Every finding on record at Leslie Lakes Retirement Center

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility staff failed to implement standard precautions as evidenced by: 1) failure to perform hand hygiene and don gloves during medication administration, 2) failure to doff PPE prior to exiting resident room, and 3) failure to clean and disinfect a whirlpool bath.Findings: #1. Review of the facility's Infection Control Guidelines for All Nursing Procedures policy dated 01/15/2026 revealed: General Guidelines 1. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. 4. In most situations, the preferred method of hand hygiene is with alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: d. Before preparing or handling medications; g. After contact with a resident's intact skin; On 02/26/2026 7:47 a.m. during medication administration observation S5LPN failed to perform hand hygiene: 1) prior to medication administration, 2) between tasks during medication administration, 3) after medication administration. It was noted, medication fell from Resident #30's mouth onto her shirt. S5LPN picked up the medication with an ungloved hand and administered to Resident # 30. This action occurred three times. #2. Review of the facility's Enhanced Barrier Precautions policy effective 04/01/2024 revealed: Disposal of PPE PPE used during resident care, including care of residents placed in Enhanced Barrier Precautions are not regulated medical waste requiring disposal in a biohazard bag, and should be discarded as routine non-infectious waste. Facilities should remember to have an appropriate disposal container available in the resident room to allow for removal of PPE inside the room. On 02/23/2026 at 2:34 p.m., S9CNA assisted with turning and repositioning during wound care observation for Resident #11. S9CNA exited Resident #11's room without doffing PPE. Following completion of wound care, interview with S3ADON confirmed that Resident #11 had EBP precautions in place due to wounds. S9CNA re-entered room in PPE. On 02/23/2026 at 2:45 p.m., interview with S9CNA confirmed PPE was not removed and replaced before room re-entered. On 02/23/2026 at 2:50 p.m., interview with S3ADON confirmed S9CNA did not doff PPE before exiting Resident # 11's room. #3. Review of the facility's undated policy for whirlpool disinfection revealed the following: The facility will maintain whirlpool equipment in a clean sanitary condition. Whirlpools will be cleaned and disinfected after each resident use and thoroughly cleaned daily in accordance with manufacturer instructions. Disinfection will be circulated through jets for the required contact time. Tub will be drained, rinsed thoroughly, and allowed to air dry. Staff will wear appropriate personal protective equipment (PPE) during cleaning. Observation on 02/23/2026 at 4:27 p.m. with S4CNA Team Lead revealed the whirlpool tub 400 hall was had a brown colored substance and hair inside of the pool. During an interview on 02/23/2026 at 4:27 p.m., S4CNA confirmed the whirlpool tub on 400 hall was unclean and reported it should have been cleaned after each use.

Based on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for bleeding while a resident was receiving an anticoagulant for 1 (#11) of 5 residents reviewed for unnecessary medications.Findings: Review of the medical record for Resident #11 revealed an admission date of 10/21/2025. Resident #11 had diagnoses including atrial fibrillation, hypothyroidism, hyperlipidemia, schizophrenia, dementia and depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #11 had a BIMS score of 8 which indicated moderate cognitive impairment for daily decision making. Review of the current care plan revealed Resident #11 was at risk for bruising and bleeding related to anticoagulant therapy. Further review of the care plan revealed approaches included to observe resident for signs and symptoms of bleeding. Review of the February 2026 physician orders revealed an order dated 12/02/2025 for Eliquis (anticoagulant) 2.5 mg, give 1 tablet by mouth two times a day related to unspecified atrial fibrillation. Review of Resident #11's January 2026 and February 2026 MAR revealed no documented evidence of monitoring for signs and symptoms of bleeding for Resident #11 while receiving Eliquis. On 02/25/2025 at 4:10 p.m. interview with S2DON confirmed there was no documented evidence of monitoring for signs and symptoms of bleeding for Resident #11 while receiving Eliquis.

Based on observations and interviews, the facility failed to ensure residents have a right to a clean, comfortable and homelike environment by having unsanitary items for resident use for 1 (#1) of 2 residents reviewed for environment. Findings:Observations of resident #1's room on 02/23/2026 at 10:00 a.m., 02/24/2026 at 9:00 a.m., and 02/25/2026 at 8:30 a.m. revealed a spilled substance on the bedside table and tube feeding pole. Further review revealed a black substance and grime on the resident's air condition unit. During an interview on 02/25/2026 at 8:38 a.m., S6Housekeeper confirmed there were spills and splatters on the bedside table and tube feeding pole. During an interview on 02/25/2026 at 8:42 a.m., S7Maintenance confirmed there was a black substance and grime on the air condition unit, and the air filter needed to be changed.

Based on observations, interviews, and record reviews, the facility failed to provide necessary care and services, in accordance to the professional standards of practice, for 2 (#31, #78) of 2 residents reviewed for respiratory care. The facility failed to 1) properly store the nebulizer mask when not in use and change nebulizer tubing for Resident #31, and 2) change the oxygen tubing weekly for Resident #78. Findings: Review of facility's Oxygen administration policy dated 01/15/2026 revealed in part: Oxygen shall only be administered by physician order, except in an emergency. Prefilled humidifier bottles and nasal cannulas/masks will be changed every week and prn. All tubing and bottles are to be labeled each week when changed. When the tubing is not being used, it should be stored properly in a zip lock bag. Resident #31 Review of the medical record for Resident #31 revealed an admission date of 08/08/2025. Resident #31 had diagnoses including pneumonia, reflux, anxiety, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #31 had a BIMS score of 10 which indicated moderate cognitive impairment for daily decision making and require assistance with ADLs. Review of Resident #31's current care plan revealed ineffective airway clearance related to pneumonia, shortness of breath, allergic rhinitis, cough and dyspnea. Further review of the care plan revealed approaches to change oxygen tubing as ordered and administer medications such as inhaled bronchodilators as ordered. Review of the February 2026 physician orders revealed an order dated 01/29/2026 for Ipratropium - Albuterol inhalation solution .5-2.5 (3) mg/3ml – inhale 3 milliliter orally every 6 hours as needed for cough and dyspnea. Further review revealed an order dated 02/06/2026 to change nebulizer tubing every week on Friday. On 02/24/2026 at 4:59 p.m., and 02/25/2026 at 7:30 a.m. observations of Resident #31's room revealed a nebulizer mask lying on the window sill uncovered and not stored in a bag and the tubing was dated 01/30/2026. An observation on 02/25/2026 at 9:00 a.m. of Resident #31's nebulizer mask and tubing with S5LPN present revealed the resident's nebulizer mask was not stored in a bag and the tubing was dated 01/30/2026. S5LPN confirmed the mask should be stored in a bag and the tubing should be changed weekly. Resident #78 Review of Resident #78's medial record revealed an admit date of 01/18/2023 with diagnoses that included in part respiratory failure. Review of resident #78's physician orders revealed an order dated 01/18/2026 for oxygen at 2 liters per minute via nasal cannula every shift. Further review revealed an order dated 02/12/2026 to change oxygen tubing every week on Thursdays. Observation on 02/23/2026 at 8:30 a.m. revealed Resident #78 with oxygen in use via nasal cannula, and oxygen tubing dated 02/13/2026. Observation on 02/23/2026 at 3:00 p.m. revealed Resident #78 with oxygen in use via nasal cannula, and oxygen tubing dated 02/13/2026. Observation on 02/24/2026 at 8:30 a.m. revealed Resident #78 with oxygen in use via nasal cannula, and oxygen tubing dated 02/13/2026. Observation on 02/24/2026 at 8:35 a.m. with S8LPN, revealed Resident #78 with oxygen in use via nasal cannula, and oxygen tubing dated 02/13/2026. During an interview on 02/24/2026 at 8:35 a.m. S8LPN confirmed the oxygen tubing had not been changed weekly and should have been.

Based on record review and interview, the facility failed to ensure the pharmacist identified irregularities related to adequate monitoring of prescribed medications for 1 (#11) of 5 residents reviewed for unnecessary medications. Findings:Review of the medical record for Resident #11 revealed an admission date of 10/21/2025. Resident #11 had diagnoses that included atrial fibrillation, hypothyroidism, hyperlipidemia, schizophrenia, dementia and depressive disorder.Review of the quarterly MDS assessment dated [DATE] revealed Resident #11 had a BIMS score of 8 which indicated moderate cognitive impairment for daily decision making.Review of the current care plan revealed Resident #11 was at risk for bruising and bleeding related to anticoagulant therapy. Further review of the care plan revealed approaches included observe resident for signs and symptoms of bleeding.Review of the February 2026 physician orders revealed an order dated 12/02/2025 for Eliquis (anticoagulant) 2.5 mg, give 1 tablet by mouth two times a day related to unspecified atrial fibrillation. Review of Resident #11's January 2026 and February 2026 MAR revealed Eliquis was administered as ordered. Further review revealed no documentation to support monitoring for signs and symptoms of bleeding was completed for Resident # 11. Review of the monthly MRR dated 01/31/2026 revealed no documentation to support the pharmacist addressed the facility's failure to monitor Resident's #11 for signs and symptoms of bleeding while receiving Eliquis.On 02/25/2026 at 4:15 p.m. interview with S2DON confirmed the pharmacist did not address the facility's failure to monitor Resident #11 for signs and symptoms of bleeding while receiving Eliquis.

Based on record review and interviews, the facility failed to conduct a MDS (Minimum Data Set) admission assessment timely for 1 (#238) of 6 (#37, #62, #66, #69, #77, #238) residents reviewed for accidents out of a total sample of 26 residents. Findings: Review of Resident #238's medical record revealed an admitted [DATE]. Review of Resident #238's admission MDS dated [DATE] revealed a status of still in progress. During an interview on 12/11/2024 at 1: 45 p.m. S3 MDS Coordinator reviewed the MDS assessment for Resident #238 and confirmed the admission assessment due by 12/06/2024, had not been completed and submitted to CMS (Centers for Medicare and Medicaid Services) in a timely manner after the resident's admission to the facility. During an interview on 12/11/2024 at 5:45 p.m. S1 DON (Director of Nursing) reviewed and reported the admission MDS assessment was due to be completed and transmitted by 12/06/2024 and was not.

