Every finding on record at Loft Rehabilitation & Nursing

Based on observation, interview, and record review, the facility failed to ensure that sufficient nursing staff was available to meet residents' needs in a timely manner and respond promptly to call lights. The facility also failed to implement and maintain an effective staffing policy that ensured adequate staffing levels to meet residents' care needs. These failures have the potential to affect all 64 residents reviewed for sufficient staffing. Findings Include:The facility's Long Term Care Facility Application for Medicare and Medicaid form dated 8/25/26 and signed by V1 (Administrator) documents that 64 residents currently reside within the facility.The facility assessment dated [DATE] documents, Consider if it would be helpful to differentiate between long-stay and short-stay residents or other categories. 600 is our skilled unit; 300 we offer increased activities geared towards dementia. Indicate your average daily census: 55-65. Consider if it would be helpful to describe the number of persons admitted and discharged , as these processes can impact staffing needs. Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of the residents at any given time. Consider if and how the degree of fluctuation in the census and acuity levels impact staffing needs. For example: Licensed Nurses: LPN (licensed practical nurse), RN (registered nurse) providing direct care. DON (director of nursing) RN full-time days; ADON (assistant director of nursing) IP (infection preventionist) LPN full-time days. RN or LPN charge nurse: 1 for each shift. 1-x (times) residents; DON may be charge nurse. 2-3 RN or LPN days and nights 12 hours shifts. Direct care staff: 5-8 days (total licensed or certified), 5-8 evenings, 3-5 nights.The facility's Resident Rights policy dated 2/12/2025 documents, the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Resident rights; the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Respect and dignity; the resident has a right to be treated with respect and dignity.The facility's Call Lights: Accessibility and Timely Response policy dated 2/6/2025 documents, The purpose of this policy is to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy explanation and compliance guidelines: 8. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 9. Process for responding to a call light: a. Response times should be a priority; b. Turn off the signal light in the resident's room; c. Identify yourself and call the resident by name; d. Listen to the resident's request and respond accordingly. Inform the resident if you cannot meet the needs and assure him/her that you will notify appropriate personnel. E. Inform the appropriate personnel of the resident's need. F. Do not promise something you cannot do. G. If you need assistance you needed with a procedure, summon help by using the call light. Stay with the resident until help arrives.The facility Certified Nursing Assistant job description dated 6/2021 documents, Position purpose: provides certified nursing assistant services to assigned residents in accordance with care plans, facility policies and procedures, and at the direction of supervisor. Personal nursing care functions: assist residents with bath functions (i.e., bed bath, tub or shower bath, etc.) as directed. Keep residents dry (i.e., change gown, clothing, linen, etc., when it becomes wet or soiled). Change bed linens. Keep incontinent residents clean and dry.The facility Registered Nurse job description dated 6/2021 documents, Provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by the certified nursing assistants in accordance with current federal, state, and local regulations and guidelines and established facility policies and procedures. Major Duties and Responsibilities: Performs rounds to ensure resident needs are being met, and personnel are performing their assigned duties. Collaborates with other members of the interdisciplinary team as needed to ensure residents' needs are holistically met. Treats all residents with dignity and respect. Promotes and protects all residents' rights.On 8/25/2026 at 10:10 AM, during a Resident Council meeting, R29 stated, Staffing here is terrible. R29 stated that approximately one to two weeks prior, she had asked for a Certified Nurse Aide (CNA) for new adult briefs. R29 stated that the staff member ignored her and walked past her room. R29 stated that when she saw another CNA, she asked for new adult briefs, and the CNA told her she would get to her when she can. R29 stated that she ultimately waited approximately 10 hours for an adult brief and remained in her own diarrhea throughout the day. R29 stated that response to call lights really depend[s] on the day and that long wait times occur all the time. R29 stated that staff members do not care. R29 further stated that staff members frequently complain, We are short of help, that is all we [the residents] ever hear. R29 stated that staff members will usually enter her room, turn off her call light, and tell her they are coming back, but do not return.On 8/25/2026 at 10:15 AM, during a Resident Council meeting, R8 stated that approximately one to two weeks prior, she turned on her call light because she had urinated in her bed. R8 stated that a Certified Nurse Aide (CNA) entered her room and told her she was too busy and will be back. R8 stated that when the CNA returned, after what felt like forever, the CNA only cleaned the bed and changed her adult brief. R8 stated that the CNA did not clean her with wipes or with soap and water. R8 stated that she gets frequent urinary tract infections (UTIs) and believes they are related to her perineal area not being adequately cleaned. R8 also stated that she asked the CNA if she could get out of bed. R8 stated the CNA responded, I'm not getting you up; you can turn the call light on as many times as you want, it's not going to do anything. R8 stated that the CNA made this statement in a threatening manner, which caused her to feel afraid to activate her call light again. R8 further stated that her medications are frequently administered late and that, on 8/24/2026, she had not yet received her morning medications at the time of the Resident Council meeting. R8 also stated that she sometimes does not receive a shower for seven days. R8 stated that staff members will tell her, I'll be back, but do not return. R8 stated that some staff members tell her, You never reminded me. R8 further stated that staff members frequently complain about having no help.On 8/24/26 at 10:26 am V7/LPN (Licensed Practical Nurse) stated, We only have two nurses to take care of all the residents in the building today. We usually have at least three nurses. I am in charge of the 200-wing and 600-wing, and the 600-wing is in the basement, so I have to be down in the basement as well. V7/LPN acknowledged the negative impact of this shortage on operations, stating that getting medications administered timely, completing resident assessments, executing treatments, and managing everything else can get rough to do.On 8/24/26 at 11:20 AM, R6 was observed sitting in a high-back wheelchair in his doorway waiting for toileting assistance, reporting that his call light had been on for over an hour because a female staff member entered, turned off the light, and told him to wait until she could find another staff member to assist her. R6 reported the staff member never came back, so R6 was forced to activate his call light a second time. R6 directly attributed the lack of timely care to facility shortages, noting that it takes staff a long time to respond to call lights. R6 stated, I don't think they have enough staff because they never come into my room to check on me either.On 8/24/26, from 11:20 AM to 11:50 AM, R6's call light remained continuously activated without a staff response.On 8/24/26 at 11:57 AM, V9/CNA (Certified Nursing Assistant) verified R6's call light had been on for a long time and stated that they don't have enough staff to get to all the residents in a timely manner. V9 stated that she was the only one covering all the hallways because most of the staff were in the basement assisting with lunch. V9 stated that when she took lunch break earlier, only one CNA was left on the hallway, and when she got back from break then she was the only CNA left on the hallway. V9 stated she was supposed to pass out all the drinks to the residents who are staying in their rooms for lunch and then pass out their lunch trays. V9 also stated that anyone who is a two-person assist must wait because there is only one CNA covering the floor during this time. V9 stated, We are consistently short on staff, and we cannot get to everyone timely. I had to ask (V10/Social Service Director) to help spot me when transferring (R6) to the toilet via mechanical lift. V10 is not qualified to assist, but we didn't have anyone else, and I didn't want to keep making (R6) wait.On 8/25/2026 at 11:25 AM, R1 activated his call light due to his colostomy bag being full, detached, and broken. R1 had fecal matter on his abdomen and right arm, as well as on his bed and bed linens. V9 (Certified Nurse Assistant) was observed walking past R1's room twice. Other staff members at the front desk did not respond to R1's activated call light. At 11:50 AM, V2 (Director of Nursing) turned off R1's call light. V2 then walked away from R1's room and proceeded to the nurse's station in the main lobby. V2 stated that she was going to take care of R1's colostomy bag and left the nurse's station. At 11:56 AM, V2 was observed entering R1's room to clean R1 and replace his colostomy bag.On 8/24/2026 at 12:20 PM, V9 was observed in the hallway passing lunch trays. V9 stated that R1's door was closed because his colostomy exploded and it smells strong in there. Upon entering R1's room, a very strong fecal odor was noted. R1 was observed lying in bed with his lunch on the bedside table and lightly moving the food around. R1 stated, The smell in here does not make me want to eat. It makes me feel icky and embarrassed by the smell. R1 stated that he did not know why V9 had closed his door. R1 further stated, I know it smells bad, but I can't help it. If they (the staff) would empty my colostomy bag more often, then this would not have happened.On 8/26/2026 at 11:10 AM, V15 (Certified Nurse Assistant) stated that staffing is usually only her for one hallway. V15 stated staff call in a lot, and there is only adequate staffing for a day or two a week.On 8/27/2026 at 2:00 PM, V17 (R27's family member) stated that over the past year, since V1 (Administrator) assumed the position of Administrator, the care provided to R27 and other residents on her hallway has declined. V17 stated that there is usually only one Certified Nurse Aide (CNA) assigned to the 300 hallway, which is a dementia unit. V17 stated that she has had meetings with V1 and V2 (Director of Nursing), during which V2 stated, We staff based on acuity. V17 stated that having only one CNA assigned to the hallway is unsafe because if a resident requires assistance with care and the CNA is not in the common area where residents are typically located during the day, there is no one available to monitor the residents. V17 stated that she has had to assist R27 with changing her adult brief instead of facility staff because she felt it was unsafe for the CNA to leave the other residents while assisting R27. V17 stated that, on one occasion, R27's bathroom had feces on the floor and toilet, and a receptionist had to clean the bathroom because facility staff stated that there was no one available to clean it. V17 stated that there have been times when R27 has gone more than two weeks without receiving a shower and that she had to demand a shower several times before R27 received one. V17 stated that she is frustrated and has attempted to bring her concerns to the facility. V17 stated that she feels the facility does not listen to her concerns and does not seem to care for their residents.On 8/27/2026 at 9:05 AM, V2 (Director of Nursing) stated that she uses the facility's staffing guide and can staff up to seven Certified Nurse Aides (CNAs) on the day shift, the same number on the evening shift, and up to five CNAs on the night shift. V2 stated that it is difficult to staff at those levels because many staff members call off and many staff members have recently quit since she assumed the position of Director of Nursing. V2 confirmed that additional staff are needed and stated that resident care is not being completed as it should be.

Based on observation, interview, and record review, the facility failed to ensure that two staff were present during a mechanical lift transfer for one of one residents (R5) reviewed for transfers in a sample of five. Finding include: The facility's Safe Resident Handling and Transfer policy, reviewed 2/10/26, documents that it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. This form documents that two staff members must be utilized when transferring residents with a mechanical lift. R5's current care plan documents that R5 has an ADL (activities of daily living) self-care performance deficit related to activity intolerance, right above the knee amputation. R5's transfer intervention documents that R5 requires a full-body lift with two staff members for transfers. On 8/19/26 at 11:45am, V4, Certified Nursing Assistant, was transferring R5 with a mechanical lift in his room, with the door open by herself. R5 was hanging in the mechanical lift sling, with his head below his buttocks and his foot in the air. R5 was flailing his arms and leg around and cursing at staff, along with facial grimacing as if in pain. V4 pushed R5 back over his reclining chair, but up in the air, and left the room to go get assistance. V4 was out of the room for approximately 90 seconds, while R5 was hanging in the air. V4 returned to the room with V3, Assistant Director of Nursing, and they assisted R5 to the reclining chair to reposition him. R5 was very anxious and yelling, Ouch, ouch, while attempting to hit staff. V3 and V4 finally got R5 situated in the mechanical lift sling to provide the care needed. On 8/19/26 at 12:00pm, V3 stated that two staff are required for all mechanical lift transfers. On 8/19/26, at 12:20pm, V4 stated that she does not know why she transferred R5 by herself. V4 also stated that she knew that two people are required for a mechanical lift transfer. On 8/19/26 at 12:30pm, V2, Director of Nursing, stated that all staff are trained on mechanical lift procedures before working the floor. V2 verified that two staff are required for mechanical lift transfers. V2 stated that V4 was suspended without pay pending an investigation.

Based on observation, interview and record review review the facility failed to maintain privacy while performing personal care for one of three residents (R5) reviewed for privacy in a sample of five. Findings include: The facility's Promoting/Maintaining Resident Dignity policy, reviewed 2/12/25, documents that it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, as well as care for each resident in a manner and in an environment that maintains or enhances residents' quality of life by recognizing each resident's individuality. This form also documents to maintain resident privacy. On On 8/19/26 at 11:45am, V4, Certified Nursing Assistant, was transferring R5 with a mechanical lift in his room, with the door open by herself. R5 was hanging in the mechanical lift sling, with his head below his buttocks and his foot in the air. R5 was flailing his arms and leg around and cursing at staff, along with facial grimacing as if in pain. V4 pushed R5 back over his reclining chair, but left him dangling in the air, and left the room to go get assistance. V4 was out of the room for approximately 90 seconds, while R5 was hanging in the air. V4 returned to the room with V3, Assistant Director of Nursing, and they assisted R5 to the reclining chair, while the door to the hall was open. On 8/19/26 at 12:30pm, V2, Director of Nursing, verified that R5's door should have been shut prior to starting any personal care.

Based on interview and record review the facility failed to ensure a resident (R2) was free of physical abuse from (R1) for two of five residents reviewed for abuse in a sample of six. Findings include: The facility's Abuse, Neglect, Exploitation policy, revised 1/23/26, documents that it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. This form documents that physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. R1's current electronic face sheet diagnoses include, but are not limited to, cognitive, social or emotional deficit, Schizophrenia, major depression, anxiety, hypersomnia, schizoaffective disorder, and bipolar disorder. R1's current care plan documents that R1 that R1 is at risk for impulsivity related to stressors. This form also documents that R1 has the potential to be verbally/physically aggressive related to mental/emotional illness and poor impulse control. R2's current electronic face sheet diagnoses include, but are not limited to, major depression and generalized anxiety disorder. R2's current care plan documents that R2 can become agitated and yell at peers and staff, disrupting others. R2's Progress Notes 7/25/26 at 740am, documents that R2 was struck by another resident (R1). Resident (R2) was assessed and appeared calm with no signs of distress. (R2) stated that another resident struck him in the face; there was no redness, bruising, swelling, or other visible injuries noted. This form documents that all the required parties were notified of the incident The facility's State Report, dated 7/25/26, documents that R1's open right hand made contact with R2's left cheek. Skin assessments were completed, and no injuries or redness were noted. R1 stated that He (R2) was cussing and all I did was put my hand up as if to tell him to stop. R2 stated that I (R2) was in the dining room and that one lady (R1) told me to get F----d when I told her to shut up; she used the back of her hand to touch my left cheek. R1's Progress Notes document that R1 was placed on one-on-one care. V10, Dietary Aide, signed statement, dated 7/25/26, documents that he witnessed R1 and R2 arguing and observed R1 strike R2 on the arm. On 8/20/26 at 9:30am, V8 and V9, Certified Nursing Assistants, verified that R1 is quite often on one on ones due to her behaviors. On 8/20/26 at 1:00pm, V1, Administrator, verified that an investigation was initiated and R1 was placed on one-on-ones for safety.

