m. smoke. She verified that the night Resident #2 left the facility; she had not locked the patio doors or set the alarm yet. She said that she saw Resident #2 at 10:00 p.m. on 3/27/14 when she was looking for her cigarette. She said Resident #2 went outside to smoke, and she went to warm up her food. S4LPN said that she left her station around 10:10 p.m. to go to "B" station to give a resident Maalox. She said she made it back to station "A" around 10:20 p.m. She said the last time she saw Resident #2 was 10:00 p.m. when she went outside to smoke. She said S6CNA was assigned to the long hall which Resident #2 resided on. S4LPN said S6CNA reported to her at 3:00 a.m. on 3/28/14 that Resident #2 was not in her room or bathroom. She said that S6CNA was making her 2:00 a.m. rounds when she found Resident #2 missing. S4LPN explained there were only two nurses on duty on 3/27/14, but there were usually three. She said that there were 5 CNAs on duty. She said at 10 p.m. on station "A" there were two CNAs assigned, one on the long hall and one on the short hall. She said on the short hall some residents require two person assist with turning and transferring, and some residents use of lift to get up which requires 2 CNAs and 1 nurse present. She said there are a lot of residents on long and short hall that need to be changed and turned q 2 hours (hrs) so she stressed to the CNAs to make rounds together. She said that she was responsible for short and long hall on station "A". Review of the Nurse Meeting minutes, dated January 2nd, 3rd 2014, revealed the following in part: Locking Exterior Doors - Make sure by 8 p.m. that all doors are locked and the alarm is turned on all 3 nurses' stations!! "C" Back door, "A" lobby, and "B" back door. Review of the attached signature sheet revealed S4LPN's signature. An interview was held on 3/31/14 at 12:25 p.m. with Resident #2's husband. He said that Resident #2 had lived at the facility since May 2007. He said that he visited Resident #2 at least 6 days week. He said that he had visited her on Wednesday 3/26/14, but he was not able to come see her on 3/27/14. He said her long term memory was still functioning, but she did not have a short term memory. He said that she could not remember what was for lunch. He said that she had her hourly routine for cigarettes, and she adhered to that. He said after watching the video of her leaving the facility that he thought she got something in her head that made her leave. He said that she walked with a goal when she went out. He explained when she was first moved into the facility she walked across the road to the vacant lot to see the flowers, and one of the aides brought her back. He said that S1Administrator did not remember this occurrence. He said that this happened seven years ago, and she was more lucid then. He said that Resident #2 was still physically capable of walking a long distance. An interview was held with S8CNA on 3/31/14 at 1:46 p.m. She said that she worked 6 a.m. - 2 p.m. She said that she had been employed for [AGE] years at the facility. She said that Resident #2 did not talk a lot, and she did not talk in sentences. An interview was held on 3/31/14 at 2:13 p.m. with S9CNA. She said that she trains the CNAs. She said that she has been working at the facility for [AGE] years. She said that resident #2 never walked away from the facility in the past. An interview was held on 3/31/14 at 2:49 p.m. with S10CNA. She said she worked 6 a.m. - 6 p.m. She said she had been employed at the facility for 6 years. She said she did take care of Resident #2 in the past. She said she took care of Resident #2 from 2 p.m. - 6 p.m. on the day she left the facility. She said Resident #2 had never left the premises in the past. An interview was held on 3/31/14 at 3:11 p.m. with S6CNA. She said she worked 10 p.m. - 6 a.m. shift. She said she had been employed at the facility for almost 1 year for the second time. She said that Resident #2 did not talk much. She said that she was assigned to Resident #2 on the night that she went missing. She said she saw Resident #2 at 10:00 p.m. for her 10:00 p.m. cigarette. She said no one goes outside when Resident #2 smokes. She said it was a little before 10 p.m. when she saw her. She said that she did not see her at the 12 midnight round, and she