Based on record review, observations, and interviews the facility failed to provide services that met professional standards during medication administration for 1 (#90) of 33 sampled residents. The facility failed to follow policies and procedures to ensure safe medication administration practices. Findings: Review of facility's Administering Oral Medications policy revealed in part: Purpose - The purpose of this procedure is to provide guidelines for the safe administration of oral medications. 16. Allow the resident to swallow oral tablets or capsules at his or her comfortable pace. 21. Remain with the resident until all medications have been taken. Resident #90 was admitted to the facility on [DATE] with diagnoses including in part chronic pain and chronic kidney disease. Review of Resident #90's Quarterly MDS (Minimum Data Set) dated 10/03/2023 revealed a BIMS (Brief Interview for Mental Status) Summary Score of 15, indicating intact cognition. Review of Resident #90's MAR (Medication Administration Record) revealed the following oral medications had been documented as administered on 11/13/2023 at 8:00 a.m. by S4LPN: Vitamin C 500 mg (milligram) one tablet po (by mouth) Vitamin D3 1,000 unit one tablet po Pepcid 20 mg one tablet po Lisinopril 20 mg one tablet po Multivitamin with minerals one tablet po Norvasc 10 mg one tablet po Duloxetine HCL (hydrochloride) DR (delayed release) 20 mg one capsule po Docusate sodium 100 mg one tablet po Preservision Areds-2 1 capsule po Metoprolol tartrate 100 mg one tablet po Macrobid 100 mg one capsule po Clonidine HCL 0.1 mg one tablet po Observation on 11/13/2023 at 8:30 a.m. revealed a medicine cup filled with 10-12 pills sitting on Resident #90's bedside table. Further observation revealed Resident #90 was in her bathroom. During an interview on 11/13/2023 at 8:40 a.m., S4LPN returned to room with surveyor and confirmed Resident #90's morning medications had been left in a medicine cup on Resident #90's bedside table. S4LPN further acknowledged she did not stay in room to confirm Resident #90 took her morning medications and should have. During an interview on 11/13/2023 at 8:40 a.m., Resident #90 confirmed the medicine cup contained her morning medications given to her by the nurse and acknowledged S4LPN as her nurse. Resident #90 further reported she had not taken her medicine yet because she wanted to get dressed first.

Based on observations and interviews the facility failed to accommodate the needs of 1 (#8) of 2 (#4, #8) residents reviewed for environment by failing to ensure Resident #8's bed control was in working order. Findings: Review of Resident #8's medical record revealed an admitted [DATE] with diagnoses that included, in part, major depressive disorder, hereditary and idiopathic neuropathy unspecified, morbid (severe) obesity due to excess calories, venous insufficiency (chronic) (Peripheral), polyosteoarthritis unspecified, and essential hypertension. During an interview on 11/14/2023 at 8:23 a.m. Resident #8 reported his bed control had not worked for 8 years and he could not adjust the head of the bed or the feet. Resident #8 also confirmed CNAs (Certified Nursing Assistant) were aware the bed controls did not work. Observation on 11/14/2023 at 8:23 a.m. revealed Resident #8's bed control was on floor at head of Resident #8's bed. During an interview on 11/14/2023 at 10:58 a.m. S7 CNA was in Resident #8's room and reported Resident #8's bed control did not work and had not worked for over a year. During an interview on 11/15/2023 at 11:15 a.m. S10 Maintenance was in Resident #8's room and confirmed the bed control did not work.

Based on record review, observations and interviews the facility failed to ensure residents who had indwelling catheters received appropriate care and treatment according to standards of professional practice and the facility's policy to prevent urinary tract infections (uti) for 3 (#12, #38, #78) of 4 (#12, #38, #78, #246) residents reviewed for urinary catheter and uti. The facility failed to ensure: 1. Resident #12, Resident #38 and Resident #78's catheter bags were kept above the floor. 2. Resident #12, who had a catheter in place, had an order for a catheter. 3. Resident #12's urine quality was being monitored and documented as per facility policy. Findings: Review of facility's Catheter Care, Urinary policy with a revision date of September 2014 revealed in part: Purpose - The purpose of this procedure is to prevent catheter-associated urinary tract infections. General Guidelines . Infection Control: . b. Be sure the catheter tubing and drainage bag are kept off the floor. Changing Catheters: 1. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Complications: 1. Observe the resident for complications associated with urinary catheters. b. check the urine for unusual appearance (i.e. color, blood, etc.) . e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 9. The signature and title of the person recording that data. Resident #12 Review of Resident #12's medical record revealed Resident #12 was initially admitted to the facility on [DATE] and was readmitted on [DATE] after hospitalization due to uti and acidosis. Resident #12's diagnoses included, in part, bacterial infection unspecified on 10/06/2023, Type 2 Diabetes Mellitus with diabetic polyneuropathy, anemia, chronic pain syndrome, essential hypertension and osteoarthritis unspecified. Observation on 11/13/2023 at 9:20 a.m. revealed Resident #12's Foley catheter bag was noted to be draining light amber colored urine that appeared cloudy. Review of Resident #12's physician orders failed to reveal an order for Foley catheter. During an interview on 11/14/2023 at 2:30 p.m. S2 DON (Director of Nursing) confirmed Resident #12 did not have an order for a catheter and should have. Observation on 11/14/2023 at 9:58 a.m. revealed Resident #12's bed was in low position and Foley catheter bag with privacy bag in place was touching the floor. Observation on 11/14/2023 at 10:45 a.m. revealed Resident #12's Foley catheter bag with privacy bag in place continued to touch the floor. During an interview on 11/14/2023 at 10:45 a.m. S8 CNA (Certified Nursing Assistant) and S7 CNA observed the Foley catheter bag covered with a privacy bag touching the floor and confirmed the bag was touching the floor. During an interview on 11/14/2023 at 10:47 a.m. S6 LPN (Licensed Practical Nurse) confirmed the Foley catheter bag covered in a privacy bag should not have been touching the floor. During an interview on 11/15/2023 at 9:55 a.m. S6 LPN reviewed Resident #12's record and reported monitoring for quality or urine was not found. During the interview on 11/15/2023 at 10:15 a.m. S3 ADON (Assistant Director of Nursing) reported Resident #12's urine quality such as color and clarity was not being documented when catheter care was being done and Resident #12 had the Foley catheter in place upon return from the hospital on 10/06/2023. Resident #38 Observation on 11/13/2023 at 9:00 a.m. revealed Resident #38's Foley catheter bag lying on the floor. During an interview on 11/13/2023 at 9:00 a.m., S4 LPN acknowledged Resident #38's Foley catheter bag was lying on the floor and should not have been. Resident #78 Observation on 11/13/2023 at 1:00 p.m. revealed Resident #78's Foley catheter bag hanging from side of bed with lower section of catheter bag and drainage valve touching the floor. During an interview on 11/13/2023 at 1:00 p.m., S4 LPN acknowledged Resident #78's Foley catheter bag and drainage valve were touching the floor and should not have been. 44414

Based on record reviews, observation and interviews the facility failed to ensure provision of necessary care and services consistent with professional standards of practice and the facility's policy for 1 (#12) of 2 (#12, #19) residents reviewed for Respiratory Care. The facility failed to ensure: 1) Resident #12's oxygen tubing and humidification bottle were labeled with date they were changed. 2) There was a physician order for Resident #12 who was receiving oxygen. Findings: Review of Oxygen Administration Policy revealed: POLICY: Oxygen shall only be administered by physician order, except in an emergency. In an emergency situation, oxygen can be administered without physician order, but the order must be obtained immediately after the crisis is under control. All safety precautions and care of equipment shall be performed according to recommended State and Federal guidelines and facility procedures. Humidifier bottles will be changed as needed. Nasal cannulas will be changed every week and prn. Review of Resident #12's medical record revealed an original admitted [DATE] with a readmission after a hospitalization on [DATE]. Resident #12's diagnoses included, in part, Anemia, Type 2 Diabetes Mellitus with diabetic polyneuropathy, essential hypertension, and senile degeneration of the brain. Observation on 11/13/2023 at 8:55 a.m. revealed Resident #12 was lying to her right side in bed with HOB (head of bed) slightly elevated and O2 (oxygen) on at 2LPM (liters per minute) via nasal cannula utilizing an oxygen concentrator. No date was observed on tubing or humidification bottle. Review of physician orders failed to reveal an order for oxygen. Review of Resident #12's current care plan failed to reveal Resident #12 was care planned for receiving oxygen. During an interview on 11/13/2023 at 12:35 p.m. S6 LPN (Licensed Practical Nurse) observed Resident #12's oxygen tubing and humidification bottle and reported they were not dated and should be. During an interview on 11/14/2023 at 1:10 p.m. S3 ADON (Assistant Director of Nursing) reported Resident #12 was on hospice and any hospice standing orders for oxygen would be added to the physician orders when a resident started using oxygen. During an interview on 11/14/2023 at 2:01 p.m. S6 LPN confirmed there was not a physician order for Resident #12's oxygen. During an interview on 11/14/2023 at 2:30 p.m. S2 DON (Director of Nursing) reported Resident #12 did not have an order for oxygen and oxygen should not have been placed on Resident #12.

Based on observations and interviews, the facility failed to ensure dietary services were provided in a sanitary environment for the 83 residents served a meal tray from the kitchen as reported by the Dietary Manager. The facility failed to ensure food was properly dated and not expired. Findings: Review of the facility's Food Receiving and Storage Policy Statement revealed: 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Observation of the kitchen on [DATE] at 8:30 a.m. revealed the following: 1. 3 packages of coconut flakes with an expiration date of [DATE]. 2. 1 package of vanilla wafers opened, not sealed without opened dated on the package. 3. 1 package of graham pie crust opened, without opened date. 4. 1 gallon of pickle relish opened in the walk-in refrigerator with an expiration date of [DATE] and an opened date of [DATE]. 5. 1 package of American cheese single slice opened, without an opened date in the walk-in refrigerator. During an interview on [DATE] at 9:00 a.m., S9Dietary Manager was in attendance during the kitchen tour and acknowledged the findings.