Based on interview and record review, the facility failed to update a resident's plan of care to reflect a recent physical altercation with another resident, for one of one resident (R2), reviewed for care plans, in a sample of 3. The facility policy, Care Plan Revisions Upon Status Change, dated (revised) 01/20/206 directs staff that the comprehensive care plan will be reviewed, and revised when a resident experiences a status change. R2's Nursing Progress Notes, dated 6/2/26 document, (R2) became physically aggressive with another resident. Skin assessment completed, no new skin issues noted at this time. Notified administrator, law enforcement, POA (Power Of Attorney) and MD (Medical Doctor). Residents were immediately separated by staff for their safety. A review of R2's current Care Plan, dated 5/28/26 does not include a Focus Area to indicate that R2 was the perpetrator of physical abuse, towards another resident. On 7/6/26 at 1:50 P.M., V9/Social Services Director stated she is aware of the incident between R1 and R2 that occurred on 6/2/26, when R2 slapped R1. States R2's care plan should have been updated immediately to include that R2 was physically abusive towards another resident, and interventions should have been put into place. On 7/6/26 at 2:18 P.M., V10/Corporate Care Plan Coordinator stated the facility is currently under-going a staffing change in care plan coordinators. States she assists the facility with care plans at this time. States an incident of physical resident to resident abuse, along with interventions to lessen the reoccurrence of additional or on-going abuse, should be included in a care plan, within 24 hours of the incident happening. States if an incident happens on a weekend, the resident's care plan would be updated the following Monday.

Based on interview and record review, the facility failed to protect the resident's (R1) right to be free from physical abuse by another resident (R2) for two of three residents reviewed for abuse, in a sample of 3.The facility policy, Abuse, Neglect, Exploitation, dated (revised) 01/23/2026 directs staff that it is the policy of the facility to prohibit and prevent abuse. This same policy states that physical abuse is willful, and includes hitting, slapping, punching, biting and kicking. R1's facility admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Depression, Anxiety and Cognitive Impairment. R1's Care Plan, dated 12/22/2025 includes the following Focus Areas: Behavioral Symptoms as evidenced by (R1) spits phlegm on the floor, instead of using a spittoon. R1's Nursing Progress Notes, dated 6/2/26 document, Resident was observed receiving physical aggression from another resident. Skin assessment completed, no new skin issues noted at this time. Residents vital are WNL (Within Normal Limits). Resident denies pain/ discomfort at this time. Notified administrator, law enforcement, POA (Power Of Attorney) and MD (Medical Doctor). Residents were immediately separated by staff for their safety. R2's facility admission Record documents that R2 was admitted to the facility on [DATE] with the following diagnoses: Wernicke's Encephalopathy, Depression and Anxiety. R2's Nursing Progress Notes, dated 5/31/26 document, (R2) observed wandering throughout the unit and entering multiple other residents' rooms. Staff attempted verbal redirection, resident initially became physically aggressive, swinging his arms toward staff and resisting efforts to guide him out of the room. After continued calm redirection, resident eventually turned around and followed staff instructions. Resident was later found lying in another resident's bed. After continued calm redirection, resident eventually turned around and followed staff instructions. No injuries noted to resident or staff. All residents remain safe. Will continue to monitor and maintain safety precautions. R2's Health Provider Notes, dated 6/1/26 document, (R2) was in his room resting in bed after breakfast. He was alert but confused and was able to answer some questions. He has increased restlessness and agitation and is combative at times. He has a wander guard in place due to frequent wandering. R2's Nursing Progress Notes, dated 6/2/26 document, Resident became physically aggressive with another resident. Skin assessment completed, no new skin issues noted at this time. Notified administrator, law enforcement, POA (Power Of Attorney) and MD(Medical Doctor) . Residents were immediately separated by staff for their safety. The facility form, facility State Report, dated 6/2/26 and prepared by V1/Administrator documents, Allegation of resident- to- resident incident involving R2 and R1. V3/Cook's interview, I was in the dining room behind the steam table preparing to begin dinner services. I observed (R2) seated across from (R1). (R1) spit on the table and (R2) told him to stop. (R1) spit again. (R2) then approached (R1) from his right side and using his left hand, made contact with right side of (R1)'s head. (V4/Certified Nursing Assistant) entered as I was moving to separate the residents, and intervened. I then reported the incident to (V5/Licensed Practical Nurse) and (V1/Administrator). V4's interview, I was assisting residents into the dining room when (V3/Cook) instructed me to separate (R1 and R2), because I was the closest staff member. I intervened immediately to separate the residents. Staff interview with (V5/Licensed Practical Nurse), Following the incident, I assessed (R1 and R2). No injuries were noted and neurological checks were initiated for (R1). (R1 and R2) were interviewed, and neither remember the incident. CONCLUSION: based on the investigative findings, the allegation of abuse is unsubstantiated. The incident involved a brief resident- to- resident interaction, and no injuries were observed or reported. No emotional distress was noted in either resident, and they remain separated, each sitting at separate tables in the dining room. Interventions and follow up: Care plans were updated, the residents are being monitored for behaviors and escalation, and follow up with psychiatric services was initiated as indicated. R2 was admitted as rehabilitation (to home) and is returning to his previous living situation. On 7/6/26 at 11:16 A.M., V3/Cook stated she has been an employee of the facility for the past 8 1/2 years as a dietary cook. States around suppertime on 6/2/26 she was behind the steam table in the dining room, and heard a loud commotion. States she stepped out from behind the table and witnessed R1 spitting on the table. States R1 frequently spits. States R2 was sitting at the same table and when R1 spit on the table again, R2 stood up and smacked R1 across the head, loudly. States R1 was cowering from R2. States at just that time, V4/Certified Nursing Assistant walked into the room and immediately separated the residents and took R2 back upstairs to the nurse. States she went upstairs and reported the incident to V5/Licensed Practical Nurse who immediately called V1 (Administrator) . States she spoke with V1 and was instructed to write a statement as to what occurred. States soon after the incident, R2 was discharged to another facility. On 7/7/26 at 10:30 A.M., V1/Administrator/Abuse Coordinator verified the incident between R1 and R2 that occurred on 6/2/26. States usually R1 sits at a table by himself in the MDR(Main Dining Room), due to his habit of spitting. States for some reason, R2 wheeled himself to R1's table and was waiting for his noon meal. States she interviewed V3/Cook who observed R1 spit on the table, R2 yell at R1 to stop spitting, R1 spit again and R2 stand up and reach across and hit R1. Confirms that R2's actions were intentional and not accidental.

Based on record review, interview and observation the facility failed ensure a resident (R2) was free from physical abuse by another resident (R1) for two of seven residents reviewed for abuse. The facility's abuse , Neglect, Exploitation Policy dated 1/23/26 documents the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and emp0lementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.R1 is a [AGE] year-old resident admitted on [DATE] with diagnoses including: Cognitive Social or Emotional Deficit Following Cerebro-vascular Disease; Schizoaffective Disorder, Bipolar Type; Major Depressive disorder, and Anxiety. R1's current Care Plan documents: (R1) has potential to be verbally/physically/aggressive related to Mental/Emotional illness, Poor impulse control.The facility's Incidents By Incident Type report, under Physical Aggression Initiated Incidents dated 4/28/26 at 11:30am documents an incident of resident-to-resident altercation initiated by R1 against R2.The facility's State Report dated 4/28/26 documents the following: (R1)'s right hand made contact with (R2)'s left upper arm. (V5) CNA/Certified Nursing Assistant stated, I saw (R2) trying to get past (R1) and they started arguing as he (R2) was trying to get by. I saw (R1) make contact with the back of her right hand to (R2)'s left upper arm.On 6/16/6 at 4:00pm V2 ADON/Assistance Director of Nursing verified R1 did strike R2 on 4/28/26 and the incident investigation found resident-to-resident physical abuse did occur.

Based on interview and record review, the facility failed to provide showers on all scheduled shower days for two of five residents (R1, R5) reviewed for activities of daily living assistance. Findings include: The facility's Activities of Daily Living Policy dated 1/2026, documents; based on the resident's comprehensive assessment and the resident's needs, care such as bathing and grooming will be provided. This policy also documents that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. R1's electronic health records document medical diagnoses which include, but are not limited to, multiple sclerosis, hemiplegia, neuromuscular dysfunction of bladder, and retention of urine. R1's quarterly Minimum Date Set dated 5/7/2026 documents R1 uses a wheelchair and is dependent for showering, meaning he is unable to shower without maximum assistance from staff. R1's care plan dated 4/3/2026 documents he is incontinent and dependent on staff for personal hygiene and for meeting physical needs related to immobility and physical limitations.On 6/9/2026 at 9:05 AM, R1 stated he has missed many showers in the past few months, sometimes going a whole week without his two scheduled showers. R1 stated evening shift seems to struggle with consistently completing all the showers, it's hit or miss if I get both my showers each week. R1 stated his assigned shower days are Tuesdays and Fridays on evening shift, after 2:00 PM.R1's Bath/Shower Report from 3/31/2026 to 5/31/2026 documents when showers were given. R1's Bath/Shower Report is blank on 4/3/2026, 4/24/2026, 5/12/2026, and 5/26/2026, indicating showers were not documented as completed on those days even though they fall on a Tuesday or a Friday, R1's assigned days of the week for showers. On 6/10/2026 at 9:45 AM, V1 (Administrator) and V2 (Assistant Director of Nursing) stated they were unable to find or provide nursing notes documenting why showers were not given on the missed days or if alternatives/rescheduling were offered to R1. 2. R5's electronic health records document medical diagnoses which include, but are not limited to, tubule-interstitial nephritis, fibromyalgia, central cord syndrome at unspecified level of cervical spinal cord, chronic kidney disease, chronic bladder pain, overactive bladder, personal history of urinary infections, and acute transverse myelitis in demyelinating disease of central nervous system. R5's care plan dated 4/2/2026 documents R5 has bowel and bladder incontinence related to overactive bladder and need for staff assistance with interventions such as providing prompt incontinence care if incontinence occurs. R5's care plan documents R5 has an activity of daily living self-care performance deficit and requires extensive assist with showering.On 6/9/2026 at 1:50 PM, R5 states she does not always receive her scheduled two showers a week at one point going almost a month without a shower. R5 admits that sometimes she refuses showers but there is no follow up from staff to reschedule the shower. R5 states that her shower days are Tuesdays and Fridays on evening shift, after 2:00 PM.R5's Bath/Shower Report from 4/30/2026 to 6/9/2026 documents when showers were given. R5's Bath/Shower Report is blank on 5/15/2026 and 5/26/2026 indicating showers were not documented as completed on those days even though they fall on a Tuesday or a Friday, R5's assigned days of the week for showers. The report documents R5 refused showers on 5/5/2026, 5/8/2026, and 5/19/2026.On 6/10/2026 at 9:45 AM, V1 (Administrator) and V2 (Assistant Director of Nursing) stated they were unable to find or provide nursing notes documenting why showers were not given on the missed days or if alternatives/rescheduling were offered to R5. V1 and V2 stated they were unable to provide nursing notes documenting why R5 refused multiple showers or if alternative accommodations were made to encourage bathing. On 6/9/2026 at 2:15 PM, V6 (Certified Nursing Assistant) stated there are times she cannot get through all showers with her assigned residents, especially if they are short staffed that evening. On 6/9/2026 at 9:15 AM, V4 (Certified Nursing Assistant) stated showers are usually the first care that gets neglected when a certified nursing assistant calls off for their shift. V4 stated second shift is the worst when it comes to missing showers.On 6/10/2026 at 7:30 AM, V2 (Assistant Director of Nursing) stated it is her expectation that residents receive showers on their assigned shower days, as needed or when a resident requests a shower. V2 also expects nursing staff to communicate to the oncoming shift if showers were missed and document in a nursing note.