thought she was in the bathroom. She explained that her light was on in her bathroom with the bathroom door closed. She said that she did not open the bathroom door or call her name. She said when she made her 2 a.m. rounds Resident #2 was not in bed, her bedroom light was out, and her bathroom light was on with the bathroom door closed, but she was not in the bathroom. S6CNA said that she told S4LPN that she could not find Resident #2. An interview was held on 4/1/14 at 8:31 a.m. with S6CNA. She explained that when she comes on duty around 10 p.m., the doors on the patio by "A" station are unlocked at this time. She said when the doors are locked then no one can come into the facility from the outside, but the residents and staff inside can go out of the facility. She said that no one had ever told her that she needed to watch Resident #2 while she was outside. She said if the nurse was at the nurse's station that she could see the residents on the patio on "A" station, but the nurse was not always at the nurse's station. She said that one door was left open for Resident #2 to come back inside after she finished smoking. She said that she assumed that all residents with the [DIAGNOSES REDACTED]. An interview was held on 4/1/14 at 8:20 a.m. with S4LPN. She explained that the staff did not have to watch Resident #2 while she was outside smoking because she was a safe smoker. She verified that she did have the [DIAGNOSES REDACTED]. When asked how she knows if a resident comes back inside safely, she explained that she would have to depend on the CNAs making their 2 hour rounds to make sure the residents are all where they should be. She explained that if she is at the nurse ' s station, she can see the residents on the patio on "A" station, but she is not always there to monitor them. She said if she cannot be at the nurse's station then she checks to see if a CNA can watch the resident on the patio, but she said sometimes a CNA is not available. She said they do not have to monitor the residents on the patio all the time. She said that there is no staff member assigned to monitor this area. She explained the exterior doors to the building are locked between 9 p.m. - 10 p.m. She said when the doors are locked that the residents and staff can go out the building, but no one can come back into the building unless someone lets them in. She said that she locked the doors each night on the patio on "A" station after Resident #2 had her 10 p.m. smoke. An interview was held on 4/1/14 at 9:26 a.m. with S11MDSNurse. After reviewing Resident #2's quarterly minimum data set (MDS) with ARD 1/22/14, she verified it revealed the following: BIMS of 9 = cognitively impaired and [DIAGNOSES REDACTED]. An interview was held on 4/1/14 at 9:32 a.m. with S2DON in the presence of S1Administrator. S2DON explained that Resident #2 was started on q 1 hour monitoring a few days after admit because she walked across the street. She said the monitoring continued until November 6, 2012. She said the unit manager, S12, reviewed Resident #2's chart and saw she was on q 1 hour monitoring, but she did not think it was needed anymore because there had been no further attempts of wandering from the premises. S2DON said it was discussed with the staffing team, and the q 1 hour monitoring was discontinued. S2DON explained in the past they were completing the elopement risk assessments on admit (started around 2012), quarterly x 1 year, and then only if something came up after the year. She explained the elopement risk assessment is a tool they use, and the results are discussed with the staffing team to determine if they feel that the resident is an elopement risk and they need to be placed on the secure unit or have more frequent than 2 hour checks. After reviewing the Elopement Risk assessment dated [DATE], S2DON verified that it revealed a total score of 10 which indicated Resident #2 was at risk for elopement. S2DON said the staffing team decided that she was not an elopement risk. An interview was held with S2DON on 4/1/14 at 11:33 a.m. She explained that she needed to clarify that it was in 2009, not right after resident #2 was admitted , when Resident #2 left the premises and went across the street when the elopement occurred. She explained her nursing staffing pattern for the facility