Based on record review and interviews, the facility failed to protect the residents' right to be free from physical abuse by another resident for 1 (#1) of 3(#1, #2, #3) sampled residents reviewed for abuse. This deficient practice resulted in an actual harm for resident #1 (who was cognitively impaired) when on 10/10/2023 at 7:30 a.m. resident #2 physically abused resident #1. Resident #2 (who was cognitively impaired) hit resident #1 in the face because resident #1 was in his bed. Resident #1 was sent to the hospital diagnosed with a nose bleed and a broken nose. Findings: Review of the facility's current Abuse Prevention Program policy revealed the following: As part of the resident's abuse prevention, the administration will: 1. Protect our resident's from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies, family members, legal representatives, friends, visitors or any other individual. Review of the facility's Abuse and Neglect Protocol Definitions revealed the following: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish. 4. Willful is used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of resident #1's medical record revealed an admitted [DATE] with a diagnosis of but not limited to anxiety disorder, bipolar disorder, unspecified dementia with behavioral disturbances, insomnia and depression. Review of resident #1's MDS (Minimum Data Set) dated 08/25/2023 revealed a BIMS (Brief Mental Status Interview) score of 00 indicating severely impaired cognition. Review of resident #1's Comprehensive Care Plan dated 10/02/2023 revealed: Potential for injury related to dementia, at risk for being abused, wanders, and enters others rooms: monitor resident socialization behavior and document, observe for changes in mental status and document, and report any negative finding to the physician. Review of the facility's incident report dated 10/10/2023 7:30 a.m. revealed S4 LPN (Licensed Practical Nurse) was called to the dementia unit and upon arriving to resident #1's room found resident #1 lying in resident #2's bed, holding his nose. Resident #1's nose was bleeding. S4 LPN asked resident #1 what happened and resident #1 stated, He hit me in my nose. S4 LPN instructed resident #1 to remain in the room. Review of resident #1's Incident/Accident Nurses Notes revealed the following: 10/10/2023 7:30 a.m. S4 LPN was called to the dementia unit by S3 CNA, upon arriving to resident #1's room, S4 LPN saw resident #1 lying in another resident's bed holding his nose. Resident #1's nose was bleeding. S4 LPN asked resident #1 what happened and resident #1 stated, He hit me in my nose. S4 LPN told resident #1 to remain in the room. 10/10/2023 8:00 a.m. Physician notified, received order to send resident #1 to the emergency room for evaluation and treatment. 10/10/2023 12:30 p.m. X-ray revealed resident #1 had a broken nose. Resident #1 had no recollection of what had happened. Review of resident 1's x-ray report dated 10/10/2023 at 9:12 a.m. revealed the following results: Findings: Fracture of the left nodes of bone with 1 millimeter medial displacement and medial angulation. Right lateral nasal septal deviation. Degenerative changes cervical spine Soft tissues: Soft tissue swelling in the nares. Frontal scalp soft tissue swelling. Sign increased attenuation nasal septum anterior inferiority. Impression: Fracture of the right and left nasal bones with associated soft tissue swelling. Thickening of nasal septum correlate for nasal septal hematoma. Review of resident #1's CT (Computerized Tomography) of brain done on 10/10/2023 revealed the following: Impression: Nasal bone fractures Review of resident #2's medical record revealed an admitted [DATE] with a diagnosis of but not limited to attention concentration deficit, major depressive disorder, unspecified dementia and Parkinson's disease. Review of resident #2's MDS dated [DATE] revealed a BIMS score of 00 indicating severely impaired cognition. Review of resident #2's Comprehensive Care Plan dated 08/25/2023 revealed; Violence, Risk for related to Psychosis, Depression approaches included: allow for quality time to communicate ,provide reality orientation during waking hours, remove objects from the immediate environment that could be used to harm self or others, provide close supervision and watch for early signs of agitation or increasing anxiety and report, psychiatric evaluation per doctor's order, provide medications as ordered and monitor effectiveness of prescribed medication used in controlling aggressive behavior and assisting to remain calm, monitor for side effects of antipsychotic medication and record. Combative Behavior approaches included: 1:1 supervision for 14 days, approach resident warmly and positively, Provide consistency with direct care providers on all shift, allow resident opportunity to make choices and participate in cares. Do not argue with resident, elicit family input for best approach to resident, social service to evaluate and visit with resident, praise resident for demonstrating desired behavior, monitor and documents resident behaviors, administer behavior medications as ordered by physicians, review drug regime at least monthly and evaluate for dosage reduction and document findings. Review of the facility's incident report dated 10/10/2023 7:30 a.m. revealed S4 LPN was called to the dementia unit and upon arriving saw resident #2 sitting with blood on his right hand. S3 CNA informed S4 LPN of resident #2 standing over resident #1 with his fists balled up and blood on his right hand. S4 LPN asked resident #2 if he had hit another resident and resident #2 stated, he deserved it. S4 LPN then asked resident #2 why did the other resident deserve it and resident #2 stated, he was in my bed and I want him out of my home. Review of resident #2's Incident/Accident Nurses Notes revealed: 10/10/2023 7:30 a.m. S4 LPN was called to the dementia unit. Resident #2 was found sitting in the dementia unit dining area with blood on his right hand. S3 CNA informed S4 LPN of resident #2 standing over resident #1 with his fists balled up and blood on his right hand. S4 LPN asked resident #2 if he had hit another resident and resident #2 stated,He deserved it. S4 LPN then asked resident #2 why did the other resident deserve it and resident #2 stated, he was in my bed and I want him out of my home. During an interview on 10/30/2023 at 3:30 p.m. S3 CNA stated, I was in the hallway and I heard some noise in resident #1's room and when I went to open to door, resident #2 hit me in the face. I told resident #2 to come out of the room and resident #2 went down to the dayroom and another CNA sat with him. When I went into resident #1's room I saw resident #1 sitting on the bed holding his head with blood on his face. I told the S4 LPN and she came and assessed resident #1. Resident #1 was sent to the hospital. Resident #2 was put on one on one supervision until they sent resident #2 to the behavioral hospital. During an interview on 10/30/2023 at 1:40 p.m. S4 LPN reported resident #1 lived on the dementia unit and was resident #2's roommate. S4 LPN stated, I was told resident #2 had hit resident #1 by S3 CNA. I went down and got resident #2 to go to the dayroom to be monitored one on one. When I assessed resident #1, I noticed him holding his nose with blood dripping from it. Resident #1 told me in reference to resident #2, He hit me in my nose. Resident #1 was sent out to the hospital. Resident #1 returned to the facility the same day with a diagnosis of a broken nose. During an interview on 10/31/2023 at 8:00 a.m. S2 DON (Director of Nurses) reported S4 LPN called and told me resident #2 had hit resident #1 by S3 CNA. S2 DON confirmed resident #1's nose was broken as a result of resident #2 hitting resident #1. During an interview on 11/01/2023 at 10:00 a.m. S1 Administrator confirmed resident #1 was hit by resident #2. S1 Administrator further confirmed resident #1's nose was broken as a result of the altercation.

Based on record review and interviews, the facility failed to provide equal access to quality care regardless of payment source for 1 (#1) of 5 (#1 - #5) residents reviewed for therapy services or potential therapy services. Findings: Review of the medical record revealed resident 1 was admitted from home to the facility on [DATE] with diagnoses of Alzheimer's disease, major depression, hyperlipidemia, hypertension, diabetes, and psychosis. Further review revealed her payer source was Vantage Medicare Advantage (Health Maintenance Organization). Review of the physician orders for March and April 2023 revealed there was not a physician order for therapy. Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The resident was incontinent of bowel and bladder. The resident had no falls noted. An interview with S3Therapy Director on 05/09/2023 at 1:15 p.m. revealed resident 1's family member asked one of the therapist if resident 1 could receive therapy. S3Therapy Director revealed the family member was informed that the facility would need to get prior approval for therapy. S3Therapy Director revealed she notified S2Business Office Manager that resident 1's family member would like for resident 1 to receive therapy. An interview with S2Business Office Manager on 05/10/2023 at 11:00 a.m. revealed she was notified that resident 1's family member would like for resident 1 to receive therapy. S2Business Office Manager confirmed she did not send the request for prior authorization for therapy to the insurance company. S2Business Office Manager further confirmed the family was not given the option of paying for therapy services out of pocket if the insurance company denied the services. An interview with S1Administrator on 05/10/2023 at 11:45 a.m. confirmed the Business Office Manager should have sent the request for therapy services to the resident's insurance and if denied by the insurance company, there should have been an option offered to the resident/responsible party to personally pay for the therapy services.

Based on observations and interviews the facility failed to provide housekeeping and maintenance services necessary to ensure a safe, clean, comfortable and homelike environment in good repair for 5 residents rooms and hallway (Hall A, Room A, Room B, Room C, Room D, and Room E) observed during the initial facility Observation. This had the potential to affect the 12 residents residing on the locked unit and 78 residents residing in the general facility. Findings: Observations of the facility on 12/12/2022 at 10:00 a.m. revealed the following environmental issues: Hall A containing rooms A,B and C: 1. 4 ceiling tiles located in the hallway with large dark brown and black fuzzy stains nearly covering the entire ceiling tile with 2 of the tiles bulging. Room A: 1. Room in disrepair with baseball sized holes in the plaster walls 2. Closet door approximately 1 foot up with dark brown stain 3. Bathroom toilet tank with no lid 4. One large brown crawling, roach like appearance insect crawling on the floor 5. Very strong smell of urine Room B: 1. Closet missing a light bulb with and empty exposed socket 2. No pull cord for the closet light 3. Bathroom floor wet and dirty with wet toilet paper stuck to the wall Room C: 1. Closet light with no pull cord 2. Bathroom floor wet and dirty Room D: 1. Closet door missing outer door knob with exposed door knob stump. 2. Dirty diaper in the bathroom floor with dinner plate sized wet area 3. Food crumbs on the floor Room E: 1. Red Emergency plug located near the floor on the wall near the head of the resident's bed with oxygen in use, was bent and hanging out of the wall exposing wires. During an accompained observation on 12/12/2022 at 11:00 a.m. S4 Certified Nursing Assistant (CNA) confirmed there was a large brown crawling, roach like appearance insect crawling on the floor in Room A, and the bathrooms in Room B and Room C were wet and dirty and needed to be cleaned. During an interview on 12/12/2022 at 11:05 a.m. S5 CNA reported the process when things needed repair was to notify Maintenance and put it on the clip board located at the nurses station. S5 further acknowledged she could not remember if she had notified maintenance of the needed repairs on Hall A. On 12/12/2022 at 1:00 p.m. an environmental tour was conducted with S3 Maintenance who verified the following observations: Hall A containing rooms A,B and C: 1. 4 ceiling tiles located in the hallway with large dark brown and black fuzzy stains nearly covering the entire ceiling tile with 2 of the tiles bulging. Room A: 1. Room in disrepair with baseball sized holes in the plaster walls 2. Closet door approximately 1 foot up with dark brown stain 3. Bathroom toilet tank with no lid 4. One large brown crawling, roach like appearance insect crawling on the floor 5. Very strong smell of urine Room B: 1. Closet missing a light bulb with and empty exposed socket 2. No pull cord for the closet light 3. Bathroom floor wet and dirty with wet toilet paper stuck to the wall Room C: 1. Closet light with no pull cord 2. Bathroom floor wet and dirty Room D: 1. Closet door missing outer door knob with exposed door knob stump. 2. Dirty diaper in the bathroom floor with dinner plate sized wet area 3. Food crumbs on the floor Room E: 1. Red Emergency plug located near the floor on the wall near the head of the resident's bed with oxygen in use, was bent and hanging out of the wall exposing wires. During an interview on 12/12/2022 at 1:00 p.m. S3 Maintenance acknowledged the housekeeping and maintenance issues had not been fixed and should have been.

Based on record reviews and interview the facility failed to ensure residents and/or the resident's representative received written information regarding advanced directives for 5 residents out of 6 (#5, #6, #12, #55, #58, #78) residents reviewed for advanced directives. Findings: Review of Resident #5's medical record revealed an admitted [DATE]. Further review of Resident #5's medical record failed to reveal documentation that the resident and/or the resident's representative received written information regarding advanced directives. Review of Resident #6's medical record revealed an admitted [DATE] with a re-admitted [DATE]. Further review of Resident #6's medical record failed to reveal documentation that the resident and/or the resident's representative received written information regarding advanced directives. Review of Resident #55's medical record revealed an admitted [DATE] with a re-admitted [DATE]. Further review of Resident #55's medical record failed to reveal documentation that the resident and/or the resident's representative received written information regarding advanced directives. Review of Resident #58's medical record revealed an admitted [DATE]. Further review of Resident #58's medical record failed to reveal documentation that the resident and/or the resident's representative received written information regarding advanced directives. Review of Resident #78's medical record revealed an admitted [DATE]. Further review of Resident #78's medical record failed to reveal documentation that the resident and/or the resident's representative received written information regarding advanced directives. During an interview on 12/13/2022 at 1:22 p.m. S1 Director of Nursing reviewed Resident #5, #6, #55, #58, and #78's medical records and confirmed there was not documentation that the resident and/or the resident's representative received written information regarding advanced directives and acknowledged there should have been.