Based on observation, interview and record review, the facility failed to ensure adequate supervision and prevent an intermittently confused resident from exiting the facility, unannounced to staff, through alarmed exit doors after a visitor silenced the door alarm without staff knowledge. Staff failed to monitor the alarm system and failed to recognize the resident's elopement. The resident exited the building unsupervised, during freezing temperatures, wearing only a tee shirt and sweatpants. Approximately 13 minutes later, the resident was discovered by a patrolling police officer in the facility parking lot, adjacent to an access road used by residents of a nearby apartment complex, creating a high risk for traffic- related injury. The resident was found lying on the ground next to an overturned wheelchair and had sustained multiple contusions and lacerations requiring an emergency room evaluation for one of four residents (R1), reviewed for accidents and supervision, in a sample of seven. The facility's failure to prevent unauthorized silencing of exit alarms; monitor alarm status; provide adequate supervision of an intermittent cognitively impaired resident and identify and respond promptly to an elopement placed the resident in immediate danger of serious injury or death, including hypothermia, trauma from falls or being struck by a vehicle. Findings include:These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 12/10/25 when R1 exited the facility, unannounced to staff, through alarmed exit doors after a visitor silenced the door alarm without staff knowledge.V1 (Administrator) and V2 (Director of Nurses) were notified of the Immediate Jeopardy on 02/23/2026 at 1:40 P.M.While the immediacy was removed on 02/23/2026, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.The facility policy, Elopements and Wandering Residents, dated (revised) 2/2/26 directs staff, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering. Including identification and assessments of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. The designated staff will look for the resident. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office. Director of Nurses or designee shall notify the physician and family member or legal representative. Police will be given a description and information about the resident: include any photos. All parties will be notified of the outcome once the resident is located. Appropriate reporting requirements to the State Survey Agency shall be conducted.R1's facility admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Sepsis, Pneumonia, Acute Respiratory Failure, Type 2 Diabetes Mellitus, Abnormalities of Gait and Mobility, Acute on Chronic Combined Systolic and Diastolic Heart Failure, Parkinson's Disease, Polyneuropathy, Repeated Falls and Weakness. R1's Clinical admission note, dated 12/2/25 and signed by V17/Licensed Practical Nurse documents mental status: resident is confused.R1's Advanced Skilled Evaluation, completed by V18/Registered Nurse on 12/4/25 documents R1 is (chronically) confused.R1's Consultation Note, dated 12/9/25 and signed by V19/Nurse Practitioner documents, (R1) sitting up in wheelchair today and in no apparent distress. Wife/POA (Power of Attorney) is present at bedside. (R1) is confused/disoriented to time.R1's Nursing Progress Notes, dated 12/10/25 at 6:54 PM by V4/Licensed Practical Nurse document the administration of Lorazepam (anti-anxiety) 0.5 MG (milligrams) by mouth due to exit seeking and upset.R1's facility form, Unwitnessed Fall, dated 12/10/25 at 7:30 PM and completed by V4/licensed Practical Nurse documents, (R1) was laying down, R1's wheelchair was on his left side. Bleeding present from left arm and abrasion present to top of left side of head. (R1) was helped by EMS (Emergency Medical Services) and taken to (local hospital). (R1) told staff he was trying to go home. Injuries observed include: Abrasion to forehead, skin tear to back of left hand and left forearm.V7/Police Officer's report of (R1's) 12/10/25 incident documents, On 12-10-25 at 1922hrs (7:22 P.M.), I (V7/Police Officer)) was on routine patrol for the city. While patrolling the area of (facility), I observed (R1) an elderly white male laying on the ground, with a tipped over wheelchair nearby. I exited my patrol vehicle and made contact with the elderly male, who stated he fell out of his wheelchair. It should be noted that at the time I found the male, it was 38 degrees, with a real feel of 26 degrees and it was starting to snow. The elderly male was only wearing a thin t-shirt and sweatpants. While I stayed with the elderly male, my ride along Police recruit, along with an on-break employee (V5/Certified Nursing Assistant) ran inside (the facility) to get assistance. I asked (R1) how he got outside, and he said he just pushed the lobby door open and left and he wanted to go home. I advised dispatch to have (city) EMS (Emergency Medical Services) respond to the scene (R1), who was alert, conscious and breathing had blood coming from a laceration on his head, a laceration on his left elbow and a laceration on his right hand. (R1) complained of head pain and stated he thought he had a concussion. At no time did I move or touch (R1) due to a possible head injury. (R1) was laying left lateral recumbent position upon initial contact. (Facility) staff members arrived and had (R1) sit up from his recumbent position. They placed a blanket around (R1) due to the cold temperatures. EMS Paramedics arrived for further care. It was determined that (R1) would be transported to (local hospital) for evaluation. I then followed the (facility) employees back into the building to gather information. The (facility) employees were identified as (V6/Licensed Practical Nurse) and (V5/Certified Nursing Assistant). (V5/CNA) was on break at the time this incident occurred and was sitting in her vehicle in the parking lot and ran into the (facility) with (the police) recruit to get further assistance. Also present was (V4/Licensed Practical Nurse). (V4/LPN) advised that prior to this incident, (R1) was sitting in the main lobby conversing with other residents. (V4/LPN) said that he left the lobby for a brief moment, went down the 300 Hall to give meds (medications) to a resident and when he returned back to the main lobby, that is when he saw (V5/CNA) and (the police) recruit running inside. (V4/LPN) stated he believes that (R1) could have been outside for about 10 minutes. I asked (V4/LPN) if the staff even knew that (R1) was gone prior to (V5/CNA) and (the police) recruit coming inside and (V4/LPN) stated they did not know that (R1) was missing and had pushed the door open and was outside unsupervised. When asking (V4/LPN) about (R1)'s medical history, he stated that (R1) has Parkinson's and also has confusion. (V4/LPN) stated that (R1) has been a resident of (the facility) since 12/02/25.R1's Emergency Department report, dated 12/10/25 documents, Encounter Diagnosis: Fall, Contusion of left hip, Multiple skin tears to left elbow and Contusion to scalp. R1's facility Fall IDT (Intra Disciplinary Team) Note, dated 12/15/25 documents that R1 fell, unwitnessed, and was found on his side, in the facility parking lot on 12/10/25 at 7:30 PM, after exiting the building without letting staff know. R1 stated he was looking for a car with keys in it so he could go home. Interventions taken: (wandering alert bracelet) placed on (R1)'s right wrist to ensure safety when (R1) is actively exit seeking.On 2/19/26 at 12:06 P.M., V11/Certified Nursing Assistant stated she had been employed at the facility for the past year. States the front door is alarmed and when an alarm goes off, she turns off the alarm. During this time, a facility visitor was observed to enter the sounding facility front door alarm, by entering a code in the alarm panel. At that time, V11/CNA stated all resident family members are given the code to enter and exit the facility.On 2/19/26 at 12:09 P.M., V3/Assistant Director of Nurses (ADON)/Wound Nurse stated that all residents are assessed upon admission for being an elopement risk per the admitting nurse. If a resident is determined to be at risk of eloping, a (wandering alert bracelet) is placed, which is checked for placement and function every shift by the nurse and documented. V3 states the facility policy is if a door alarm is sounded, staff immediately respond to the door and if a resident is unable to be located, they announce a Code Yellow. A code yellow includes facility staff surveying the surrounding area, locating the missing resident and performing a whole house head count to account for all residents. At that time, V3 stated the facility had not had a resident elopement within the past 6 months. V3 further stated that all resident family members and visitors are given the code to the facility front door to enter and exit the building, at which time any alarm would be silenced. States R1 was assessed upon admission as not being an elopement risk. States on 12/4/25, V12/Former MDS Coordinator completed a BIMS (Brief Interview of Mental Status) which documented that R1 was cognitively intact. At that time, R1 was determined to not be an elopement risk. When asked why R1 had documentation in his medical record that includes licensed staff documenting R1 was confused, V3 stated that R1's confusion was intermittent. On 2/19/26 at 12:18 P.M., V1/Administrator stated R1 did not have a (wandering alert bracelet) in place on 12/10/25 when he exited the facility door, around seven pm, unannounced to staff, in freezing temperature conditions with only a tee shirt and sweatpants on, and was found by a patrolling police officer in the middle of the facility parking lot with his wheelchair over turned, lying injured on the road. V1 states R1's BIM (Brief Interview for Mental status) was 13:15, despite licensed staff documentation of confusion. States she reviewed the facility camera footage of the front door on 12/10/25 at it shows R1 open the first door at 7:08 PM, the outside door at 7:09 PM and the front door alarming until 7:13 PM, when a facility visitor (unable to clearly see who that was) entered a code in the alarm pad, shutting off the alarm. V1/Administrator states no facility staff responded to the alarm, no Code Yellow was announced to alert staff to a missing resident, and no head count was performed to determine who the missing resident was. V1 states V5/Certified Nursing Assistant was observed leaving the facility through the front door at 7:15 PM. V1 stated that V5 reentered the facility sometime later, but she doesn't remember what time that was. When V1 was asked to share the video footage of R1 leaving the facility on 12/10/25 unattended, V1 stated she no longer was able to view the footage, as it is deleted after 3 days. V1 stated when R1 was questioned by staff after the incident he told staff he was looking for a car to steal, as he wanted to go home. V1 then stated a local police officer found R1 lying on the ground, approximately 1/10th of a mile from the entrance of the facility, in an unlit area of the facility parking lot, that is used as an access road for occupied, independent apartments. V1 states she doesn't know who the officer was and does not have a copy of the officer's report despite the officer coming into the facility to interview staff after the incident. V1 states R1 was transported to the local emergency room with a contusion to the top of his head, his left hip and his left elbow. At that time, V1 states she does not consider R1 leaving the facility as an elopement and did not report the incident to the state regional office.On 2/19/26 at 12:34 P.M., V5/Certified Nursing Assistant (CNA) stated she had been a CNA since 2019, working at the facility. States she recalls R1 on the evening of 12/10/25 as being agitated and wandering. States she witnessed the day shift nurse (V13/Licensed Practical Nurse) go to the front door during shift change and turn R1's wheelchair around and bring him back to the nurse's station, as R1 was attempting to leave the facility. States she frequently worked with R1, and he had definite periods of confusion and agitation. States as far as she recalls, R1 did not have a (wandering alert bracelet) in place. States she was assigned 500 Hall on the evening of 12/10/25 and R1 was her resident. States no one told her to monitor R1 closely that evening or to do anything different for R1. States she doesn't recall hearing the front door alarming prior to her leaving around 7:15 P.M. to go to her car in the parking lot to take a break. States she recalls it was very cold outside; the wind was blowing, and it was snowing. States as she was walking towards her car, she saw a police car down by the facility mailboxes stopped in the road, and a wheelchair overturned and a person lying in the road. States she had no idea it was a facility resident. States when she ran towards the scene, she realized it was R1. States that V7/Police Officer was providing care for R1 and stated she had called an ambulance for R1 as he was bleeding from his head and his elbow. States she ran back to the facility to get R1's nurse (V4/Licensed Practical Nurse) and some blankets, as R1 was laying on the ground, stating he was cold, in only a tee shirt and a pair of sweatpants. States after R1 left via ambulance, V7 came into the facility, and she was required to give a statement of the details. On 2/19/26 at 12:55 P.M., V13/Licensed Practical Nurse (LPN) stated she has worked at the facility for the past two years as a nurse. States she worked day shift the day of 12/10/25 and (R1) was her assigned resident. States R1 had recently admitted , had periods of confusion and agitation and liked to wander in his wheelchair. States she recalls the night nurse (unable to recall who) told her R1 had been agitated most of the night (12/9/25) and was still agitated during the morning of 12/10/25. States during shift change, at 6:00 P.M. she had to go to the front door and turn R1's wheelchair around, as he was trying to leave. States she passed on to V4/Licensed Practical Nurse the oncoming nurse about R1's agitation. On 2/19/26 at 1:27 P.M., V9/R1's spouse stated R1had been in the hospital prior to being brought to the facility, for a period of time with pneumonia. States she had to hire help to sit with R1 around the clock as he was restless, confused and agitated. States she told facility staff about R1's confusion upon his admission to the facility and they told her they could not provide one to one care for him. States she had been to the facility the day of 12/10/25 and R1 kept stating he wanted to go home and had tried to get out the door. V9 states that R1 frequently stated he wanted to go home and was restless. V9 states when she got the call from the facility that R1 was found outside of the facility she wasn't surprised. V9 states she met with V1/Administrator, V2/Director of Nurses and another nurse she is unable to recall whom, in the DON's office after the incident. V9 states she asked V1 why R1 didn't have a (wandering alert bracelet) in place prior to his leaving the facility unattended and V1 states that in hindsight, he should have had an alarm on.On 2/23/26 at 9:25 A.M., V14/Maintenance Director stated all facility exit doors are alarmed and a code must be entered to enter or exit the facility. States the facility front door has two doors to enter/exit. States the first door is for the (wandering alert bracelet) system, which will not allow a resident with a (wandering alert bracelet) to exit, as it locks the door if a resident with a bracelet gets too close. States the second door is locked at all times and a code must be entered. States he conducts routine weekly checks of all facility doors. States if the door alarm is sounding and someone entering the facility enters the code, the door is unlocked, and the alarm is silenced. States as far as he is aware, most family members have been given the code to the doors so they can enter and exit as desired. On 2/23/26 at 9:32 A.M., V1/Administrator stated staff are trained during orientation by the Social Services Director (V16) on the facility Code Yellow protocol. States the facility does Code Yellow drills but is unable to state how frequently. States when a door alarm is sounding, the facility protocol is for someone to respond to the alarm and do a preliminary search of the area, if no resident is seen, Code Yellow is announced, and the nurses are responsible for completing a facility wide head check. If a missing resident is noted, then a wider facility perimeter check is completed and if the resident is unable to be located at that time, the police are called. On 2/23/26 at 9:38 A.M., V16/Social Services Director stated most (facility) family members have the code to the front door so they can enter and exit anytime.On 2/23/26 at 9:47 A.M., V4/Licensed Practical Nurse stated he was working the evening of 12/10/26 and R1 was assigned to him. States he had been assigned to R1 in the past and knew R1 was confused at times. States he had witnessed R1's spouse enter the code to the front door in front of R1 many times during the evening. States R1 even knew the code to the front door as V4 had overheard R1 repeat it. States when he came to work on 12/10/25 at 6 PM, he was told in report that R1 was very agitated and anxious. States when he talked with R1, that R1 was very fixated and adamant that he had to be somewhere. States R1 was wandering around, going to the front door repeatedly. States he made the decision to administer Lorazepam 0.5 MG (milligrams) by mouth to R1 in an effort to get R1 to calm down. States after he administered the Lorazepam at 6:54 PM, R1 remained in the lobby, in his wheelchair while V4/LPN headed down the hall to pass evening medications to other residents. States he did not place R1 on 1:1 supervision. States he did not inform R1's assigned CNA to increase supervision of R1. States he did not hear the door alarm when he was down the hall taking care of other residents and did not know that R1 had exited the facility. States he only became aware of the situation when V5/Certified Nursing Assistant ran back into the facility to alert him that R1 was injured in the parking lot. States it is common practice in the facility for resident family members to be given the code to the door alarm, so they can come and go as they want. On 2/23/26 at 10:10 A.M., V7's spouse entered the facility front doors by entering a code into the two doors. At that time, stated his spouse has been a resident since last fall and facility staff provided him with the code to the doors upon her admission.On 2/23/26 at 11:29 A.M., V8 and V9's daughter entered the facility front doors by entering a code into the doors. At that time, she stated how else am I supposed to get in and out. They gave me the code a long time ago.Abatement Plan received on 2/23/26 at 5:48 P.M., from facility Administrator. After review, revision requested.Abatement Plan received on 2/24/26 at 11:23 A.M., from Facility Administrator. After review, revision requested.Abatement Plan received on 2/24/26 at 1:10 P.M., from facility Administrator. After review, Abatement Plan was accepted on 2/24/26 at 4:19 P.M.On 02/24/2026 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:Immediate action(s) taken:Resident in question was discharged to home on [DATE] and no longer resides at facility. On 12/10/25, resident was placed on facility's elopement program with placement of (wander alert bracelet). Elopement assessment and care plan were updated to reflect his risk for wandering/elopement by social service director/DON/designeeOn 2/23/26, a facility-wide elopement audit using the elopement assessment in PCC was conducted by Social Service Director.On 2/23/26, all exterior door codes were changed by facility Maintenance Director On 2/23/26, all employees in-serviced by all department managers on elopement and wandering residents and accidents and supervision policy including only employees are to have door codes.On 2/23/26, Care Plans reviewed and updated as needed for residents at risk for elopement by social service director/DON/designee2. Immediate action(s) taken to ensure all residents at risk for elopement are reported and assessed:On 2/23/26 Elopement policy was reviewed by administrator/regional nurse consultant/DONDON will review all new admission to monitor all interventions are in place for residents at risk for elopementAs part of our orientation new hires will receive education on wandering, elopement, and safety by social service director/DON/designeeOn 2/23/26 all department mangers in-service by administrator on elopement and wandering residents and accidents and supervision policyOn 2/23/26, all employees in-serviced by their department managers on elopement and wandering residents and accidents and supervision policy including only employees are to have door codes. Employees are to assist all visitors in and out of the facility to ensure resident safety2/24/26 (wander alert bracelets) are in the 300-narcotic drawer nurses are in-serviced by DON. Nurses are aware of how to place (wander alert bracelet) on residents. The DON/designee will be informed3.Immediate action(s) taken to ensure the facility is adequately monitoring and assessing all residents at risk for elopement QAPI policy and improvement to review and interpret all audit findings. All findings will be discussed at monthly QAA for a minimum of 3 months or until facility is compliant at risk for elopement. DON/designee will audit 3 times a week for 1 month then weekly for 2 months using the elopement assessmentResidents at risk for elopement will be reviewed and (wander alert bracelet) applied, care plan updated, doctor orders obtained, and placed in elopement binder by social service director/DON/designeeIDT during morning meeting to review high risk residents who are at risk for wandering and or elopementAll new admissions and readmissions will be reassessed for wandering and risk for elopement and will update plan of care as needed by social service director/DON/designeeSocial Service Director will maintain the elopement binder and update care plan with all new interventionsMonitoring of all residents for statements such as I want to go home or other expressions indicating a desire or need to leave, to help maintain their safety will be conducted by nurses/social service director/DON/designee Abatement completion date: 2/23/26