was as follows: 6 a.m. - 6 p.m. 5 nurses (2 nurses on station "C" 2 nurses on station "A", and 1 nurse on station "B"); 6 p.m. - 6 a.m. 3 nurses (1 nurse on each station). She said there have been rare occasions with 3 nurses until 10 p.m. and then 2 nurses until 6 a.m. She said this is for instance if a nurse calls in and she can't find a staff member or an agency nurse for coverage. She explained when this occurs station "C" nurse remains on the secure unit, and the other nurse is assigned to stations "A" and "B". She verified on 3/27/14 S7LPN worked 6 p.m. - 6 a.m. on station "C", S4LPN worked 6 p.m. - 6 a.m. and was assigned to stations "A" and "B" after S13LPN left work at 9:29 p.m. Review of S13LPN's time card revealed on 3/27/14 she clocked in at 6:09 a.m., and she clocked out at 9:29 p.m. Review of S7LPN's time card revealed on 3/27/14 she clocked in at 5:49 p.m., and she clocked out at 7:04 a.m. Review of S4LPN's time card revealed on 3/27/14 she clocked in at 5:57 p.m., and she clocked out at 7:04 a.m. Review of S6CNA's time card revealed on 3/27/14 she clocked in at 9:54 p.m., and she clocked out at 6:03 a.m. An interview was held on 4/1/14 at 11:55 a.m. with S2DON. After reviewing the census on 3/27/14, she verified that S4LPN, night shift nurse, was assigned to care for the residents on "A" station and "B" station after 9:29 p.m. She verified there were 48 residents on "A" station and 18 residents on "B" station on 3/27/14. An interview was held on 4/1/14 at 3:00 p.m. with S1Administrator. She explained that all exterior doors of the facility should have been locked at dark and the alarms should have been set. Review of the facility investigation revealed of the elopement of Resident #2 revealed the following: INCIDENT INVESTIGATION EMPLOYEE STATEMENT DATE 3/27/14 Resident #2 C.N.A. assigned to Resident at the time of the incident. S6CNA Resident was last seen at 10 p.m. when she came to nurses' station and got 1 cigarette and a lighter to smoke. It was reported to me at 3 am that the above resident was not in her room. I was in another resident's room at this time. I S4LPN and employees immediately began to search facility and then S7LPN called S1Administrator. Signed - S4LPN 3/28/14 INCIDENT INVESTIGATION EMPLOYEE STATEMENT DATE 3/28/14 Resident #2 C.N.A. assigned to Resident at the time of the incident. S6CNA Arriving on "A" station for my 10 p.m. - 6 a.m. "A" long shift. Resident #2 was stating her usual statement, "This is my last one y'all, my last one." Nurse (S4LPN) gave her a cigarette and lighter. She went out the "A" side doors to smoke. When making my 10:00 rounds in her room, I assumed she was still smoking. 12:00 rounds-she wasn ' t in bed-I thought she was in the bathroom. 2:00 round-she still wasn ' t in the bed and again she wasn ' t there and again I thought she was in the bathroom. I came up front and finished my books. I thought let me go check on her in this bathroom she must be sick in the bathroom all night. I proceeded to her room and she wasn ' t ' t in it nor bathroom. I looked in rooms and dining room no Resident #2. I asked the other worker, including the nurses did they seen her. We all started looking the entire building and surrounding areas Signed S6CNA INCIDENT INVESTIGATION EMPLOYEE STATEMENT DATE 3/28/14 Resident #2 C.N.A. assigned to Resident at the time of the incident. ________ At approximately 3:00 a.m. I was notified that Resident #2 location was unknown. At this time, this nurse, S4LPN and all scheduled CNA's checked every room in the facility. This check was done not only to look for Resident #2, but also to verify location of each resident in the facility. All other residents' location was verified. After the completion of the search inside and directly outside the facility was complete, I notified S1Administrator of the incident. Then I called the police station and spoke with W .... W ... was given a brief description of the resident, what she was wearing, age, and the name she answers to usually "M ... M ..." Signed S7LPN INCIDENT INVESTIGATION EMPLOYEE STATEMENT DATE 3/28/14 Resident #2 C.N.A. assigned to Resident at the time of the incident. ________ The last I seen Resident #2 was at 10:00 p.m. She was coming out of the dining room and I was headed to the time clock. Signed S14CNA 3/28/14 5:43 p.m.