Based on record review, observation and interviews the facility failed to ensure personal privacy for 1 (#33) out of 8 (#66, #10, #83, #78, #11, #33, #45, #36) residents reviewed for ADL (Activities of Daily Living) care for a dependent resident. Findings: Review of facility's Confidentiality of Information and Personal Privacy policy revealed (in part) Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation: 2. The facility will strive to protect the resident's privacy regarding his or her medical treatment and personal care. Observation on 12/13/2022 at 1:45 p.m. revealed S9 CNA (Certified Nurse Assistant) exiting Resident #33's room. Observation revealed Resident #33 exposed and fully visible to hallway in bed uncovered, revealing resident to be undressed with just an adult brief on and covering her breast with her hands. Upon entering Resident #33's room revealed the blinds were open. S9 CNA failed to close the blinds, cover resident and close the door when exiting Resident #33's room. During an interview on 12/13/2022 at 1:45 p.m. S9 CNA reported she stepped out of Resident #33's room to find staff to assist with repositioning Resident #33. S9 CNA confirmed Resident #33 was undressed and uncovered when she exited Resident #33's room leaving the door open. S9 CNA confirmed Resident #33 should have been covered before exiting the room and closed the door when she exited the room for Resident #33's personal privacy. During an interview on 12/13/2022 at 2:00 p.m. S8 LPN (Licensed Practical Nurse) reported the blinds should have been closed and Resident #33 should have been covered when S9 CNA opened the door to Resident #33's room. During an interview on 12/14/2022 at 10:50 a.m. S2 ADON (Assistant Director of Nursing) confirmed the blinds should be closed and residents' doors should remain closed when providing personal care for residents.

Based on record reviews, observations, and interviews the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#66) of 2 (#6, #66) residents reviewed for pressure ulcers out of 21 total sampled residents. The facility failed to ensure a dressing was applied to #66's pressure ulcer. Findings: Review of Resident #66 Medical Records revealed admitted [DATE] with the following diagnoses, in part: Stage 4 pressure ulcer to left buttocks, muscle wasting and atrophy, Type 2 Diabetes Mellitus with hyperglycemia and diabetic neuropathy, and acquired absence of right leg above knee. Review of Resident #66 December 2022 Physician's Order dated 9/14/22 - cleanse stage 4 pressure to left buttocks with wound cleanser, loosely fill tunneling with idoform packing strip, then CA (calcium) alginate with silver to wound bed, then 4x4 and dry dressing QD (everyday) until healed. Observation on 12/13/2022 at 9:35 a.m. revealed during peri care Resident #66's wound to left buttock did not have a dressing in place. During an interview on 12/13/2022 at 9:37 a.m. S10 CNA (certified nursing assistant) reported she had changed Resident #66 earlier in the day and the dressing was off and she had not reported it to the nurse and should have. During an interview on 12/13/2022 at 9:55 a.m. S11 ADON (assistant director of nursing)/WCN (wound care nurse) reported the dressing for wound to left buttock should have been in place and was not. S11 ADON/WCN further reported she had not been notified that Resident #66's dressing to left buttock wound had come off.

Based on observation, record review and interview the facility failed to ensure 1 (#78) of 1 (#78) residents reviewed for accidents received adequate supervision to prevent accidents/falls. The facility failed to ensure Resident #78 received supervision while in a wheelchair. Finding: Review of the Accident/Incident Report for 11/2022 revealed Resident #78 had a fall on 11/16/22 on the day shift, her forehead sustained a bruise/hematoma and Resident #78 was transferred to the emergency room . Review of Resident #78s Physician Orders dated 11/16/22 revealed an order to: Keep resident at the nurse's station in view of staff when up in wheelchair every shift. Observation on 12/12/22 at 9:00 a.m. revealed Resident #78 sitting in high back wheelchair in resident room. Resident had padded lap tray in place and resident was leaning forward pushing lap tray away from her body. Observation on 12/12/22 at 11:00 a.m. revealed Resident #78 sitting in high back wheelchair in resident room. Observation on 12/12/22 at 3:30 p.m. revealed Resident #78 sitting in high back wheelchair in resident room. During an interview on 12/13/22 at 2:30 p.m. S10 LPN (licensed practical nurse) reported Resident #78 does try to move the padded lap tray and get out of the wheelchair. During an interview on 12/13/22 at 2:25 p.m. S10 LPN acknowledged one of the interventions following Resident #78's fall on 11/16/22 was to keep resident #78 at the nurses station while in the wheelchair and she failed to do so.

Based on observations and interviews, the facility failed to ensure failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 1 (#70) out of 1 (#71) resident reviewed for respiratory care out of a total of 21 sampled residents. The facility failed to ensure humidifier bottle was changed and dated weekly and the filters were clean. Findings: Review of Resident #70 December 2022 Physician's Orders: 11/03/22 - Change O2 (oxygen) tubing Q (every) week on Friday prn (as needed) usage Observation on 12/12/22 at 9:15 a.m. revealed Resident #70 sitting up in wheelchair with continuous oxygen at 2LPM (liters per minutes) via nasal cannula. Further observation revealed two filters on oxygen concentrator with gray particles noted and humidifier bottle dated 12/02/22. Observation on 12/13/22 at 9:20 a.m. revealed Resident #70 lying in bed wearing continuous oxygen via nasal cannula. Further observation revealed two filters on oxygen concentrator with gray particles noted and humidifier bottle dated 12/02/22. During an interview on 12/12/22 at 9:35 a.m. and observation accompanied by S6 LPN (licensed practical nurse) confirmed Resident #70's humidifier bottle dated 12/02/22 and should have been changed every week and the filters should have been cleaned.