Based on record review, observation, and interview, the facility failed to protect a resident from physical abuse for one of four residents (R1) reviewed for abuse in the sample of four. This failure resulted in V3 and V4 being physically abusive during cares to R1 resulting in R1 sustaining finger tipped shaped bruising to both of R1's upper arms.Findings include:The facility's Abuse, Neglect, and Exploitation policy, revised 2/11/2025, documents: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.R1's Electronic Medical Record/EMR document the following: R1 was admitted , to the facility, 10/21/25; Diagnosis to include- Acute Pyelonephritis, Urinary Tract Infection, Cerebral Infarction, Rheumatoid Arthritis, Congestive Heart Failure, Age-Related Osteoporosis, Cognitive Communication Deficit, Lack of Coordination, Abnormalities of Gait and Mobility, Atrial Fibrillation, Gastro-Esophageal Reflux Disease, Hypertension, Presence of Cardiac (implantable) Defibrillator, Cardiomegaly, and Urge Incontinence; and R1's Brief Interview for Mental Status is 15/15 which indicates R1 is cognitively intact.The local police department Officer Incident Report, written by V7/Police Officer, dated 10/29/25, documents: At 1659hrs [4:59 p.m.], I [V7] made contact with [V2/Director of Nursing]on the phone. The following is a summary of my [V7] conversation with [V2]: She advised that she is the Director of Nursing for [the facility] and had received a phone call from [V5/Certified Nursing Assistant-CNA], who told her that [R1] had reported to [V5] that two CNAs from dayshift, identified as [V4/CNA and V3/CNA] had been forceful with [R1] and threw [R1] into a recliner. [V2] reported that [V5] told [V2] that [R1] has visible bruising on both arms. [V2] said that [V2] is no longer at work, but that [V5] is currently working 2nd shift and would be able to tell me [V7] in more depth as to what happened and what was reported to her. I [V7] advised [V2] that I [V7] would be going out to [the facility] to speak with [V5] and to [R1] if possible. At 1716hrs [5:16 p.m.], I [V7] arrived [the nursing home name] and initially spoke with [V8/Licensed Practical Nurse-LPN] at the main nurse's station. [V8] advised that she would be taking me to [R1's] room, where [V5/CNA] and [V6/LPN] were currently with [R1]. I [V7] entered the room and began speaking with [R1] about what she had reported to [V5]. [R1] said that after breakfast this morning, she went to physical therapy from 9:00-9:30 am. [R1] said when she was done with physical therapy, the therapist wheeled her into the hallway to wait for the CNAs to come and get her and take her back to her room. [R1] said the (V3 and V4) arrived and wheeled (R1) back to her room. [R1] said that the CNAs were verbally forceful with her and demanding that she get up from her wheelchair and sit in her reclining chair. (R1) said that she tried to tell (V3 and V4) that due to her physical limitations from osteoarthritis and osteoporosis, she was not physically capable of getting up from her wheelchair and getting into her recliner. [R1] said that (V3 and V4) started yelling at her and telling her she was being uncooperative and started getting very angry at her. [R1] said that was when (V3 and V4) grabbed her under her arms, squeezed her, and then forcefully threw her down in her recliner. [R1] said she told (V3 and V4) to stop being so forceful with her and told (V3 and V4) that they hurt her. [R1] said after (V3 and V4) got her in the chair, they left and she never saw anyone else throughout the day until [V5] came in to check on her at the start of 2nd shift. I [V7] asked [R1] if I [V7] could take pictures of her bruises that were caused by the earlier incident with (V3 and V4). [R1] told me I [V7] could take pictures. Those pictures have been attached to this report. I [V7] then asked [R1] what she would like to see happen with this incident that was reported. [R1] said that [R1] does not want to have [V4] or [V3] as her CNAs anymore and requested that they [V3 and V4] stay away from her [R1]. [R1] further said that she did not want [V4] and [V3] to get in trouble with the Police, but she would be okay if they got suspended or removed from their position at [the facility] so they are not able to hurt anyone else. After general conversation with [R1], I [V7] asked [R1] again before I [V7] left [R1's] room if [R1] wanted to file charges against the CNA's and [R1] said no and just wanted them disciplined through [the facility]. I advised [R1] that I would be doing a report and sending the report to the [State] Department of Public Health, as would [V2] after [V2's] report is completed, so that [State Agency] could investigate this incident. R1's Skin check document, dated 10/29/25, at 6:21 p.m., document R1's New Skin Issue in-house acquired bruises: Right front axilla 3 centimeters/cm by 3 cm; Left front axilla 4 cm by 4 cm; Left upper outer arm 3 cm by 3 cm; Right upper outer arm (no measurement); Left front axilla 3 cm by 3 cm; Left front axilla 3 cm by 3 cm; and Left front axilla 1 cm by 1 cm. On 10/31/25, at 1:25 p.m., R1 was observed to have bruising on R1's upper inner arms and right forearm. Bruising is the shape of the pads of a person's fingers, purplish in color. When advised about the reason for the State Agency visit, R1 stated I did not want it to go this far; I just don't want (V3 and V4) taking care of me again. R1 also stated, They (V3 and V4) tried to physically put me in bed, grabbed around [R1 put her hands around her upper arms] and I yelled ouch and they threw me in bed. On 10/31/25, at 10:50 a.m., V2 confirmed the investigation, into the abuse allegation, is on-going, however, the plan is termination [of V3 and V4].On 11/4/25, at 10:05 a.m., V2 confirmed due to the completed facility investigation, V3 and V4 are being terminated.On 11/4/25, at 10:24 a.m. and 10:34 a.m., V3 and V4, respectively, both confirmed: providing cares to R1 on 10/29/25 during day shift and being suspended due to R1's abuse allegation.

Based on interview and record review, the facility failed to follow its policy for Oxygen Administration to ensure that oxygen was available for one (R1) resident of three residents reviewed for oxygen saturation in the sample of three. Findings include: Facility's Oxygen Administration Policy dated 2/10/25, documents: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. R1's current Care Plan documents: (R1) has altered respiratory status/difficulty breathing related to Chronic Obstructive Pulmonary Disease/COPD, unspecified. Intervention: Oxygen at 6 Liters per minute Via Nasal Cannula; Goal To Maintain 02/oxygen saturation greater than 90 percent. R1's Diagnoses include: Acute and chronic respiratory failure with hypoxia; Chronic Obstructive Pulmonary Disease/COPD, Unspecified dementia, anxiety. R1's Hospital Notes dated 3/5/25 documents: Diagnosis Hypoxia; reason for visit shortness of breath. R1's Physician Orders include: Every shift ensure resident has (oxygen) on. On 3/26/25 at 9:55am, V2 Director of Nursing/DON stated that CNAs can check oxygen tanks; stated that when R1 was sent to Emergency Department/ED on 3/5/25, that no one had checked R1's oxygen tank when R1 went down to Activities prior to being sent out. At this time V2 stated: (V10 Registered Nurse/RN) told me that she got the (portable oxygen tank), put it on R1's wheelchair and put the nasal cannula in R1's nose; that she did not check to see if the tank was full. The Activity Director (V7) came to get R1 after breakfast, Activity was an hour. (V10) went to get R1 from Activities and realized the portable was empty; it was light. She took R1's 02 (oxygen saturation) and it was 64%--never went up higher than that. (R1) was sent to the ED. On 3/26/25 at 11:10am, V10 Registered Nurse/RN stated that on 3/5/25, R1 was in Activities and V10 checked on R1; stated that she did not know who took R1 down to Activities and was not sure if R1's portable oxygen tank was checked. Stated that in Activities, she checked R1's tank and it was empty; that when she checked R1's oxygen saturation, it was lower than her base. V10 stated, I did not know (R1's) tank was empty until I checked it when she was at Activities. On 3/26/25 at 10:52am, V11 Licensed Practical Nurse/LPN stated that during her morning rounds, she checks R1's oxygen level to make sure it is okay as it drops below her base (90 to 95) at times when R1 is sleeping. V11 stated, I like to keep an eye on (R1) because her oxygen saturation went to 85 at one time. She has issues with breathing and has COPD (Chronic Obstructive Pulmonary Disease). On 3/26/25 at 1:30pm, V2 DON stated: Ultimately the nurse should make sure oxygen is on and it (portable tank) is filled; responsibility is the nurses to make sure the oxygen is on, tank is filled and make sure the resident has oxygen.

Based on interview, observation, and record review the facility failed to monitor a urinary indwelling catheter every shift for color and clarity and ensure an indwelling urinary catheter was free of kinks and had freely flowing urine for one of three residents (R5) reviewed for indwelling catheters in a sample of 11. These failures resulted in R5 being admitted to the hospital with Severe Septic Shock, Acute Kidney Injury, and Hyperkalemia which required R5 to be hospitalized for eight days. Findings include: The facility's Catheter Care Policy, dated 1/24/23, documents, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 1. Catheter care will be performed every shift and as needed by nursing personnel. 8. Empty drainage bag every shift maintaining below two thirds full. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. 24. Document and record output. Ensure to include amount, color, and clarity. R5's Admission Record documents R5 was admitted on [DATE] with the following, but not limited to, diagnoses Unspecified Dementia without Behavioral Disturbance, Chronic Kidney Disease, Obstructive and Reflux Uropathy. R5's Census List dated, 10/30/24, documents R5 went to the hospital on 10/2/24. This same form documents R5 was admitted back to the facility on [DATE]. R5's MDS (Minimum Data Set), dated 9/10/24, documents R5 has an indwelling catheter with the diagnosis of Obstructive Uropathy. R5's Care Plan, dated 9/25/24, documents (R5) has an indwelling catheter related to Urine Retention. Diagnoses Obstructive Uropathy with Bladder Distention. Interventions: Check tubing for kinks frequently each shift, and monitor/record/report to MD (Medical Doctor) for signs and symptoms of UTI (Urinary Tract Infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. This same care plan documents R5 has an ADL (Activities of Daily Living) self-care deficit as evidenced by dementia and lack of coordination. R5's Progress Note, dated 9/26/24 and signed by V24/LPN (Licensed Practical Nurse) documents (R5) c/o (complained of) pain and discomfort with catheter. (V24) assessed the area, no signs and or symptoms of infection or irritation. Area is free from malodourous scent and no redness or swelling present. (V24) flushed catheter and there was no resistance or blockage noted. (R5) has output, which is at 200 milliliters, urine does not have any blood clots, or any abnormality to color. Catheter bag was placed below waist height and secured. From 9/26/24 through 10/2/24 no evidence of further documentation regarding catheter monitoring was noted. R5's ED (Emergency Department) Note, dated 10/2/24 and signed by V14/emergency room Doctor, documents HPI (History of Present Illness): (R5) is an [AGE] year-old male comes in for further evaluation. (R5) was brought in by ambulance. (R5) was little obtunded is complaining of abdominal pain. (V22/R5's POA (Power of Attorney) saw (R5) yesterday at the (local nursing home) and felt (R5) was a little bit more out of it and a lot more lethargic. This same note documents, Abdomen: Abdomen is distended, tender in suprapubic region. Genitals: (R5) has an indwelling catheter that was noted to be twisted and when it was untwisted no drainage was coming from it. (R5) has significant erythema/yeast dermatitis in the groin and inguinal area. Once it was discovered the indwelling catheter was twisted, it was untwisted and nothing drained. Thick mucus/exudate was drained some, bladder scan showed greater than 1200 cc/cubic centimeters in bladder, a large CBI (Continuous Bladder Irrigation) catheter was placed and finally the bladder started to drain thick exudate. Concern for Sepsis: Yes, Source of infection: Sepsis Infection Source: Urinary, Sepsis/severe/septic shock. On 10/28/24 at 10:10 AM R5 was lying in his bed with his catheter drainage bag secured to the side of R5's trashcan. No kinks were noted in R5's catheter tubing. R5 was unable to recall going to the hospital. On 10/30/24 at 1:15 PM V12/LPN stated, I worked with (R5) four or five days prior to (R5) being sent to the hospital. (R5) was complaining of some discomfort with his catheter. When I went to observe (R5's) indwelling catheter, the catheter and the tubing was kinked. As soon as I untwisted the catheter, urine started flowing back into the drainage bag. V12/LPN stated she does not assess or monitor a resident's catheter when she works. V12 stated, I sign out the order for catheter care, but the CNAs (Certified Nursing Assistants) are supposed to perform catheter care, so I assume they are. I don't monitor catheters or chart on them unless an issue is reported to me. On 10/31/24 at 11:35 AM V6/LPN stated, We (the licensed nurses) do not do catheter care or monitor resident's catheter every shift. The CNAs are supposed to do that, and I assume they do. We do not chart on clarity or color or patency of the catheter as I do not check them unless an issue is reported to me by a CNA. V6 also stated that R5 had a physician order for catheter care every shift, but the nurses do not perform the catheter care, they just mark it off as complete assuming the CNAs are doing it. On 10/31/24 at 12:10 PM V21/CNA stated, I took care of (R5) on 10/1/24. (R5) wasn't acting right or himself so I went and told (V19/LPN) that (R5) wasn't acting right, was having diarrhea, and had the hiccups. I did not pay attention to (R5's) catheter whether it was twisted or not. On 10/31/24 at 12:15 PM V18/CNA stated, On 10/1/24 (V22/R5's Power of Attorney/POA) requested for us to clean (R5) up due to (R5) having diarrhea. (V22) stated (R5) was lying in diarrhea and was not acting himself. When I went and changed (R5) I noticed (R5) had some thick reddish drainage in (R5's) catheter bag. It was also not normal for (R5) to lay around like he was, (R5) is usually up moving around the building. I reported the thick reddish colored urine to (V19/LPN) and let her know (R5) was having diarrhea as well and not acting right. On 10/31/24 at 11:40 AM V19/LPN stated, I worked with (R5) a few shifts prior to (R5) being sent to the Hospital. On 9/30/24 and 10/1/24 (R5) did not leave his room which is not normal for him. Staff reported to me that (R5) was barely eating or drinking anything and wasn't having a lot of output. (R5) did have some episodes of diarrhea and hiccups both days I worked so I just monitored him. I did not do an assessment on (R5) or observe (R5's) indwelling catheter. V19/LPN also stated, We (the nurses) never perform catheter care on any resident, and I do not monitor catheter tubing or catheters to see if it is free of kinks or draining appropriately. The only time I will look at anyone's catheter is if they have a complaint something hurts. I did not assess (R5's) catheter bag or drainage tubing when staff reported to me on 10/1/24 that (R5) was not acting right. (V12/LPN) had been reporting something was a little off with (R5) prior to 10/1/24 and (R5) had issues with his catheter being kinked, but the only thing I reported to (V26/R5's Primary Physician) on 10/1/24 was (R5) had been having diarrhea and hiccups for the past few days. On 10/31/24 at 8:13 AM V14/emergency room Doctor stated that when R5 arrived in the emergency room , R5 was lethargic and R5's abdomen was distended. Upon assessment of R5, R5's catheter tubing was severely twisted into a pretzel and dirty. R5's indwelling catheter was unable to be flushed. V14 stated, When I was finally able to remove (R5's) indwelling catheter, thick pus was coming out. (R5's) bladder scan showed more than 1200 cc/cubic centimeters of urine in (R5's) bladder. (R5's) bladder couldn't drain because of how much pus was in his abdomen which caused (R5's) kidneys to shut down and (R5) had to be admitted to Intensive Care Unit. The urine was thick and foul smelling after we did a bladder irrigation for (R5). On 10/31/24 at 9:40 AM V22/R5's POA (Power of Attorney) stated, The day before (R5) was sent to the emergency room (R5) was not acting right when I was visiting him. (R5) was laying in diarrhea when I arrived at the facility and (R5's) pants were pulled halfway down. (R5's) diarrhea was dried as if no one had even checked on him. (R5) was not acting right and was very out of it. I reported it to his nurse (not aware of her name) and told them my concerns. The nurse stated she would do an assessment and have the CNA clean him up. When a CNA finally came in to clean (R5) up and I ended up leaving for the day. I had not heard anything from the facility regarding (R5's) condition so I went in the next day to check on (R5). (R5) was lethargic, laying there motionless, and in the same position he was in from the day before. (R5) was very sick. (R5) has dementia and cannot take care of himself. The staff think (R5) can, but he can't. (R5) needs to be monitored and provided with assistance more frequently. On 10/31/24 at 10:55AM V2/Assistant Director of Nursing stated she is not aware of the nurses documenting on catheter color/clarity or the catheter tubing being patent each shift on (R5). V2 stated, I know some of the staff think that (R5) can empty his own urinary draining bag or take care of his own catheter, but (R5) cannot. (R5) has Dementia and his indwelling catheter should be monitored at least every shift to ensure no kinks are in (R5's) indwelling catheter and that its draining normal without signs of infection. There is a lot of training that needs to happen. On 10/31/24 at 11:03 AM V4/Interim Director of Nursing stated the nurses should be documenting on indwelling catheters at least daily. V4 stated, The nurses should be monitoring the resident's indwelling catheter tubing, documenting on color/clarity, and if any sediment is noted in an indwelling catheter draining bag or tubing. They should also be ensuring the catheter tubing is patent and draining urine freely. I know they are not doing that now. We (the facility) have a lot of new nurses and I believe it's caused by lack of training that we are working on now. On 10/31/24 at 6:36 PM V23/Agency LPN stated, When I arrived on my shift on 10/2/24, I received report that (R5) had been having diarrhea, hiccupping, and belching for at least the past two days and that (R5) was not acting like himself. When I assessed (R5) you could see (R5's) abdomen was clearly distended. I did not check (R5's) catheter tubing or urinary drainage during that time, I just sent him out to the emergency room .