Based on record review, observations, and interviews, the facility failed to ensure 1 (Resident #1) of 17 (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) residents reviewed for impaired cognition with a diagnosis of Dementia or Alzheimer's Disease and the potential to elope was adequately supervised to prevent elopement from the facility. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on 09/24/2022 at 4:20 p.m. when Resident #1 exited through the front door of the facility unsupervised. Resident #1 had a diagnosis of Dementia and a documented history of intermittent confusion and wandering behavior. The facility failed to assess Resident #1 as an elopement risk and did not supervise Resident #1 to prevent Resident #1 from eloping. Resident #1 has not been located and has the likelihood of serious injury, harm or death. S3 DON (Director of Nurses) was notified of the Immediate Jeopardy on 10/07/2022 at 10:49 a.m. The Immediate Jeopardy was removed on 10/07/2022 at 5:01 p.m. when the following facility Plan of Removal was approved: 1. Resident #1 left the faciity on [DATE] at 4:40 p.m. and has not been found. All residents who have an impaired cognition have the potential to be affected. 2. Wandering/elopement risk assessments were performed on all residents on 10/06/2022. The facility noted 16 residents (12 are on the Alzheimer's Unit) at risk for wandering/elopement. Residents who were identified to have an elopement/risk were placed on monitoring whereabouts for wandering every hour (located on MARs [Medication Administration Records]) on 10/7/22. A door alarm (sounds when doors are opened) was placed on the front entrance of the facility on 9/25/22. All exit door codes were changed on 10/7/22 at 1:00 p.m. and will be changed weekly. All exit doors will be inspected daily to ensure doors are working properly. Maintenance director ensured all exit doors had appropriate instructional signage (please don't hold door open; exit only) and inspected all doors on 10/7/22. An in-service was held on 10/7/22 and 10/7/22 with all staff discussing monitoring of exit doors, ensuring instructional signage, and reporting any defective doors to Maintenance director or NFA immediately. 3. Maintenance director or designee will inspect all exit doors daily (including weekends) to ensure they are working properly. Front entrance door alarm and instructional signage will be inspected daily x 2 weeks, then 3x/week x 2 weeks, then randomly thereafter x 2 months. NFA (Nursing Facility Administration) will in-service all staff again on 10/25/22 and then each quarter for reporting defective equipment. DON (Director of Nursing) or designee will monitor MARs & nurses' notes 3x/week x 4 weeks, then 1x/week x 4 weeks, then randomly thereafter x 2 months to ensure any residents with potential for wandering/elopement are assessed and interventions are completed. All prn (as needed) and agency staff will be in-serviced at the beginning of their shift, starting on 10/7/22 and completed by 10/11/22. Implementation date 10/7/22 This deficient practice continued at a potential for harm for 14 current residents who did not reside on the locked Dementia Care Unit, had a diagnosis of Dementia and/or Alzheimer's Disease with severe or moderate cognitive impairment, and were able to either ambulate or propel themselves in their wheelchairs throughout the facility with the potential to elope (#3, #6, #7, #8, 9, #10, #11, #12, #13, #14, #15, #16, #17, #18). Findings: Review of the facility's Wandering, Unsafe Resident policy revealed in part: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Review of the facility's Dementia-Clinical Protocol policy revealed in part: .as part of the initial assessment, they physician will help identify individuals who have been diagnosed as having dementia or otherwise irreversibly impaired cognition .if a psychiatric consultant is called to help manage behavioral issues in the individual with dementia, the IDT (Interdisciplinary team) will retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that affect mood, cognition, and function, monitoring for complications related to treatment and evaluating progress .The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician. Review of the facility's Elopement policy revealed in part: .Staff shall investigate and report cases of elopement. Definitions-Elopement-an act or instance of leaving a safe area or premise done by a resident with a mental disorder or decrease in cognitive function .It is the resident's right to leave the facility at any time and refuse all treatments prescribed by a physician or practitioner. Staff is to consider resident's cognitive function and/or impairment when making decisions and document any decline in the medical record. Staff shall promptly report any cognitive impaired residents who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. If an employee observes a cognitive impaired resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner, get help from other staff members in the immediate vicinity, if necessary, and instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises . Review of the facility's Risks Assessments policy revealed in part: The facility will identify residents who are at risk according to the risk assessments listed in this policy .MDS nurse or charge nurse will complete .Wandering/Elopement Risk-risk assessment to determine all residents who are admitted on the Alzheimer's and Related Disorder Unit (ARDU) wandering and elopement status. Nurses will monitor resident's mood and behaviors each shift and if any resident, (who does not reside on the ARDU) is noted to be a wanderer, then a wandering/elopement assessment will be completed. Resident #1: Review of Resident #1's record revealed an admitted [DATE], a discharge date of [DATE]. Diagnoses included Unspecified dementia with behavioral disturbance, Insomnia, and Major depressive disorder. Review of Resident #1's physician's orders revealed orders including: 08/01/2021-monitor mood and behaviors every shift 10/08/2021-zoloft 75milligra.m.s (mg) every day, monitor side effects 10/07/2021-Namenda 10 mg twice a day for unspecified Dementia, unspecified severity with behavioral disturbance 10/18/2021-Referral for Mental Health Services-Uncertain if resident is cognitively appropriate-refer for both psychiatry and psychotherapy. Review of Resident #1's MDS (Minimum Data Set) Assessments revealed the following Cognitive Assessments: Admit MDS with Assessment Reference Date (ARD) of 10/20/2021-BIMS (Brief Interview for Mental Status) score=6 indicating severe cognitive impairment. Disorganized thinking was continuously present, did not fluctuate. Quarterly MDS with ARD of 01/11/2022-BIMS score=6 indicating severe cognitive impairment. Disorganized thinking was continuously present, did not fluctuate. Quarterly MDS with ARD of 04/11/2022-BIMS score=6 indicating severe cognitive impairment. Disorganized thinking was continuously present, did not fluctuate. Quarterly MDS with ARD of 07/05/2022- BIMS score=6 indicating severe cognitive impairment. Disorganized thinking was continuously present, did not fluctuate. Annual MDS with ARD of 09/21/2022-BIMS=12, no inattention, no disorganized thinking, no altered LOC. This BIMS was entered into the electronic chart on 10/03/2022 at 1:22 p.m. and was not available to staff on 09/24/2022 when the resident eloped. During an interview on 10/03/2022 at 3:33 p.m. S4 MDS Nurse reviewed resident #1's MDS assessments from 10/20/2021, 01/11/2022, 04/11/2022, 07/05/2022, and 09/21/2022. S4 MDS Nurse confirmed all assessment showed Resident #1's BIMS scores as being 6 indicating severe cognitive impairment up until 09/21/2022 which showed BIMS of 12 indicating moderate cognitive impairment. During an interview on 10/03/2022 at 3:33 p.m. S5 MDS Nurse reported if you hover the computer mouse over any MDS section in the electronic chart, it showed who completed the section and when. S5 MDS Nurse hovered the mouse over resident #1's 09/21/2022 annual MDS Section C and indicated it was completed by S3 DON on 10/03/2022 at 1:22 p.m. Both S4 MDS Nurse and S5 MDS Nurse reported they could not explain the change in the BIMS score since the BIMS interview was conducted by S3 DON. After further review of the electronic and paper chart, the surveyor was unable to locate any Wandering Risks Assessment performed on Resident #1. Review of Resident #1's Comprehensive Care Plan revealed the resident was care planned for a potential for impaired thought processes and impaired communication related to diagnoses of dementia and depression. Further review revealed no problems or interventions related to wandering behavior. Review of Resident #1's Physician Notes revealed notes including: 11/16/2021 by S7 MD (Medical Doctor) -Poor historian, lived with girlfriend, displaced due to hurricane, minimal family support. The patient is unable to provide the information, family is not available .Review of Systems mostly obtained from staff due to patient's cognition . +Dementia .06/28/2022 by S7 MD- .Alert, calm, and cooperative during assessment, pleasantly confused at times, Alzheimer's Dementia with insomnia-progressive-continue with supportive care. Review of Resident #1's MDB Behavioral Health Services Psychiatric Evaluation dated 09/15/2022 by S22 PMHNP-BC (Psychiatric Mental Health Nurse Practitioner-Board Certified) revealed the resident had poor insight, impaired attention/concentration, was oriented to self only, impaired fund of knowledge, loose association, impaired judgment, impaired insight, impairment short-term memory, and abnormal thoughts/hallucinations. Visit summary notes indicated the resident endorsed some sadness, anxiety and audio-visual hallucinations. Staff had reported the resident used to pack his packs daily to go home when he was on other hall. Client was reported to get upset but was always able to be redirected. Staff reported that client was observed walking the hall crying and then moments later was happy. Review of Resident #1's nursing notes revealed notes including: 01/14/2022 1:29 p.m. by S28 LPN (Licensed Practical Nurse) -Resident is alert, confused and cooperative. His LTM (Long Term Memory) is intact .ambulates about the facility per self without assist . he is able to follow simple commands but has a difficult time making decisions . 01/14/2022 4:51 p.m. by S25 LPN- .Impaired STM (Short Term Memory) and often needs to be redirected. Easily agitated at times due to frustration and repetitive reminders. Ambulates ad lib (as desired) without assistive devices .Monitored frequently due to wandering. 01/15/2022 10:00 a.m. by S18 LPN- Confusion noted . 01/18/2022 2:24 p.m. by S25 LPN- .alert and aware with intermittent confusion noted .wandering needing frequent redirecting . 01/19/2022 1:41 p.m.by S28 LPN Resident is alert, cooperative and confused .stated he's waiting to board his flight . 03/07/2022 at 3:06 a.m. by S25 LPN .can be vocal but conversation can be confused and incomprehensible. STM/LTM is impaired with resident forgetting what he did just a short while ago, can't recall past and rarely call names or speaks of family members. Dresses and [NAME] self .ambulates ad lib with a steady stride and gait . 04/07/2022 2:54 a.m. by S25 LPN- .Alert and oriented to person and situations with forgetfulness and cognitive impairment . able to follow simple instructions with guidance .STM/LTM impaired .ambulates independently with steady gait and balance . 05/07/2022 5:32 a.m. by S25 LPN- alert and aware with forgetfulness and confusion at times .anxious and easily cries when he is in a state of forgetfulness and confusion .easily redirected. 06/07/2022 5:58 a.m. by S25 LPN - .Intermittent confusion is noted with resident sometimes thinking and verbally saying that he has to get out of here to catch a boat for work and everybody is leaving him. Easily redirected and guided back to his room but it doesn't last long (repetitive scene of walking back and forth.) 07/07/2022 3:49 a.m. by S25 LPN . STM/LTM is impaired with confusion and delusions noted at times. Sometimes it is difficult to understand what resident is trying to relate due to incoherent speech, anxiousness, and agitation . 08/07/2022 6:01 a.m. by S25 LPN- .intermittent confusion at times .sometimes incoherent/ramble when anxious or confused. STM/LTM impaired requiring continuing instructing and redirecting .ambulatory ad lib usually wandering and pacing . 08/28/2022 6:06 a.m. by S25 LPN Resident usually disoriented in the morning needing cueing and instructions to get going .ambulates ad lib usually wandering and pacing . 09/14/2022 1:24 p.m. by S28 LPN-resident is alert, confused and cooperative. His Long Term Memory is intact.ambulates about the facility per self without assist. Steady gait noted. He is able to follow simple commands, but has a difficult time making decisions. 09/21/2022 4:42 p.m. by S6 LPN: Resident is ambulatory to self in hall asked if he would like to watch TV in the day room with other residents and he states yea, sure, assisted to day room. No distress noted at this time, will continue to monitor. Further review of nursing notes revealed no other notes prior to the resident leaving the facility. Review of nursing notes after the resident left the facility included: Note dated 09/24/2022 at 5:30 p.m. by S18 LPN . S21 Receptionist stated that another resident saw resident outside window walking towards apartments. Staff immediately started searching for resident. Staff searched every room and bathroom in its entirety and searched the grounds with no success. Resident was previously seen by staff ambulating around facility. Camera reveals another family member let resident out at 4:21 p.m. Resident was seen on camera almost sprinting after he left out the front door. Resident is self-responsible. This nurse notified DON administrator, and informed to call police. Staff and police along with DON started searching throughout the town and on interstate with no success. _____ police and _____ sheriff Office notified of description of resident and what he was wearing and given a picture of resident. This nurse called police department to get update. Police department were continuing to search for resident. This nurse questioned staff and other residents on if resident stated he was leaving. Other residents voiced they heard resident saying he was getting the hell out of here and going back down south. This nurse checked resident sign in/out book and resident did not sign self out. This nurse called multiple hospitals in surrounding area and they all stated he was no brought into any of their hospitals . Note dated 09/24/2022 at 5:45 p.m. by S3 DON: Received call from S17 LPN/ADON stating Resident #1 had left the facility AMA (Against Medical Advice) walking. Resident #1 is his own responsible party. This nurse called the facility and nurse on duty, S18 LPN stated she saw resident walking in the hallway within the last hour. She was notified that resident didn't come to supper and went to get him from his room but didn't find him. She and other staff did a complete search of facility and its grounds for resident. One resident (Resident #19) told staff resident had left facility walking. Resident #1 didn't sign out. After speaking to other staff, some of the residents voiced to them