Based on observation, interview, and record review the facility failed to ensure all facility door alarms sounded loud enough for immediate staff response, immediately search the premises for a resident once a door alarm was heard sounding and provide adequate supervision to a cognitively impaired resident with a history of exit seeking for one of three residents (R1) reviewed for elopement risk in the sample of five. These failures resulted in R1, a severely cognitively impaired resident with the diagnosis of Dementia, exiting the facility without staff knowledge or supervision on 9-10-24, walking over 1635 feet down a hill, falling by a tree that was located approximately 25 feet from a main street, causing R1 to sustain two fractures to the end of the forearm (at the wrist), excruciating pain, abrasions to the chin and right arm, and hospitalization for treatment. Findings include: These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9-19-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. The facility's Elopements and Wandering Residents policy dated 5-6-24 documents, Policy: The facility ensures that resident who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering and elopement risk. Definition: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Policy explanation and compliance guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risk, and monitoring of effectiveness and modifying interventions when necessary. 4. Monitoring and managing residents at risk for elopement or unsafe wandering. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team. b. The interdisciplinary team will evaluate the unique factors to contributing the risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the residents' behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. R1's Admission Record documents R1 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Parkinsonism, Dementia, Neurocognitive Disorder with Lewy Bodies, Altered Mental Status, Depression, Muscle Weakness Unsteadiness on Feet, Lack of Coordination, Hallucinations, and a History of Falling. R1's current Order Summary Report documents, Order date 1-31-24: (electronic monitoring bracelet) check for function and placement daily. R1's current Care Plan documents, Focus 2-2-24: I (R1) wander with no rational purpose, seemingly oblivious to my needs or safety throughout the healthcare center. Goal: I will wander safely within the facility by next review. Interventions: I wear an (electronic monitoring bracelet) to my left wrist. Please check it works routinely to ensure my safety. I am at risk for falling due to lack of coordination, limited mobility, forgetting my limits, the diagnosis of Parkinsonism, and due to psychotropic medication use. R1's Fall assessment dated [DATE] documents R1 was at a high risk for falls. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired. R1's Elopement Risk assessment dated [DATE] documents R1 was a high risk for elopement, was fully ambulatory, wanders aimlessly, and has two or more diseases (Dementia, any type of mental illness). R1's Social Service Note dated 2-2-24 at 1:26 PM and signed by V10 (Social Services) documents, (R1) admits for long term care. (R1) did reside with (V6/R1's Family member) but due to (R1's) progression of Dementia, (V6) is unable to care for (R1) at home safely. (R1) at times is able to answer conversations appropriately (and) other times seems to not understand or articulate answer that goes with conversation at hand. (R1) is in the memory unit. (R1) also has displayed exit seeking behaviors generally toward afternoon and nights. (R1) does have an (electronic monitoring device bracelet) for safety measures as (R1) is new to her environment and does have episodes of active wandering and exit seeking behavior. R1's Local Police Department Incident #24-EUREKA-03436 dated 9-10-24 at 4:55 PM and signed by V3 (Local Police Officer) documents, On 9-10-24 at approximately 4:55 PM, I (V3) was on routine patrol around the (facility campus) and I was flagged down by (V4/Chief Executive Officer Assisted Living) in regard to a missing resident (R1). I advised (V4) that I was not notified of any missing person and advised that I was just driving through, but that I would help locate (R1). (V4) advised (R1) has been reported missing from the memory care facility within (the facility) about 15 minutes prior to (V4) flagging me down. Several staff members were on foot looking for the missing female. While searching the area, (V1/Administrator) flagged me down and advised that the missing resident (R1) had been located in the front of the building. I was advised that (R1) was walking and fell down the steep hill and has several injuries. It appeared that (R1) had a broken left wrist, a laceration on her right elbow, a laceration on her chin, had bit her tongue which was causing her mouth to bleed, and was complaining of back pain. It should be noted that (R1) told nearby staff that she was trying to escape from the building on purpose. (R1) said she was waiting on everyone to leave for the day, and she was planning her escape out the doors, which (R1) was successful at and had been missing for about 15 minutes before it was noticed that (R1) was gone from the facility. R1's Health Status Note dated 9-10-24 at 5:09 PM and signed by V5 (Agency LPN/Licensed Practical Nurse) documents, (R1) noted outside in front of facility laying on her backside. Upon assessment (R1) has a swollen left wrist and an abrasion to her chin area. (R1) c/o (complains of) pain and states she is unable to stand with assistance. When asked what occurred prior to fall (R1) states that she was on her way to her appointment, when she lost her balance and fell , landing on her back. AMT (Advanced Medical Transport) contacted for transportation to ER (emergency room ). (V6/R1's Family Member) also notified of (R1's) fall and elopement. Staff waiting along with (R1) until AMT is here for transport. Will continue to monitor. R1's Health Status Note dated 9-10-24 at 5:22 PM and signed by V5 (Agency LPN) documents, AMT present to transport (R1) to (local hospital) for evaluation and possible treatment. All appropriate parties notified. Bed hold sent with (R1). Will continue to monitor. R1's Health Status Note dated 9-10-24 at 5:55 PM and signed by V8 (LPN) documents (V8) was reported that elopement of (R1) outside of the parking lot. (V8) went to observe (R1) laying on the ground. (R1) was on her back side with open areas on her elbow and knee. (V8) also noticed that (R1's) left wrist was swollen. EMT (Emergency Medical Transport) were called and (V6/R1's Family Member) and (V7/R1's Physician) notified. (V8) went to check doors to see how (R1) escaped. (V8) noticed that hall six fire exit door alarm was going off. (V8) came back upstairs and noted that no sound of alarm or light (was) going off at the nurse's station. (V8) notified staff to call maintenance man to come assess the alarm system. R1's Emergency Department Note dated 9-11-24 documents, Chief Complaint: (R1) left the (facility) and was found lying down after rolling down/sliding down a hill. EMS (Emergency Medical Service) reports deformity to the left wrist. (R1) complained a 10/10 pain and EMS provided 50 mcg (micrograms) of Fentanyl, four mg (milligrams) of Zofran, and splint the left wrist. (R1) has dementia. (R1) states she was going out to get her car when she began to stumble and slid down a hill and hit a tree. Has pain in her left wrist but denies further pain. Abrasion to midline chin noted. Clinical Impressions: Closed fracture of distal end of left ulna and left radius (end of forearm bones at the wrist). R1's X Ray Report of the Left Wrist dated 9-11-24 documents, Impression: Acute distal forearm fractures with associated soft tissue swelling. R1's Health Status Note dated 9-11-24 at 4:35 AM and signed by V9 (LPN) documents, (R1) arrived back to facility at approximately 3:30 this am via transport from (V6). (R1) has an ulnar (forearm) fracture as well as a radial (wrist) fracture. (R1) also has an abrasion of the face. (R1) has a referral made with (Orthopedics). (V6) will keep us updated on exact date of appointment. (R1) currently in room in bed resting. On 9-13-24 at 2:00 PM V23 (Maintenance Director) used a measuring wheel to measure and determine the distance from the door of where R1 exited the building on 9-10-24 to where R1 was found lying on the ground by the tree. There were two routes R1 could have taken. V23 measured both routes with one route measuring 1635 feet from the exit door to the right, through the parking lot, and down a hill to the tree. The other route measured 2475 feet from the exit door to the left and around the building to the bottom of the tree. The tree where R1 was located was approximately 25 feet from the main street in (City facility is located). On 9-13-24 at 3:15 PM R1 was lying in bed at a local hospital. R1 had a four-centimeter scabbed abrasion to the chin, seven-centimeter-long dark purple bruise to the right elbow, and a few small abrasions to the right lower arm. R1's left forearm was in a removable casting splint. R1 was confused to time and place. On 9-13-24 at 6:15 AM V1 (Administrator) stated, On 9-10-24 around 4:47 PM, (V11/Housekeeping Supervisor) heard an (electronic monitoring device) alarm going off at the north door of the basement level. (V11) was trying to shut the alarm off and could not get the alarm to shut off. (V11) grabbed me to help. We initially looked around outside and did not see any residents. (V22/Human Resource Director) called a 'code yellow' over the intercom and we did a head count in the facility and noticed (R1) was missing. (V11) and I went outside and searched the entire perimeter of the facility. Other staff helped look for (R1) and (V12/CNA/Certified Nursing Assistant) found (R1) down by the road, on the ground by a tree. It appeared (R1) had fractures her wrist and was sent to the emergency room . After the incident I watched the cameras and saw (R1) go to the elevator and go downstairs at approximately 4:20 PM. I saw (R1) go down the hallway and around to the back. There are no cameras in the back hallway to see what (R1) did after that. Since the (electronic monitoring device) alarm was sounding we determined (R1) had exited out of the north door. That door has a delayed egress of 15 seconds but there is no alarm hooked up to sound when the door opens except for the (electronic monitoring device) alarm. On 9-13-24 at 6:30 AM V14 (CNA) stated, (R1) says frequently that she wants to go home. (R1) forgets her walker and we must remind her to use it. On 9-13-24 at 6:40 AM V18 (CNA) stated, (R1) is not safe to go outside unattended and forgets to use her walker. On 9-13-24 at 8:00 AM V20 (Activity Director) stated, (R1) tries to exit seek and gets confused. (R1) goes to the lobby doors and tries to go out. On 9-13-24 at 8:10 AM V11 (Housekeeping Director) stated, I heard an alarm that sounded muted like a phone alarm going off (on 9-10-24). It was around 4:45 PM. I had to look around to find where the alarm was sounding off. I found the north basement door (electronic monitoring device) alarm sounding at the north door in the basement. (R5) was standing down by the door, so I thought (R5) had sounded the alarm. I tried to shut the alarm off and could not get the alarm to shut off. I found (V1) and had (V1) go down with me to try to shut the alarm off. In the meantime, two CNAs (V12 and V21) came down and were looking for (R1) to give (R1) a shower. (V1) then said maybe (R1) had set off the alarm. (V1) and I went outside to look for (R1) and a 'code yellow' was sounded over the intercom. (V1) and I searched the entire perimeter and could not find (R1). A little while longer (V12) found (R1) on the ground, down the bottom of a hill, by a tree, that was by the road. (R1) had walked a long way without her walker and had fallen. (R1) had to be sent to the emergency room . The tree is close to the road. On 9-13-24 at 10:00 AM V12 (CNA) stated, I was working on 9-10-24 from 2:00 PM to 10:00 PM. Sometime before supper (V21) was looking for (R1) to give (R1) a shower and could not locate her. Me and (V21) searched all the hallways and resident rooms and could not find (R1). We went downstairs and looked for (R1) and could not find her. That is when I found (V11) by the back door. I got (V13/MDS/Minimum Data Set Coordinator) to help look for (R1). I have been a CNA for a long time and thought I needed to search by the road first. I found (R1) down a hill, lying by a tree on her back with her left leg crossed over her right leg. (R1) had blood on her chin, had bit her tongue, had abrasions to her arms, and her left wrist looked deformed. I got help from (V1 and V13) and 911 was called. On 9-13-24 at 10:20 AM V13 (MDS Coordinator) stated, On 9-10-24 (V12) asked for my help to find (R1). I went outside to help find (R1). (R1) was found lying on her back by a tree and her left wrist was swollen. (R1) was sent to the emergency room and had a broken wrist. Earlier that day (R1) had asked for a code to try to leave through the front door. (R1) was always saying she wanted to go home. (R1) came to this facility for more security because she had eloped from another facility prior to her admission here. (R1) is not safe to be outside unattended by staff. On 9-14-24 at 10:10 AM V6 (R1's Family Member) stated, I was called on 9-10-24 and was told (R1) was being sent to the hospital because she had got out of the building and had fell . (R1) had broken her wrist in two places and had abrasions on her legs, arms, and chin. I had put (R1) in the nursing home because (R1) needed more supervision and her dementia was worsening. I put (R1) in a nursing home and (R1) had got outside of that nursing home unattended, so that nursing home decided (R1) needed more supervision. So, back in January (R1) was transferred to this facility. (R1) cannot be outside without supervision. (R1) does not even know where she is at or what town she is in. The Immediate Jeopardy started on 9-10-24 at 4:20 PM when R1 left the facility without knowledge or supervision of staff and eloped over 1635 feet down a hill, falling by a tree that was located approximately 25 feet from a main street, causing R1 to sustain two fractures to the end of the forearm (at the wrist), excruciating pain, abrasions to the chin and right arm, and hospitalization for treatment. On 9-17-24 at 9:45 AM, V1 (Administrator) was notified of the Immediate Jeopardy. On 9-19-24 this surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 9/10/2024 and 9/12/2024 V1 (Administrator) in-serviced all staff in the facility regarding policies and procedures on elopement and wandering residents, prompt response to door alarms, utilization of facility protocol internal alert code alerts code yellow for elopement wandering residents, head count, and notifications. All staff not in the facility were in-serviced prior to their next scheduled shift. 2. On 9/12/2024 V24 (Social Service Director/SSD) and V13 (MDS Coordinator) conducted an audit to ensure all current residents at high risk for wandering and elopement had a care plan in place and interventions in place to ensure their safety. 3. On 9/12/2024 V1 and V25 (Vice President of Clinical Services) ensured the communication book was updated with all residents at high risk of wandering. 4. On 9/11/2024 V25 completed new elopement assessments for all residents. 5. V23 is continuing audits of door function daily for six weeks. 6. V1 is continuing to audit the communication book daily for 6 weeks to ensure the elopement procedure is fully implemented. 7. On 9/11/2024 V25 provided in-service to the Interdisciplinary Team (IDT) regarding assessing all residents quarterly who wander/exit seek and with any changes in behavior. IDT continues to review the 24/72-hour notes to assess for changes in behavior and possible completion of a current wandering risk assessment. 8. On 9/10/2024 V6 (R1's Family Member) and V7 (R1's Physician) were notified of R1's elopement with injuries and an order was given to send R1 to the emergency department for evaluation and treatment. 9. On 9/19/2024 at 11:45 AM a tour was done, and all exit doors were checked for enunciators. The front entrance door and the basement service doors were not alarmed with an enunciator as stated by the abatement plan. V1 revised the abatement plan to include applying an enunciator to the basement service doors on 9/19/24 by V26 (Corporate [NAME] President of Plant Operations) and assuring the front entrance door was double alarmed. On 9/19/24 at 1:46 PM the basement service door was alarmed with an enunciator and the front entrance door was double alarmed. Abatement completion date: 9-19-24

Based on observation, interview, and record review the facility failed to protect a resident (R5) from physical abuse from another resident (R4). This failure affects two of three residents (R4 and R5) reviewed for abuse in the sample of six. Findings include: The facility's Abuse, Neglect, and Exploitation policy dated 12-5-22 documents, Policy: Each resident has to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies, family members, legal guardians, friends, or other individuals. Physical abuse includes, but not limited to hitting, slapping, pinching, and kicking. R4's MDS (Minimum Data Set) assessment dated [DATE] documents R4 is cognitively intact. R5's MDS assessment dated [DATE] documents R5 is severely cognitively impaired. The facility's Final State Report dated 8-22-24 and signed by V6 (Administrator) documents, CNA/Certified Nursing Assistant (V10) notified abuse coordinator about (R4) hitting (R5). (V10) immediately removed (R5) from the area. (R5) has three small scratches on left side of face. Allegation of abuse substantiated. V3's (Local Police Officer's) Incident Report #24-EURK-03129 dated 8/21/2024 documents, I (V3) made contact with (the facility) Administrator (V6) in regard to (R4) that had struck another resident (R5) in the face approximately three times with her hand on 08/17/2024 at approximately 11:30 hours. V6 stated that another employee (V10/CNA/Certified Nursing Assistant) had checked on (R5) on said date and time because (R5's) door was shut. According to (V10's) statement (V10) checked on (R5) and asked him why his door was shut. (R5) informed (V10) that (R4), who lives across the hall, entered his (R5's) room, yelled at (R5). and smacked (R5) in the face approximately five times. (V10) also states that (R5's) face was red and he did have two fresh scratches on his face with blood. According to (V10), (R4) functions normal and is aware of the actions she takes. (V10) stated she reviewed the hallway video and observed (R4) walk into (R5's) room then walk back to (R4's) room approximately thirty seconds later, during the time of the incident. V10's statement dated 8-17-24 documents, I (V10) went to get (R5) up for lunch. When I got to (R5's) room, I noticed his door was shut. (R5) replied that the lady (R4) across from him came to (V5's) room and yelled at him and smacked (V5) five times in the face and told (V5) to shut up and then shut his door. (R5's) face was red and (R5) did have two fresh scratches on his face with blood. R5's statement dated 8-17-24 documents, I was sleeping in my bed and a lady (R4) across the hall came in. I forget what (R4) said but she said quite a bit. (R4) hit me three times. I told (R4) to stop. R4's statement dated 8-19-24 documents, (R4) stated, I know exactly who you are talking about, and I am not going to admit or deny that anything happened. It is his (R5's) word against mine. I have put up with his (R5's) yelling for a very long time and it is not right that I have to listen to (R5) every day and every night. I have lived here for [AGE] years, and I cannot stand it no longer. That is all I have to say about that. You can leave now. R5's Progress Notes dated 8-17-24 and signed by V5 (RN/Registered Nurse) document, Skin note: Two 0.5 cm (centimeter) abrasions to left jawline. On 8-30-24 at 9:40 AM, R4 was sitting in a recliner in her room. R4 refused to talk to this surveyor about the incident regarding her and (R5). R4 stated, I am not saying nothing. I was tired of (R5) screaming so I took care of it. On 8-30-24 at 11:00 AM, R5 was sitting in a recliner in his room. R5 had a 0.5 cm round scab to his left jaw. R5 stated, A few weeks ago, I was lying in bed and (R4) came in my room and hit me in the face three times. I got a couple scratches from her fingernails. On 8-30-24 at 11:10 AM, V10 stated, On 8-17-24 right before lunch I noticed (R5's) door was shut which is not normal. I went into (R5's) room and (R5) told me (R4) had just slapped him five times. (R5's) left cheek was red and had two scratch marks where it looked like (R4) had got (R5) with her fingernails. I immediately got the nurse (V5/RN/Registered Nurse) to clean the blood off (R5's) face. On 8-30-24 at 11:20 AM, V6 (Administrator) stated, I was the administrator when (R4) hit (R5) in the face. I watched the cameras and saw (R4) go into (R5's) room at the time when (R5) reported that (R4) hit him in the face three times.

Based on Observation, Interview and Record Review, the facility failed protect a resident from staff-to-resident verbal and mental abuse for one of three residents (R315) reviewed for abuse in the sample of 39. This failure resulted in R315 experiencing extreme fear and mental anguish. Findings include: The facility's Abuse, Neglect and Exploitation Policy, dated 12/5/2022 documents Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friend, or other individuals. Definitions: 2. Abuse means the willful infliction injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual acted deliberately, not that the individual must have intended to inflict injury or harm. 3. Verbal Abuse means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. 6. Mental abuse also includes abuse that is facilitated or caused by nursing home staff or using photographs or recording in any manner that would demean or humiliate a resident(s). R315's Admission Record documents R315 is an [AGE] year-old female who admitted to the facility on [DATE]. This same form documents R315 has the following diagnoses: Dementia without behavioral disturbance, Major Depressive Disorder, Hypothyroidism, Type Two Diabetes Mellitus, Hypertension, and Gastro-esophageal Reflux Disease. R315's BIMS (Brief Interview of Mental Status), dated 7/24/24, documents R315 has moderately impaired cognition. R315's State Final Report, dated 7/28/24, documents Conducted an interview on 7/28/24 at approximately 1:35 AM with Certified Nursing Assistant (CNA) 2 (identified as V10/CNA), who witnessed CNA 1 (identified as V17/Agency CNA) shoving her phone in (R315's) face and telling her to call the jail to come get her. (V10) intervened and (V17) then walked back to the nurse's station, while (V10) tried comforting resident. Conducted an interview on 7/28/24 at approximately 1:45 AM, with CNA 3 (identified as V8/CNA) and she stated (V17) was screaming and walking up to (R315) aggressive and yelling at (R315) and just very aggressive. (V8) walked over to resident sitting in her wheelchair and offered water, as (V17) walked away. This same Final Report documents allegations against (V17) are substantiated based on two CNA witnesses (V8 and V10). (V17) worked for an outside agency. Agency is aware and that (V17) will not be allowed to return to work at this facility. On 7/30/24 at 9:45 AM R315 was lying in her bed and was dressed appropriately. A large purplish/black bruise was observed to R315's posterior right wrist. R315 looked terrified and tearfully stated, I am afraid of some of the staff here. I was screamed at and threatened multiple times the other night and I was scared. I am not sure who the person was. They told me I was going to go to jail. I don't feel safe. On 7/30/24 at 1:40 PM V10/CNA stated, On 7/28/24 around 12:30 AM (R315) started screaming help me from her room. (V8/CNA) and I went to (R315's room) to see what was going on. When we entered her room (R315's) voice was hoarse and she was saying I can't breathe. I took her vital signs, and they were within normal limits. (V8) and I went to the nurse and reported that (R315) stated she couldn't breathe. (V8), (V17/Agency CNA), and I were all by the nurse's station when we heard (R315) keep screaming from her room. (V17) then said, Oh no we aren't doing this tonight. (V17) then starting aggressively walking towards (R315's) room. (V8) and I started walking towards (R315's) room and beat (V17) to (R315). (V8) and I were trying to calm (R315) down from yelling, but she was agitated. (V8) and I decided to give (R315) some space in the lobby area and started walking down a different hallway to provide care to other residents. (V17) was near the nurse's station at that time charting. (V8) and I then could hear (R315) start screaming again. (V8) and I saw (V17) walk over to (R315) and she started screaming in (R315's) face telling her to shut up, you're nothing but a nuisance, and that she needed to sit down. When (V17) started yelling at (R315), (R315) looked scared, started screaming louder, and was crying. (R315) went over to the couch in the lobby area and sat down. As I started walking down the hallway, I heard what sounded like a slap. I immediately went back to the lobby area and asked what happened. (R315) was screaming help me I want to leave at that time. (V17) stated as she was walking towards (R315) when she tripped over the couch and the couch moved. (V17) stated the sound I heard was from the couch sliding. During this time (R315) was still screaming for help. (V17) then aggressively went over to (R315) pulled out her cellphone and dialed 911 on the screen. (V17) then shoved the cell phone in (R315's) face and said Call the cops because you are going to jail. The jail is right down the street and that is where you are going for acting like this. Come on call them. (R315) was really screaming and crying then. I then intervened and told (V17) she could not act like that to a resident and notified (V18/Agency Licensed Practical Nurse) of (V17's) behavior. On 7/31/24 at 9:55 AM V8/CNA stated, I witnessed (V17/Agency CNA) be verbally and mentally abusive to (R315). (R315) was walking down the hallway screaming in the middle of the night. (V17) was at the desk and said something like we are not doing this tonight. (V10) and I tried to comfort (R315) but she was agitated. We left (R315) in the lobby area to calm down and give her space. (V17) was at the nurse's station charting during this time. When I was walking down a different hallway with (V10) I heard (R315) start yelling again asking for help and screaming she wanted to leave. I then heard and saw (R315) walk over towards (R315) and started screaming at her and pointing fingers in her face. (V17) was screaming You are being a nuisance, I told you we aren't doing this tonight, you do this every night I work, and I am done. I couldn't hear everything (V17) was saying because (R315) was screaming and crying. I then witnessed (V17) pull out her cellphone, dial 911, and shove it in (R315's) face telling (R135) to call the cops because she was going to send her (R315) to jail and kept screaming in (R315's) face that the jail was right down the street and that's where she (R315) is going to live. I was scared of (V17's) behavior and scared for (R315). (R315) was very scared and crying. (V10) and I walked up to (R315) to comfort her. (V10) told (V17) to stop and (V17) walked way. I reported it to (V18/Agency Licensed Practical Nurse) with (V10) and was told by (V18/Agency Licensed Practical Nurse) to call (V1/Administrator in Training) so I did. On 7/31/24 at 2:45 PM V1/Administrator in Training stated, (V8/CNA) and (V10/CNA) called and reported to me alleged verbal and mental abuse from (V17/Agency CNA) to (R315). (V8) and (V10) both stated they witnessed the abuse. (V17) will not be allowed to come back to work here. I have not spoken with (R315) yet regarding the incident and wasn't aware that she stated she was scared. We don't have a Social Service Director, so no one has been able to provide psychosocial support for her after the alleged incident on 7/28/24. V1/Administrator in Training also verified that she had no record of Abuse Training for (V17) from the facility. V1 stated she has a binder at the nurse's desk that the agency staff reads and signs off on but verified that the abuse policy was not in the binder.