that Resident #1 voiced he was getting the hell out of here and going back down south to his home. Resident #1 didn't tell his nurse nor any staff that he was leaving. _____ Parish Sheriff Department and _____ Police department were called to perform a wellness check on the resident due to how he left AMA and didn't let any staff know his location of where he was going. Camera footage reveals resident left out the front door after another family member let him out. Resident was wearing a blue long sleeve shirt with blue colored jeans, and tennis shoes. Generally, resident is able to make needs known and understands others. S 29 LPN called the other resident's family who was present when the resident went out of the door. She stated resident went over the black rails near the apartments and walked on the left side road near the apartments. Resident previously resided down south Louisiana. Staff reports Resident #20 stated resident was going home today even if he had to walk, however Resident #20 didn't tell anyone until after Resident #1 had left the facility. This nurse, along with other staff, and the police searched the entire town, and neighboring towns with no success. All gas stations, restaurants, abandoned building, & grocery stores were searched with no success. MD was notified that resident left facility AMA . Note dated 09/25/2022 at 3:00p.m. by S3 DON- .Resident #1's Family Member voiced that he is not surprised resident left as this is his norm. Resident #1's Family Member was informed that resident left facility AMA and we are still searching for him along with local and _____ parish police. Resident is still not found. Resident #1's Family Member states he probably has hitched back a ride with someone as he is known to do this in the past. Resident #1's Family Member stated he is smooth talker and when he sets his mind to do something that is what he does . Note dated 09/25/2022 at 4:30 p.m. by S18 LPN: S3 DON spoke with Resident #1's Family Member who reported he doesn't have any money so he might be trying to hitch hike down here. Note dated 09/26/2022 at 10:00 a.m. by S3 DON . Resident #1's female companion voiced that resident can be very manipulative and probably hitched a ride with someone .spoke with police who are still looking for resident. All local hospitals contacted with no success. Note dated 09/27/2022 at 9:00 a.m. by S3 DON-called police department for an update with no success. Resident #1's female companion stated he still hadn't made it to South Louisiana where he used to live. Police were made aware. Note dated 9/28/2022 at 3:00 p.m. by S3 DON-no update on whereabouts from police department. An Against Medical Advice form dated 09/24/2022 was in Resident #1's paper chart, and indicated the resident left without signing See Nurse's notes. Review of Resident #1's unsigned Discharge Summary dated 09/24/2022 (place for Nurse Signature left blank) revealed it was documented the resident left AMA and Police were called to do a wellness check. Review of the facility's Sign in Book with Patient Check-Out revealed no record of Resident #1 signing himself out. Review of the _____ Police Department report #2022-09-16IR dated 09/30/2022 revealed incident start date 09/24/2022 at 6:30 p.m. and end date of 09/24/2022 at 6:45 p.m. Type Missing Persons, Persons Involved=Resident #1. Narrative: S18 LPN reported that a patient Resident #1 had left the facility and had not returned. _____ Police Department) and _____ Parish Sheriff Office officer searched the area for hours without locating the subject. Resident #1's information was placed in NCIC (National Crime Information Center.) S30 _____ Police Officer. A Voluntary Statement Form and a Picture of Resident #1 were attached to the report. Review of Voluntary Statement Form attached to the police report dated 09/24/2022 by S18 LPN: This is my voluntary statement concerning the incident under investigation: Resident #1 DOB (Date of Birth) xx/xx/xxxx, SSN (Social Security Number) xxx-xx-xxxx, at approximately 4:21 p.m. resident was seen on camera wearing a long sleeve blue button up shirt, blue jeans, and black tennis shoes leaving out the front entrance of the facility. Resident #1 has been a resident at the facility since 10/07/2021. He has a diagnosis of dementia. Review of facility maintenance logs with door checks from 08/01/2022 to 09/25/2022 revealed no monitoring of doors had been done on Saturdays and Sundays. Review of the facility's video footage from multiple cameras with S20 Maintenance Director from 09/24/2022 at 4:00 p.m. to 09/24/2022 at 5:45 p.m. revealed in part: 4:15 p.m. S21 Receptionist seen sitting at the desk at the main nursing station. 4:17 p.m. A visitor was seen walking down the hallway and out the front door by having S21 Receptionist push the button to allow the door to open. The visitor went to the left of the door. 4:20:33 p.m. from the camera directly in front of the main nursing station, Resident #1 walked into view straight past nursing station looking straight ahead with no pauses. S21 Receptionist was looking at her cell phone, and never pushed the button to allow the front door to open. Resident #1 continued walking at a brisk pace with no pauses down the hall and straight out the front door. Further observation revealed no staff looked at the front door to see who went out the door. 4:20:58 p.m. Resident #1was seen walking out front door, turned before reaching the steps that lead to the parking lot and headed west. 4:21:35 p.m. from camera outside Hall B westerly facing toward apartments: Resident #1 came into view and was seen walking down the street of the parking lot heading towards the main road and out of view. 4:21:51 p.m. S21 Receptionist was in her chair looking at her cell phone. Review of facility Inservice Records revealed no inservices related to the wandering resident or elopement after Resident #1 eloped from the facility on 09/24/2022. During an interview on 10/03/2022 at 3:45 p.m. S6 LPN indicated she had worked in the facility for 10 months and was familiar with Resident #1. S6 LPN indicated the resident's mental ability included intermittent confusion, was able to ambulate without assistance. During a telephone interview on 10/04/2022 at 9:53 a.m. Resident #1's female companion indicated she last spoke with the resident about a month ago. Resident #1's female companion indicated this would have been about 2 weeks before he walked out of the facility. When she asked him what he did do to keep himself busy here he told her right now we're trying to take the water out of the ocean, but we don't have anywhere to put it. Resident #1's female companion indicated she could ask him a question and before you knew it he was talking about something else. She also reported the resident was a smooth talker when he was in his right mind and could talk anyone into doing anything. Resident #1's female companion further reported she had not heard from the resident and still did not know where he was. During a telephone interview on 10/04/2022 at 10:21 a.m. Resident #1's Family Member reported to his knowledge the resident did not have identification or a cell phone with him. Resident #1's Family Member indicated he came to visit the resident about 2 weeks before he went missing. Resident #1's Family Member confirmed the resident had dementia and talks a little off the wall sometimes, goes back in time. Resident #1's Family Member was unsure if Resident #1 would remember what his address was. He reported the resident was in and out of real time and was all over the place in time. Resident #1's Family Member reported Resident #1 knew he was in a nursing facility, but thought he was still in his home town area. Resident #1's Family Member told him he was about 6 hours or 350 miles from home. Resident #1's Family Member reported the facility told him Resident #1 had left all of his things at the facility and left with only the clothes he was wearing. During an interview in the hallway on 10/04/2022 at 1:23 p.m. Resident #21 was cognitive, and reported he remembered Resident #1. Resident #21 said Resident #1 was a sweet guy, a sensational guy, his mind would just come and go. Resident #21 indicated the resident never said anything to him about wanting to leave the facility. During a telephone interview on 10/04/2022 1:34 p.m. S7 MD (Medical Doctor) said ooh the runaway. S7 MD reported if you met Resident #1 in the grocery store he was capable of holding a conversation, capable of calculating and planning something, looked like a normal guy who you wouldn't think lived in a nursing home. S7 MD was not sure if Resident #1 had the mental ability to be able to make it to Houma on his own. During an interview on 10/04/2022 at 1:41 p.m. S8 CNA indicated she was working hall A and hall B on 09/24/2022. S8 CNA reported she was part of the search looking for Resident #1, and S3 DON had everybody looking. S8 CNA reported other people in the facility (she could not recall who) said he had tried to get out before, but she never seen him try. During an interview on 10/04/2022 at 1:50 p.m. S9 CNA reported she was not working the day Resident #1 walked out of the building. S9 CNA reported she had received no inservices on the wandering resident or elopement since Resident #1 walked out of the building. During an interview on 10/04/2022 at 1:56 p.m. S10 CNA/Transportation Clerk reported she was not working when Resident #1 left the building. S10 CNA/Transportation Clerk reported she had received no inservices on the wandering resident or elopement since Resident #1 walked out of the building. During an interview on 10/04/2022 at 2:07 p.m. S11 NP (Nurse Practioner) indicated she was familiar with Resident #1. S11 NP confirmed Resident #1 had a dementia diagnosis. S11 NP reported she did not think Resident #1 could take care of himself outside of the facility, and he would be at high risk if he walked out. S11 NP expressed that she was concerned for Resident #1, concerned for his safety, and did not think he was capable of living on his own. During an interview on 10/04/2022 at 2:26 p.m. S12 CNA reported he was not working the day resident left. S12 CNA further reported everybody has been concerned that Resident #1 was missing, and everybody was in an uproar. S12 CNA indicated he had not had any inservice training on the wandering resident or elopement since the Resident #1 walked out of the building. During an interview on 10/04/2022 at 2:34 p.m. S13 CNA indicated to her knowledge there have been no trainings on elopement, wandering residents, or a resident leaving without signing out since Resident #1 walked out. During an interview on 10/04/2022 at 2:43 p.m. S14 CNA indicated she was familiar with Resident #1 and was working the when he was discovered missing. S14 CNA indicated she had not been told by him or any other residents that he was going to leave, and had never heard him talk about leaving. S14 CNA reported she was working with an Agency CNA who discovered at around 4:30 p.m. that Resident #1 was not in his room and had not shown up to the dining room. S14 CNA reported she let the nurse know and they immediately started looking for him inside and outside the building. S14 CNA reported the last time she had seen Resident #1 she was on 09/24/2022 at about 3:00 p.m. when she was checking on another resident a few rooms away from his. S14 CNA reported staff searched all around the facility and in all the rooms. S14 CNA indicated Resident #1 had never seemed confused to her and was able to carry on a conversation coherently. S14 CNA confirmed all of Resident #1's clothing was left in his room. S14 CNA further indicated she was worried about Resident #1 because him leaving was out of character for him and was very concerning. During an interview on 10/04/2022 at 3:05 p.m. Resident #19 was cognitive, and indicated Resident #1 would sometimes come to his room to visit. Resident #19 then admitted he saw Resident #1 walking slowly down the road (pointing westward) outside the building from his window on a Saturday a few weeks ago. Resident #19 indicated everyone was looking for Resident #1 later but they never did find him. During an interview on 10/04/2022 at 3:15 p.m. Resident #22 was cognitive, and reported talking with Resident #1 after lunch the day he left. Resident #22 reported what Resident #1 was saying didn't make any sense. Resident #22 reported Resident #1 didn't tell him he was going to leave, and he never saw him trying to leave. Resident #22 further reported Resident #1 looked kind of regular like he didn't live in a nursing home. During an interview on 10/04/2022 at 3:20 p.m. S17 LPN/ADON (Assistant Director of Nursing) indicated she was the administrative nurse on call the day Resident #1 left. S17 LPN/ADON reported she received a call from S18 LPN who told her they were getting the residents ready for supper and couldn't find Resident #1. S17 LPN/ADON indicated she instructed S18 LPN to call S3 DON and get everybody in the building to start looking for him. S17 LPN/ADON further reported she then called S3 DON and told her she had been notified staff could not find Resident #1. S17 LPN/ADON reported Resident #1 never told her he wanted to leave, and she never knew of him trying to get out. Procedure when a resident was missing was to have everyone working look for them inside and outside the building and then call DON if they could not be located. The normal procedure for a resident who left AMA was for the nurse to complete an AMA form and have a discussion with the resident and the physician. S17 LPN/ADON reported to her knowledge there was no discussion with Resident #1 prior to him leaving, he just left and staff didn't know he was gone. S17 LPN/ADON reported she did not think Resident #1 was able to safely sign him to sign himself out to go to the store period. He wasn't from here and wouldn't know his way around. S17 LPN/ADON indicated Resident #1 walking out of the facility was a Scary situation, where could he be. S17 LPN/ADON reported she assisted with the search for Resident #1 that was still continuing the next day. S17 LPN/ADON indicated she had an inservice about the AMA policy with staff on 09/25/2022, and confirmed there were no inservice trainings on the wandering resident or elopement after Resident #1 walked out of the facility. S17 LPN/ADON further reported she didn't classify it as AMA, S3 DON classified it. S17 LPN/ADON reported they wouldn't call the police and spend 2 days looking for someone who left AMA. During a telephone interview on 10/04/2022 at 3:43 p.m. S18 LPN confirmed she was working as the nurse caring for Resident #1 the day he left. S18 LPN reported they did not know it when Resident #1 left. S18 LPN indicated she was doing a med pass in the dining room when the receptionist told her another resident saw him out their window walking in the parking lot. S18 LPN indicated Resident #1 had never talked to her about wanting to leave. S18 LPN indicated she notified the nurse on call, and instructed CNAs to search every single room, every bathroom, every other room such as the board room, and to search outside. S18 LPN reported she called the police because of the way Resident #1 left for a welfare check. S18 LPN confirmed Resident #1 did not sign himself out. S18 LPN reported she was worried that s [TRUNCATED]