Based on Observation, Interview and Record Review, the facility failed to monitor blood sugar glucose levels and administer physician ordered sliding scale insulin timely, hold subsequent doses of insulin after a medication error, ensure a physician prescribed medication for Parkinson's (Sinemet) was dose adjusted and reordered to prevent withdrawal of therapeutic medication levels and complete medication error reports after errors were identified for two of five residents (R5, R52) reviewed for medications in the sample of 39. This failure resulted in R5 eating breakfast without scheduled insulin, suffering fatigue, drowsiness, confusion, and an elevated blood sugar level of 487 and resulted in R52 not receiving Sinemet for 25 days, resulting in increased tiredness, unsteady gait, increased tremors and decreasing the therapeutic blood level of R52's Sinemet from the prescribed dosage increase plan. Finding include: The Facility Medication Administration Policy, dated [DATE], documents Medications administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. This policy also documents for medication administration Administer within 60 minutes prior or after scheduled time unless otherwise ordered by physician. The Facility Medication Error Policy, dated [DATE], documents It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents care and services safely in an environment free of significant medication errors. Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principals which apply to professionals providing services. Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. This policy also documents The facility must ensure that it is free of medication error rates of five percent or greater as well as significant medication error events. The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include but not limited to incorrect dose, route of administration, dosage form, time of administration, medication omission, and incorrect medication. This policy also documents If a medication error occurs, the following procedure will be initiated. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. Document actions taken in the medical record. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report. The Facility Timely Administration of Insulin Policy Dated [DATE] documents It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. This same policy documents All insulin will be administered in accordance with physician's orders. Insulin administration will be coordinated with mealtimes and bedtime snacks unless otherwise specified in the physician order. The facility's Medication Reordering Policy, dated [DATE], documents, Policy: It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. Definitions: Acquiring medication is the process by which the facility requests and obtains a medication. Policy Explanation and Compliance Guidelines: 1. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting. 1. R5's current Medication Administration Record (MAR), dated [DATE]-[DATE], documents R5 has an order for blood glucose monitoring followed by a sliding scale Insulin Aspart Injection Solution 100 units/milliliter. Inject as per sliding scale: if 110 - 140 = 5; 141 - 169 = 6; 170 - 199 = 7; 200 - 229 = 8; 230 - 259 = 9; 260 - 289 = 10; 290 - 319 = 11; 320 - 349 = 12; 350 - 399 = 13 call provider for above 400, subcutaneously before meals related to Type Two Diabetes Mellitus. This (MAR) documents administration times are 7:30 AM, 11:30 AM and 5:30 PM, before meals. R5's current Care Plan, dated ,d+[DATE], documents (R5) has Type 2 Diabetes Mellitus. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Fasting Serum Blood Sugar as ordered by doctor. Monitor/document/report as needed any signs or symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul (abnormal rapid breathing) breathing, acetone breath (smells fruity), stupor, coma. On [DATE] at 10:30 AM, R5 was sitting in his room in a wheelchair. R5 appeared to be tired and had difficulty keeping his eyes open when spoken to. R5 did not give verbal response when questioned and required assistance with taking morning medications. At this time V14 (Registered Nurse) confirmed that R5 did not have a 7:30 AM blood glucose check or insulin and that R5 has already eaten breakfast. V14 stated she is new and just hadn't got to R5 yet during her morning medication pass. At 10:40 AM, V14 checked R5's blood sugar and the result was 487. V14 then left R5 in his room and went to the nurse's station. On [DATE] at 11:28 AM, V13 (R5's Nurse Practitioner) called V14 (Registered Nurse) and gave a verbal telephone order for R5 to be given 14 units of Insulin Aspart subcutaneously and recheck blood sugar in 15 minutes. On [DATE] at 11:42 AM, V14 administered 14 units of Insulin Aspart to R5. R5's MAR dated [DATE]-[DATE] documents on [DATE] at 12:24 PM R5's blood sugar was 356 and V14 administered another 13 units of scheduled Insulin Aspart. This same MAR documents on [DATE] at 5:30 PM, R5's blood glucose level was 91 and no sliding scale Insulin Aspart was indicated to be administered. On [DATE] at 1:49 PM, V13 (R5's Nurse Practitioner) confirmed she gave a one-time order for R5's insulin on [DATE] when his blood sugar was elevated. V13 stated she was not made aware that R5 missed his 7:30 AM blood glucose monitoring and sliding scale insulin that morning. V13 stated I was not aware that (R5) had eaten without insulin. Knowing that may have changed my treatment. I would not expect the high dose of insulin to be given and then administer another large amount of insulin less than an hour later. The additional 13 units of sliding scale insulin should have been held. (R5's) blood sugar should have just been monitored at that point since the one-time dose was given so close to the next scheduled sliding scale dose. (R5) is not typically sleepy or lethargic when I see him in the facility. That was likely from eating and missing the morning insulin which resulted in his blood sugar elevating. Nurses should be letting me know all the facts. I depend on them to alert me of changes since they see the residents every day and can recognize what is and isn't normal. R5's current electronic medical record does not document a medication error report was completed for R5's insulin medication error on [DATE]. On [DATE] at 10:30 AM, V1 (Administrator in Training) stated she does not have a medication error report for R5. 49187 2. R52's Neurology After Summary Visit, dated [DATE] and signed by V15 (R52's Neurology Nurse Practitioner), documents Read the attached information 1. Carbidopa; Levodopa Tablets 2. Parkinson's Disease. Start Sinemet 25-l00 mg (milligram) tablets. Week l: 0.5 tablet in AM, Week 2: 0.5 tablet twice a day. Week 3 and 4: 0.5mg TlD (three times a day). (The Facility) staff is to update this office weekly while titration. Will send refills if tolerating. This same Summary Visit had attached information as follows: Carbidopa; Levodopa Tablets- treats the symptoms of Parkinson disease. It works by increasing the amount of dopamine in your brain, a substance which helps manage body movements and coordination. This reduces the symptoms of Parkinson, such as body stiffness and tremors. Do not stop taking except on your care team's advice. You may develop a severe reaction. Parkinson's Disease- causes problems with movements. It makes it harder for you to walk or control your body. It is a long-term condition that gets worse over time. Symptoms of this condition can vary. The main symptoms can be seen in your movement. These include shaking or tremors that you cannot control. This happens while you are resting. Stiffness in your neck, arms, and legs. Trouble making small movements that are needed to button your clothing or brush your teeth. Losing facial expressions. Walking in a way that is not normal. You may walk with short, shuffling steps. Loss of balance when standing. You may sway, fall backward, or have trouble making turns. R52's MAR (Medication Administration Record), dated [DATE], documents no administration of Sinemet from [DATE] to [DATE] or a new physician order to give Sinemet for a total of 19 missed days. R52's Fax Sheet, dated [DATE] and signed by V15/R5's Neurology Nurse Practitioner, documents Resume Sinemet ,d+[DATE] titration as attached on this prescription. Nursing to contact once beginning of Week 4 with an update of medication (or sooner if needed). Will determine new dose adjustment after update is received. Do not allow medication to expire. R52's MAR, dated [DATE], documents no administration of Sentiment from [DATE] to [DATE] or a new physician order to give Sinemet for a total of five missed days. On [DATE] at 9:54 AM, R52 had a (electronic wandering monitor bracelet) located on her left wrist. Resident was sitting on the couch sleeping in the activity room on the memory care unit. On [DATE] at 10:11AM, R52 was sitting hunched over on the couch sleeping in the activity room on the memory care unit. R52 was non-responsive to verbal stimuli. V9 (Licensed Practical Nurse) stated, (R52) has been sleeping all day recently. That is not like (R52). When (R52) does wake up she has been shaky and has an unsteady gait. I am not sure what is going on with her. V9 confirmed that (R52's) Sinemet order had expired on [DATE]th and no new order was received from V15's (R52's Neurology Nurse Practitioner) office before it expired. On [DATE] at 1:41 PM, V16/Neurology Office Nurse stated she was unaware that R52's Sinemet order had expired and that this is not the first time (the facility) has allowed this to happen. V16 stated, (R52) came to our office in [DATE] due to the family having concerns with (R52's) gait, balance, increased tremors, and sleepiness. (V15/R52's Neurology Nurse Practitioner) wrote a new order to start Sinemet for Parkinson's Disease. (V15) wrote the order to titrate the dose over four weeks. Before the four weeks were up the facility was supposed to update us with how (R52) was tolerating the new medication and to not allow the medication prescription to expire. We (Neurology) did not receive an update and did not know the facility allowed the Sinemet order to expire. (The facility) did not call our office until [DATE] letting us know they had allowed the Sinemet order to expire and forgot to call and give us an update. (The facility) reported (R52) had not received the Sinemet since [DATE]. (The facility) reported at that time they noticed a difference when (R52) was on the Sinemet and that she was more awake, and alert and her balance was much better. (V16) wrote a new order on [DATE] to start the Sinemet titration over again and for the facility to call our office to update how (R52) is tolerating the mediation. It was instructed to call us before week four was up and to not allow the medication order to expire. (The facility) has not called us to give us an update and I was unaware (R52) has not received her Sinemet since [DATE]. (R52) could experience increased fatigue, unsteady gait, and tremors for stopping the medication once again. On [DATE] at 2:30 PM, V2 (Regional Nurse Consultant/Interim Director of Nursing) stated she was unaware that R52 has not been receiving her Sinemet or that the facility did not call to give Neurology an update and allowed the medication order to expire and that this is the second time it has happened. V2 stated, I am unsure what the nurses are supposed to do when a medication has been missed or a medication error has been made. They should have caught it before hand and called the ordering physician. I would have to look at the Medication Policy to see what the nurses should have done. No medication error report was filled out for the missed doses of Sinemet in June or [DATE]. On [DATE] at 10:30 AM, V28/R52's Primary Physician stated the facility did not notify him of needing an updated order for R52's Sinemet in June or [DATE] or that R52 had missed doses of her Sinemet. V28 stated, (R52) could experience increased tremors and excessive tiredness when stopping Sinemet. It's not good (R52) missed her doses. It doesn't cause a long-term effect, but It can cause a short-term effect for (R52).

Based on Interview and record review, the facility failed to provide eight hours of Registered Nurse Coverage seven days a week. This has the potential to affect all 64 residents living in the facility. Findings: The Facility's Nursing Schedule for the month of July states there is no Registered Nurse coverage for the following days: 7/06/24; 7/07/24; 7/13/24; 7/20/24; 7/21/24; 7/26/24; 7/27/24; 7/28/24. The document, (Facility) Daily Posting of Nurse and Certified Nurse Assistant, was also checked for Registered Nurse (RN) coverage. Several days (which are the same dates of no RN coverage) were not posted: 7/06/24; 7/07/24; 7/13/24; 7/20/24; 7/21/24; 7/26/24; 7/27/24; 7/28/24. This was confirmed by V1, Administrator in Training, on 7/31/24 at 2:15 PM. On 8/01/24 at 10:25 AM, V1, Administrator in Training, stated, We have given you what you requested, including the Agency Nurses that worked. It has been difficult to have Registered Nurse coverage on weekends. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24, signed by V1, Administrator in Training, documents 64 residents currently reside within the facility.