Based on record review, observations, and interviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure 1 (Resident #1) of 17 (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) residents reviewed for impaired cognition with a diagnosis of Dementia or Alzheimer's Disease and the potential to elope was adequately supervised to prevent elopement from the facility. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on 09/24/2022 at 4:20 p.m. when Resident #1 exited through the front door of the facility unsupervised. Resident #1 had a diagnosis of Dementia and a documented history of intermittent confusion and wandering behavior. The facility failed to assess Resident #1 as an elopement risk and did not supervise Resident #1 to prevent Resident #1 from eloping. Resident #1 has not been located and has the likelihood of serious injury, harm or death. S3 DON (Director of Nurses) was notified of the Immediate Jeopardy on 10/07/2022 at 10:49 a.m. The Immediate Jeopardy was removed on 10/07/2022 at 5:01 p.m. when the following facility Plan of Removal was approved: 1. Resident #1 left the faciity on [DATE] at 4:20 p.m. and has not been found. All residents who have an impaired cognition have the potential to be affected. 2. Wander Data Collection Tool risk assessments were performed on all residents on Oct. 6, 2022. The facility noted 16 residents (12 are on the Alzheimer's Unit) at risk for wandering/elopement. Those 16 residents were provided with arm bands that included facility's name, address, and phone number on 10/7/22. An elopement binder (includes all residents identified as wandering/elopement risk face sheet and pictures) was placed at ezch nurses' station on 10/7/22. Residents who were identified to have an elopement/risk were placed on monitoring whereabouts for wandering every hour (located on MARs [Medication Administration Record]) on 10/7/22. An in-service was held with all staff on 10/6/22 and 10/7/22 discussing the updated elopement policy, identifying wandering/elopement risk residents, and intervention during an emergency situation in which a resident elopes. 3. Elopement/wandering policies were updated on 10/7/22 to include wandering/elopement risk to be completed on all new admits on admission and on residents who experiences a change in cognition (immediately then quarterly.) Wander Data Collection Tool will be completed on admission for all residents. Residents identified as a risk for wandering/elopement, the Wander Data Collection =Tool will be completed on admission and each quarter. QA (Quality Assurance) team (consists of department heads) will audit all new admits and current residents at risk for elopement/wandering 3x/week x 4 weeks, then weekly x 4, and randomly thereafter x 2 months to ensure compliance. New admits who are found to be at risk will be immediately added to each elopement binder. QA team will in-service all employees again on 10/25/22 and then each quarter for elopement/wandering and prn any policy changes. All prn and agency staff will be in-serviced at the beginning of their shift, starting on 10/7/22 and completed by 10/11/22. Implementation Date: 10/7/22 This deficient practice continued at a potential for harm for 14 current residents who did not reside on the locked Dementia Care Unit, had a diagnosis of Dementia and/or Alzheimer's Disease with severe or moderate cognitive impairment, and were able to either ambulate or propel themselves in their wheelchairs throughout the facility with the potential to elope (#3, #6, #7, #8, 9, #10, #11, #12, #13, #14, #15, #16, #17, #18). Findings, Cross Reference F689: Review of the facility's Wandering, Unsafe Resident policy revealed: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Review of the facility's Dementia-Clinical Protocol policy in part: a part of the initial assessment, they physician will help identify individuals who have been diagnosed as having dementia or otherwise irreversibly impaired cognition .if a psychiatric consultant is called to help manage behavioral issues in the individual with dementia, the IDT (Interdisciplinary team) will retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that affect mood, cognition, and function, monitoring for complications related to treatment and evaluating progress .The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician. Review of the facility's Elopement policy revealed in part: Staff shall investigate and report cases of elopement. Definitions-Elopement-an act or instance of leaving a safe area or premise done by a resident with a mental disorder or decrease in cognitive function .It is the resident's right to leave the facility at any time and refuse all treatments prescribed by a physician or practitioner. Staff is to consider resident's cognitive function and/or impairment when making decisions and document any decline in the medical record. Staff shall promptly report any cognitive impaired residents who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Review of the facility's Risks Assessments policy revealed in part: The facility will identify residents who are at risk according to the risk assessments listed in this policy .MDS nurse or charge nurse will complete .Wandering/Elopement Risk-risk assessment to determine all residents who are admitted on the Alzheimer's and Related Disorder Unit (ARDU) wandering and elopement status. Nurses will monitor resident's mood and behaviors each shift and if any resident, (who does not reside on the ARDU) is noted to be a wanderer, then a wandering/elopement assessment will be completed. Review of Resident #1's electronic and paper chart on 10/03/2022 to 10/05/2022 failed to reveal any Wandering Risks Assessments performed on Resident #1. Review of Resident #1's Comprehensive Care Plan revealed the resident was care planned for a potential for impaired thought processes and impaired communication related to diagnoses of dementia and depression. Further review revealed no problems or interventions related to wandering behavior. Review of facility maintenance logs with door checks from 08/01/2022 to 09/25/2022 revealed no monitoring of doors had been done on Saturdays and Sundays. Review of video footage from multiple cameras with S20 Maintenance Director from 09/24/2022 at 4:00 p.m. to 09/24/2022 at 5:45 p.m. revealed in part: 4:20:33 p.m. from the camera directly in front of the main nursing station, Resident #1 walked into view straight past nursing station looking straight ahead with no pauses. S21 Receptionist never pushed the button to allow the front door to open. Resident #1 continued walking at a brisk pace with no pauses down the hall and straight out the front door. Further observation revealed no staff looked at the front door to see who went out the door. Review of facility Inservice Records from 01/01/2022 through 10/03/2022 revealed an inservice dated 09/25/2022 related to AMA policy. There were no notes or attachments related to the actual content of the inservice. The inservice was signed by nursing, housekeeping, and dietary staff. There were no further staff inservice records related to the wandering resident or elopement after the resident eloped from the facility on 09/24/2022. During an interview on 10/04/2022 at 1:50 p.m. S9 CNA reported she had received no inservices on the wandering resident or elopement since Resident #1 walked out of the building. During an interview on 10/04/2022 at 1:56 p.m. S10 CNA/Transportation Clerk reported she had received no inservices on the wandering resident or elopement since Resident #1 walked out of the building. During an interview on 10/04/2022 at 2:26 p.m. S12 CNA indicated he had not had any inservice training on the wandering resident or elopement since the Resident #1 walked out of the building. During an interview on 10/04/2022 at 2:34 p.m. S13 CNA indicated to her knowledge there have been no trainings on elopement, wandering residents, or a resident leaving without signing out since Resident #1 walked out. During an in person interview on 10/04/2022 at 3:20 p.m. S17 LPN/ADON (Assistant Director of Nursing) indicated she had an inservice about the AMA policy with staff on 09/25/2022, and confirmed there were no inservice trainings on the wandering resident or elopement after Resident #1 walked out of the facility. S17 LPN/ADON further reported she didn't classify it as AMA, S3 DON classified it. S17 LPN/ADON reported they wouldn't call the police and spend 2 days looking for someone who left AMA. During a telephone interview on 10/04/2022 at 3:43 p.m. S18 LPN reported she called the police because of the way Resident #1 left for a welfare check. S18 LPN confirmed Resident #1 did not sign himself out. S18 LPN reported she was worried that she could not find the resident since he had a diagnosis of dementia. When questioned about the difference between AMA and elopement, S18 LPN was unable to explain what an elopement meant. During an interview on 10/05/2022 at 9:09 a.m. S3 DON confirmed nurses who interacted with Resident #1 said he had periods of confusion. S3 DON reported she received a call from S17 LPN/ADON on 09/24/2022 informing her Resident #1 had left the facility walking. S3 DON indicated she came to the facility, spoke with S18 LPN and went looking for him herself. S3 DON indicated she had called S2 Administrator who told her she was sick and couldn't handle it then, so she called S1 Regional Administrator. S3 DON reported S1 Regional Administrator asked her a series of questions, such as was Resident #1 cognitive enough to understand where he was going and she said yes; Did he sign himself in, yes; Was he his own responsible party; yes. S3 DON reported S1 Regional Administrator told her it was the resident's right to leave and decided he left AMA even though he left all of his clothes here. S3 DON reported she had staff look for Resident #1 because she was concerned about his safety, and because he was not from around here. S3 DON indicated the Local Police were notified because staff didn't know where Resident #1 was going or if he could get there because he was walking. S3 DON indicated she usually called elderly protection if a resident left AMA and they thought the resident was in danger. S3 DON indicated she did not call elderly protection because they had called the police and didn't have an address to give elderly protection. S3 DON confirmed the resident had no discussions with staff about wanting to leave. S3 DON reported last time S3 DON confirmed she obtained no written statements from staff except from S18 LPN. S3 DON confirmed they did not normally do a thorough search and notify police for a resident who left AMA. S3 DON confirmed they followed the policy for a missing resident with cognitive decline because they were all concerned and thought Resident #1 needed a welfare check. S3 DON confirmed the staff did not know where Resident #1 was going or why he left. S3 DON indicated she expressed her concerns to S1 Regional Administrator on 09/24/2022, and he said we could continue to search and could post it on social media if we wanted to. S3 DON indicated she expressed her concerns to S1 Regional Administrator again on 09/25/2022 and was told the resident left AMA, but they could keep looking if they wanted to. During an interview on 10/06/2022 at 3:05 p.m. S14 CNA indicated the facility did not have any special thing to easily identify a resident as a wandering/elopement risk like they do the residents who are a fall risk. During an interview on 10/06/2022 at 3:18 p.m. S24 LPN was unable to answer who determined if a resident needed a wandering/elopement risk assessment done. S24 LPN indicated she would report wandering behavior to the ADON after recording it in the MAR. S24 LPN further indicated there was nothing in place she was aware of to easily identify wandering residents at risk for elopement. S24 LPN reported she not receive any additional training or inservice about the wandering resident or elopement procedures since Resident #1 walked out of the facility. During an interview on 10/06/2022 at 3:45 p.m. S3 DON reviewed Resident #1's nursing notes and facility policies and confirmed the notes should have triggered wandering/elopement risk assessment for resident and did not. S3 DON further confirmed the wandering assessments should have been repeated quarterly and were not. S3 DON indicated there should also be something on the resident's care plan that addressed wandering and there was not. S3 DON confirmed Resident #1 had documented behaviors of wandering and to her knowledge had never had a wandering risk assessment performed. S3 DON confirmed there was no process for monitoring the nursing notes and MAR entries for behaviors that would trigger the resident to be assessed for wandering risk. S3 DON further agreed the current policy was to do a wandering risk assessment after a behavior happened rather than proactively before it happened. S3 DON further confirmed staff did not assess everybody in the building for wandering after Resident #1 walked out of the building. S3 DON further acknowledged the facility failed to have CNAs and nurses on duty watch Resident #1 more closely, and failed to make sure the lock on the front door was latching properly. S3 DON further indicated the facility failed to make sure all residents at risk for wandering and/or elopement were appropriately identified. During an interview on 10/06/2022 at 4:06 p.m. S5 MDS Nurse produced a Wander Data Collection Tool for Resident #1 dated 10/20/2021 and 01/11/2022 that determined he was not at risk for wandering, even though the tool indicated the resident was cognitively impaired with poor decision-making skills, was a new admission not accepting the new situation, and ambulated independently with or without the use of assistive devices. S5 MDS Nurse indicated if nursing staff documented wandering behaviors and didn't tell her about it, a repeat assessment would not get done. S5 MDS Nurse reviewed Resident #1's nursing notes reflecting wandering behavior and confusion, and confirmed a wandering assessment should have been repeated and was not. During an interview on 10/07/2022 at 4:28 P.M. S3 DON confirmed Resident #1 eloped and did not leave AMA. S3 DON acknowledged another resident reporting Resident #1 was getting out of here was not sufficient to determine Resident #1 left AMA. After reviewing video footage for 09/24/2022 when Resident #1 eloped, S3 DON confirmed facility staff did not do a room to room search for Resident #1 and they should have. Review of Resident #3's record revealed a diagnosis of Dementia and Alzheimer's Disease, no Wandering Assessment, BIMS score on MDS dated [DATE]=1 indicating severe cognitive impairment, independent with locomotion on and off unit. Review of Resident #6's record revealed a diagnosis of Vascular Dementia-Wandering Assessments dated 07/26/2022 showing the resident was a wandering/elopement risk, BIMS score on MDS dated [DATE]=1 indicating severe cognitive impairment, supervision with setup help only for locomotion on and off unit. Review of Resident #7's record revealed a diagnosis of Dementia, no Wandering Assessment, BIMS score on MDS dated [DATE] =10 indicating moderate cognitive impairment, limited assistance with 1 person assist for locomotion on and off unit. Review of Resident #8's record revealed a diagnosis of Dementia, no Wandering Assessment, BIMS score on MDS dated [DATE] =12 indicating moderate cognitive impairment, supervision with set up help only for locomotion on and off unit. Review of Resident #9's record revealed a diagnosis of Dementia and Alzheimer's Disease, no Wandering Assessment, BIMS score on MDS dated [DATE] =11 indicating moderate cognitive impairment, supervision with setup help only for locomotion on and off unit. Review of Resident #10's record revealed a diagnosis of Dementia, no Wandering Assessment, BIMS score on MDS dated [DATE] =12 indicating moderate cognitive impairment, supervision with setup help only for locomotion on and off unit. Review of Resident #11's record revealed a diagnosis of Dementia and Alzheimer's Disease, no Wandering Assessment, BIMS score on MDS dated [DATE]=2 indicating severe cognitive impairment, supervision with setup help only for locomotion on and off unit. Review of Resident #12's record revealed a diagnosis of Dementia, no Wandering Assessment, BIMS score on MDS dated [DATE]=4 indicating severe cognitive impairment, supervision with setup help only for locomotion on and off unit. Review of Resident #13's record revealed a diagnosis of Dementia, no Wandering Assessment, BIMS score on MDS dated [DATE]=10 indicating moderate cognitive impairment, independent with locomotion on and off unit. Review of Resident #14's record revealed a dementia and Alzheimer's disease, no Wandering Assessment, No BIMS score on MDS-admitted [DATE]-MDS assessment still in progress. Review of Resident #15's record revealed a diagnosis of Dementia, no Wandering Assessment, BIMS score on MDS dated [DATE]=3 indicating severe cognitive impairment, limited assistance with 1 person assist for locomotion on and off unit. Review of Resident #16's record revealed a diagnosis of Alzheimer's Disease, no Wandering Assessment, BIMS score on MDS dated [DATE]=7 indicating severe cognitive impairment, supervision with setup help only for locomotion on and off unit. Review of Resident #17's record revealed a diagnosis of Alzheimer's Disease, no Wandering Assessment, BIMS score on MDS dated [DATE]=3 indicating severe cognitive impairment, limited assistance with 1 person physical assist for locomotion on and off unit. Review of Resident #18's record revealed a diagnosis of Alzheimer's Disease, no Wandering Assessment, BIMS score on MDS dated [DATE]=6 indicating severe cognitive impairment, independent walking in room and corridor, locomotion on and off unit did not occur. During an interview on 10/06/2022 at 3:45 p.m. S3 DON indicated the facility failed to make sure all residents at risk for wandering and/or elopement were appropriately identified.

Based on observations, record review and interviews, the facility failed to ensure 1 (#1) of 5 (#1, #2, #3, #4, #5) residents reviewed for abuse was free of physical abuse by facility staff. This deficient practice resulted in an actual harm on 04/11/2021 at 3:01pm when S5LPN (Licensed Practical Nurse) and S4TNA (Temporary Nursing Assistant) physically abused Resident #1 by hitting and kicking Resident #1 in the facility. Resident #1 was sent to the hospital, treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of the facility's Abuse and Neglect Policy revealed the following: Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. Review of Resident #1's Medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Social Service assessment dated [DATE] revealed resident #1 had a BIMS (Brief Interview for Mental Status) score of 10 indicating moderately impaired cognition. Review of Resident #1's Nurses Notes revealed the following entries by S6 Weekend RN (registered nurse): 04/11/2021 3:29 pm - I was called to A-Hall on intercom as soon as possible. This nurse ran to hallway, upon arrival I met Resident #1, noting he was sweating, agitated, redness and bruising to left cheek, abrasions to right eye and lacerations to left lower leg. I asked resident #1 what happened and he stated, they jumped on me! I asked resident to come to his room, further assessment, neuro checks and vitals assessed. I screamed for local EMS (emergency medical services) and authorities to be called. 04/11/2021 3:30pm- This nurse called DON (director of nursing) from the resident's room, notifying her of possible altercation and to review video footage. Stated she would and she was en route to the facility. DON called me back and instructed me to immediately remove S3CNA (certified nursing assistant), S4TNA and S5LPN from the A-Hall and from present duty. 04/11/2021 3:31pm- I made contact with S4TNA in hallway she stated, You better get him! He hit me. I further made contact with S5LPN who stated this resident hit S4TNA, we were protecting ourselves. S5LPN and S4TNA were removed from hallway. Review of the facility's Investigation Report completed by S6 Weekend RN on 04/11/2021 at 3:29 pm revealed the following documentation: Resident condition before incident -agitated, anxious - I was called to A- Hall on intercom as soon as possible. This nurse ran to hallway, upon arrival I met resident #1, noting he was sweating, agitated, redness and bruising to left cheek, abrasions to right eye and lacerations to left lower leg. I asked resident #1 what happened and he stated, they jumped on me! I asked resident to come to his room, further assessment, neuro checks and vitals assessed. I screamed for local EMS and authorities to be called. First Aid administered -dressing to right leg, resident taken to the hospital for treatment. Type of Injury-Abrasions to ears and eye, laceration to leg. Review of Resident #1's emergency room visit report dated 04/11/2021 3:53 pm revealed resident #1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Behavior agitated. Resident was treated and released back to the facility. Review of Resident #1's emergency room visit report dated 04/11/2021 10:09 pm revealed resident #1 was treated a second time for a complaint of pain to right rib area, lower right side, left lower leg. Further review revealed a CT (computed tomography) of cervical spine, chest and head showed no fractures. Portable chest x-ray showed no fractures and resident #1 was discharged back to facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #1's Comprehensive Care Plan revealed: Actual Abused Resident in altercation with staff members, noted with abrasions and bruises- provide close supervision and watch for early signs of agitation or increasing anxiety and report to MD (medical doctor); sent to local emergency room . Review of the facility's video footage (without sound) of the altercation that occurred on 04/11/2021 revealed the following: 3:00 pm-S5LPN, S4TNA and S3CNA sitting in A-Hall dayroom talking. 3:01 pm- Resident #1 walks up to the dayroom door and talks to staff. 3:01 pm- S4TNA walks up to dayroom door and talks to resident #1. 3:01 pm- S4TNA pushes Resident #1 with both hands away from door and then puts her hand on Resident #1's shoulder and attempts to push him toward the direction of his room and resident #1 leaned toward S4TNA and S4TNA threw a punch at Resident #1 with a closed fist. S5LPN gets in between Resident #1 and S4TNA. S5LPN then pushes Resident #1 back toward his room. S3CNA walks up and physically restrains S4TNA. S5LPN and Resident #1 can no longer be seen in the video frame at 3:01:04 pm. 3:02 pm-S3CNA continued to physically restrain S4TNA. S5LPN and Resident #1 returned to video frame. Resident #1 and S5LPN are entangled in a scuffle and resident #1 has hold of S5LPN's hair and they both fall to the floor. Resident #1's arms are around S5LPN's waist on the floor as S5LPN hits him multiple times in the back, chest and stomach area. S4TNA breaks away from S3CNA, runs over, to resident #1's back area and punch's resident #1 multiple times, and knees resident #1 in the side area as S5LPN continues to punch resident #1. Resident #1 remained on the floor and S4TNA continues to punch Resident #1 in his back. S5LPN manages to stand up and proceeds to kick resident #1 in his chin/mouth area, and walks away. S4TNA stands up and walks away leaving resident #1 on the floor. Resident #1 stands up and walks toward S4TNA but then falls back to the floor and hits his head on the water fountain. Resident #1 gets up and stumbles out of video frame. 3:03 pm- S3CNA, S4TNA, and S5LPN are back in dayroom. S5LPN leaves the dayroom and enters the nurse's station. End of video. During an interview on 04/26/2021 at 10:00 am, S3CNA confirmed she was present and witnessed the altercation related to resident #1 on 4/11/2021. S3CNA reported Resident #1 was walking back and forth to the back door in an agitated manner. Resident #1 came to the dayroom door and started cussing at us, calling us B***** and saying f*** yall. S4TNA pushed resident #1 out of the door and that is when it started, I stood in between them and tried to hold S4TNA back. S3CNA further reported S5LPN continued to engage resident #1 and attempted to get resident #1 to go to his room. S4TNA broke loose from my grip and S4TNA and S5LPN continued to hit and kick Resident #1. S3CNA further reported S6 Weekend RN came and took care of resident #1 and they called the police and Resident #1 was sent to the emergency room . During an interview on 04/26/2021 at 11:30 am Resident #1 stated, They jumped on me and beat me up. It started when I went to the door to ask them girls what time was we going to smoke. I had been napping and did not know what time to smoke. They told me to go back to my room and shut the door and don't come out and I said don't talk to me like I am a punk, I told her f*** you, B**** and one girl came to the door and pushed me and the other one came and they attacked me and kept hitting me. They kicked me and hit me; I had blood everywhere, scratches on my back, messed up my eye. I had to go to the hospital a few times because I was hurting so bad. They did x-rays at the hospital but nothing was broken. The two girls that attacked me was fired. I have never had a problem with them girls before. I was not trying to hurt them I was just trying to defend myself. During an observation on 04/30/2021 at 1:00 pm revealed Resident #1 had a healing skin tear with a black scab on Resident #1's left lower leg. During a phone interview on 04/27/2021 at 10:02 am S6 Weekend RN reported, I did not witness the altercation but was called to the hall over the intercom, to come to the A- Hall as soon as possible. S6 Weekend RN continued to report, meeting resident #1 in the hallway, very agitated. Resident #1 had bruising and blood on his face, blood on his left leg. Resident #1was assessed in his room noted to have abrasions on both ears. I notified S2DON by phone and asked her to look at camera and see what happened. Resident #1 told me the staff jumped on him. S6 Weekend RN further reported S2DON continued the investigation. S3CNA, S4TNA and S5LPN were removed from facility after giving statements to the police. Resident #1 was sent to the emergency room for evaluation and treatment. During an interview on 04/27/2021 at 11:00 am, S2DON confirmed, upon arriving at the facility on 4/11/2021 Resident #1 was still agitated and had bruising to his face, abrasions on both ears, and blood on his face and leg. S2DON further confirmed the physical abuse of Resident #1 by S4TNA and S5LPN on 4/11/2021 was substantiated and confirmed by video footage. During an interview on 04/27/2021 at 1:30 pm, S1Administrator confirmed physical abuse of Resident #1 was substantiated after facility investigation.