Based on Observation, Interview and Record Review, the facility failed to: properly cool down and document potentially hazardous foods; maintain a clean kitchen; label food items; discard outdated food items; replace rusted shelving. This has the potential to affect all 64 residents living in the facility. Findings: The document Cooling Cooked Potentially Hazardous Foods/Time Temperature Controlled for Safety, dated 1/16/24, states, Hot foods are cooled in the refrigerator from 135 degrees Fahrenheit (F) to 70 degrees F within two hours. Within four more hours the food is cooled to 41 degrees F. Cooling time from 135 degrees F to 41 degrees F does not exceed a total of six hours. The time and temperature are recorded at the beginning of the cooling process. The timing of the cooling process begins when the temperature of the food is at 135 degrees F. Two hours later the temperature is taken and recorded. The food needs to be 70 degrees F or lower. If the food is not 70 degrees F or lower, the food is discarded. The temperature is taken and recorded again four hours later. The food needs to be 41 degrees F or lower. If the food is not 41 degrees F or lower, it is discarded. The United States Department of Agriculture, (USDA) Hazard Analysis Critical Control Points (HACCP) Cool Down Temperature Log, states, The total cooling process may not exceed six hours. Potentially hazardous foods must be cooled from 135 degrees Fahrenheit (F) to 70 degrees F within two hours. These food items must be chilled from 70 degree F to 41 degrees F or below within four hours. Record temperatures every hour during the cooling cycle. Record corrective actions, if applicable. The food service manager will verify that food service employees are cooling food properly by visually monitoring foodservice employees during the shift and reviewed, initialing, and dating this log each working day. Maintain this log for a minimum of one year. The documents, Cooling Down Foods - Tracking Chart, (for potentially hazardous foods) provided by the facility are inconsistently filled in and difficult to decipher. The year was not written on the charts. There are no Cool Down Temperature charts for the months of 8/2023; 9/2023; 12/2023; 3/2024; 4/2024; 5/2024; only one temperature is recorded for 2/2024 and 6/2024. A total of 13 Cool Down Temperatures were provided for the past 12 months. The temperature at six hours is not recorded for several foods and many of the temperatures at two hours are also blank without documentation. The food temperatures taken by staff were not initialed or verified/initialed by the Dietary Manager. On 7/29/24 at 10:45 AM. V5, Dietary Manager, stated, Yes, we are supposed to fill in the Cool Down Temperature Logs but the log for July isn't filled in. I've only been here for six weeks, and I don't know why the charts were not completely filled in or why not all the months had logs of the cool down temperatures. They should have been. I do know that the meals we served today were cooked this morning. The document, Cleaning Schedule Policy, dated 1/16/24, states, The healthcare community stores, prepares, distributes and serves food in a sanitary manner to prevent foodborne illness. A daily cleaning schedule will be posted in the kitchen with specific cleaning assignments to include both routine cleaning/sanitizing tasks along with deep cleaning tasks. Director of Food and Nutrition Services will review the cleaning a schedule each day to assure the tasks have been completed in a satisfactory manner. The documents, Cleaning Matrix, the form is undated, state, These are daily requirements. If you see something needs to be cleaned at any time, you are expected to do so. AM Cook. Every morning check labeling and dating. Deep Clean Preparation Area. PM Cook. Clean preparation shelf. Empty/Clean/Re-Organize utensil containers /drawers; Degrease and clean oven. AM Dietary Aide. Wipe down all doors in kitchen; clean refrigerator by sink; clean refrigerator in (food) preparation area. PM Dietary Aide. Clean refrigerator in (food) preparation area; Clean refrigerator by sink. Not all kitchen areas/items are included on the cleaning charts. The document, Ice Dispensing, dated 1/16/24, states, The ice machine is cleaned at a frequency specified by the manufacturer or absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. On 7/29/24 at 10:05 AM, on the plate that is the threshold for the ice well in the interior of the ice machine had visible wet/slimy in appearance pink and brown spots of a substance, on its lip. The ice machine was full, and the ice was within touching distance of the substance. V5, Dietary Manager (DM), confirmed the substance, stating, I didn't notice that it needed cleaning. Food splashes of unknown origin were on the walls of the kitchen. The bottom area along the walls and around standing appliances had an accumulation of old black grime, grease and dirt. The floors had a sticky dried substance that was not fresh. Drawers containing cooking utensils had crumbs in the bottoms of the drawers. The ceiling of the microwave oven had old unknown brown dried food particles. The doors on the bottom of the storage unit by the range had a sticky grease residue covering. The ovens and range grease trays needed contained dried grease. The reach in cooler doors needed to be wiped down on the inside and outside. The air vent unit on the wall in the kitchen had rust and accumulated dust on the grill. The racks on the shelving units holding pots and pans and various vessels were rusted. V5 confirmed these deficiencies that needed cleaning, stating, 'I've been trying to get everyone to help get the kitchen cleaned up. I didn't know rust was an issue in the kitchen. The document, Storage of Dry Goods/Foods, dated 1/16/24, states, Food stored in bins (e.g., flour or sugar) is removed from original packaging. Bins are labeled and dated. Opened products are labeled, dated with the use by date and tightly covered to protect against contamination from insects and rodents. Opened products that have not been properly sealed and dated are discarded. The document, Storage of Refrigerated Foods Policy, dated 1/16/24, states, Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality. Food in the refrigerator is covered, labeled and dated with a use by date. Open products that have not been properly sealed and dated are discarded. On 7/29/24 at 10:15 AM, the cooler contained a one-gallon jar of mustard, 20 percent full, with a brown crusty substance along the lid area. A 21 fluid ounce container of an electrolyte replacement beverage was opened, 30 percent full, no open date or label. An eight fluid ounce container of a Thickened Dairy Beverage had an expiration date of 7/25/24. Two opened two-pound containers of vanilla yogurt, each 50 percent full, did not have a label or open date. Both had received by dates of 6/26/24. A half of a case of thawed eight-ounce health shakes were in the cooler. These did not have a thaw date. V5, Dietary Manager, confirmed these deficiencies in the cooler, and stated, I didn't know that the thaw date was needed. I'll need to get in touch with the company. Enclosed inside a large metal container sitting under the food preparation area were a 50-pound sack of sugar, 25 percent full and a 50-pound sack of rice, 80 percent full, both in their original paper packing. When the bag of sugar was lifted, a 50-pound paper sack, empty and scrunched remained in the container. The container did not have a label describing its contents and the lid was not tight fitting failing to seal the container when closed. V5 stated, I've been trying to get some new storage containers but haven't got around to it. The upstairs dining room's refrigerator held three take out containers that appeared to have been in the refrigerator for some time. These contained lasagna; beef stew with potatoes on top of rice; unknown dried food item, possibly hamburger. There were no labels or dates on the containers. The refrigerator also held two custard pies, loosely covered with parchment paper, dated 7/22/24 to be used 7/24/24; an eight fluid ounce container of a Thickened Dairy Beverage had an expiration date of 4/26/24; an opened 10 ounce jar of medium chunky salsa, 25 percent full, had a crusty substance surrounding the lid, without an open date or label; a half full plastic cup containing an unknown substance did not have a label or date; a five pound 50 percent full container of Parmesan cheese did not have a label or open date. V5 acknowledged these deficiencies. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24, signed by V1, Administrator in Training, documents 64 residents currently reside within the facility.

Based on interview, observation and record review, the facility failed to provide oversight and leadership to Administrator in Training and nursing staff to ensure implementation of its policy and procedures regarding advanced directives, abuse prevention, abuse reporting, abuse investigation, hospital transfers, medication administration, medication errors, resident supervision, quality assurance meetings and infection Preventionist requirements. Cross reference F578, F600, F607, F609, F610, F623, F625, F689, F727, F759, F760, F868 and F882. These failures have the potential to affect all 64 residents residing at the facility. Findings include: The facility's Administrator job description, dated June 2021, documents Major duties and responsibilities: Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility. Evaluates key performance indicator outcomes with department heads to determine the need for action from leadership and/or management such as re-education or revision related to the facility's outcomes, regulatory compliance and/or customer satisfaction. Ensures implantation of any and all new policies, procedures, guidance and regulations as directed by the (facility) corporate team. Ensures delivery of excellent customer service and compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff, employee turnover, general cleanliness, physical plant condition, and optimal resident functioning-physically and psychosocially. Ensures resident incidents and concerns that rise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation, etcetera, are reported to the correct entity within the stated regulatory requirement. Promotes safe work practices, safety rules, and accident prevention procedures to prevent employee injury and illness. The facility's Social Services Designee job description, dated June 2021, documents The Social Services Designee will assist the Administrator in the planning, developing, organizing, implementing, evaluating, and directing of social services programs of this facility. The social service designee will meet with administration, medical and nursing staff, and other related departments in planning social services, as directed. The social services designee will assist the administrator in ensuring that staff members are knowledgeable about resident's rights and encourage staff to maintain and enhance each resident's dignity in recognition of each resident's individuality. The social services designee will engage in advance care planning for assigned residents upon admission, and make sure that any advanced directives are reviewed with the resident/resident representative on a regular basis. The social worker will ensure that staff members are made aware of the resident's code status and end of life wishes and will assist with informing and educating residents and their representatives about health care options and ramifications. The social services designee will advocate for residents and assist them in assertion of their rights within the facility. The social services designees will assist with investigations of abuse allegations. The facility's Facility Assessment, dated 7/24/24, document the facility's provided services and care is based off of residents needs and includes the following roles; Administration, Social Services, Director of Nursing and Infection Control and Prevention Specialist. R315's State Final Report, dated 7/28/24, documents witnessed verbal abuse and intimidation from V17 (Certified Nursing Assistant) to R315 on 7/28/24, was substantiated. On 7/31/24 at 2:45 PM, V1 (Administrator in Training) stated (V17) will not be allowed to come back to work here. I have not spoken with (R315) yet regarding the incident and wasn't aware that she stated she was scared. We don't have a Social Service Director, so no one has been able to provide psychosocial support for her after the alleged incident on 7/28/24. V1 also verified that she had no record of Abuse Training for (V17) from the facility. V1 stated she has a binder at the nurse's desk that the agency staff reads and signs off on but verified that the abuse policy was not in the binder. On 7/30/24 at 10:15 AM, R47 stated she had an incident with a nurse (V7, Licensed Practical Nurse) where V7 made her feel afraid to speak to her. R47 stated she ended up being moved to a different room and the former Director of Nursing (V23) acted like it was her fault. R47 stated that V7 still works in the facility and has spoken to her since the incident but they do not get along. On 7/30/24 at 11:52 AM, V1 (Administrator in training) stated I was aware of the verbal abuse allegation (for R47), but anything medication wise, I let the DON (Director of Nursing) handle. I am aware it was a verbal abuse allegation but (V23) was handling it. At this time V1 confirmed she does not have any abuse documentation, investigation or reported incidents to document any of R47's verbal abuse and intimidation allegations. V1 confirmed she also does not have any documented measures to prevent R47 from being abused, feeling intimidated or feeling scared after the alleged incident. On 7/29/24 at 12:18 PM, V20 (R12's Family Member) stated she has concerns with the facility not doing what is best for the residents. V20 stated R12 has lived in the facility for several years and lately they have had more problems. V20 stated In the Spring 2024, other family alerted us that (R12) wasn't acting herself. (R12) said she wasn't getting her medications and when I asked about this, the Administrator (in Training, V1) said I don't know what the nurses do. That was all the resolution we received. On 7/29/24, at 10:40 AM V14 (Registered Nurse) completed a significant medication error after not administering R5's scheduled accucheck and insulin prior to the breakfast meal. V14 went to the nurses station after R5's blood glucose monitoring result was elevated and outside of insulin parameters. V14 stated she needed to notify R5's provider (V13, R5's Nurse Practitioner). V14 looked around the nurses station and was unable to locate a phone number for V13 for 10 minutes. V14 then picked up the phone to call V1 (Administrator in Training) and stated Today is my first day, I don't know the flow or where things are. I am not sure how to dial out on the telephone. I don't even know what the Administrator (in training) looks like. I don't think (the facility) has a DON. At 10:50 AM, V1 came to the nurses station and also searched for several minutes before locating V13's telephone number for V14 to call. R52's Medication Administration Record, dated July 2024, documents no administration of R52's Sinemet from 7/25/24 to 7/30/24 or a new physician order to give Sinemet for a total of 5 missed days. On 7/30/24 at 2:30 PM V2 (Interim Director of Nursing) stated she was unaware that (R52) has not been receiving her Sinemet or that the facility did not call to give Neurology an update and allowed the medication order to expire. V2 confirmed this is the second time it has happened. V2 stated, I am unsure what the nurses are supposed to do when a medication has been missed or a medication error has been made. They should have caught it before hand and called the ordering physician. I would have to look at the Medication Policy to see what the nurses should have done. No medication error report was filled out for the missed doses of Sinemet in June or July 2024. On 7/30/24 at 1:30 P.M., V1(Administrator in Training) verified that the facility was unable to provide documentation that residents or their representatives have been provided a bed hold policy when residents are sent out to the hospital. V1 stated, We (the facility) currently do not have a Social Service Director and only have an Interim-Director of Nursing, so I am not sure the nursing staff are even aware to give a bed hold policy to resident's when they discharge to the hospital. On 7/30/24 at 2:15 PM V1 (Administrator in Training) verified R15 and R60's Physician order and POLST (Physician Order for Life Sustaining Treatment) form do not match. V1 stated, Social Services is responsible for ensuring the resident's physician order for advance directives match the resident's current POLST form. We (the facility) currently don't have a Social Service Director, so I have been trying to help with the advance directives. I have not done an audit to ensure the order and POLST form match to ensure the staff know the appropriate code status for the residents. On 7/31/2024 at 11:35 PM V1 (Administrator in Training) confirmed that V2 is the Interim Director of Nursing and is filling duties for the facility's Infection Control Preventionist. V1 stated, I was not able to locate the Infection Preventionist certificate. On 7/31/24, at 11:00 AM, V1 (Administrator in Training) stated she has her temporary Nursing Home Administrator license and started working as the facility's administrator on 8/13/2023. On 8/1/24 at 11:35 AM, V1 confirmed the facility has several agency nurse and nursing assistants. V1 stated The nurses on the floor are responsible for reconciling physician orders and making sure they are implementing those. (V2, Interim Director of Nursing) has been helping out as well. When Nurses or CNA's (Certified Nursing Assistants) are agency they are orientated when they come in for their first shift. I orientate now, or the CNA or Nurse that they are working with will. So when a new agency nurse comes here there is a binder they are to look at and the nurse working with them should train them. Monday (7/29/24) we had two agency nurses (V14 Registered Nurse and V24 Licensed Practical Nurse) and so (V12 Licensed Practical Nurse) was our nurse who should be making sure (V14) was orientated since it was her first day. (V12) was also training (V35, Licensed Practical Nurse) and they were downstairs working on the 600 hall. (V14) was working upstairs. V1 confirmed she was made aware of more abuse concerns this week. V1 stated We have had the two prior abuse citations recently. One was in April and another in June. Both were sexual abuse and the same perpetrator. We talk about Abuse in QAA (Quality Assessment and Assurance) monthly and we started talking about it more in April with the first Abuse citation we received. We don't have a designated Infection Control Preventionist (ICP), those duties have been completed by the DON. I know they are supposed to be separate roles. We didn't have either the ICP or the DON at our July meeting. In March I think I just wasn't able to be there (QAA meeting) that day and in November we didn't have the Medical Director present (at the QAA meeting). The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24 documents 64 residents currently reside within the facility.

Based on Interview and Record Review, the facility failed to ensure the required members attended the facility's scheduled Quality Assurance meetings. This failure has the potential to affect all 64 residents residing in the facility. Findings include: The facility's Facility Assessment, dated 7/24/24, documents the assessment was reviewed on 7/24/24 with the QAA/QAPI (Quality Assessment and Assurance/Quality Assurance and Performance Improvement) committee. The facility's QAPI plan, dated 7/3/24, documents The QAA committee will review data from areas the organization believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for our organization. Members of the QAA committee may be added according to the perceived needs of the community, however will have as key members the following positions: Medical Director, Administrator, Director of Nursing, Regional Nurse Consultant, Regional Operations Consultant, Infection Preventionist. The facility's (undated) Quality Assurance Committee list, provided by V1 (Administrator in Training), does not include an Infection Control Preventionist (ICP). The facility's QA (Quality Assurance) sign in sheet, dated 7/25/24, documents the Interim Director of Nursing (DON, V2) was not in attendance to the July 2024 meeting. The facility's QA sign in sheet, dated 3/13/24, documents the only members in attendance to the March 2024 QA meeting were V23 (Former Director of Nursing), V28 (Medical Director) and V34 (former Dietary Manager). The facility's QA sign in sheet, dated 11/16/23, documents the facility's Medical Director (V28) was not in attendance. On 8/1/24 at 11:35 AM, V1 (Administrator in Training) confirmed that all required members have attended the quarterly QAA meetings. V1 stated We don't have designated ICP, those duties have been completed by the DON. I know they are supposed to be separate roles. We didn't have either the ICP or the DON at our July meeting. In March I think I just wasn't able to be there that day and in November we didn't have the Medical Director present. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24 documents 64 residents currently reside within the facility.

Based on record review and interview the facility failed to protect one resident (R1) from continued sexual abuse from a known sexually aggressive resident (R2) reviewed for abuse in the sample of three. This failure resulted in an Immediate Jeopardy. Findings Include: The Immediate Jeopardy was identified to have begun on 6/2/2024. The facility was notified of the IJ on 7/2/24 at 11:30 A.M. The Facility's Abuse, Neglect and Exploitation policy dated 6/8/2020 documents Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friend or other individuals. The Facility's Abuse, Neglect and Exploitation policy dated 6/8/2020 documents Abuse means the willful infliction injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial wellbeing. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual acted deliberately, not that the individual must have intended to inflict injury or harm. The Facility Abuse, Neglect and Exploitation policy dated 6/8/2020 documents that Sexual abuse is nonconsensual sexual contact of any type with a resident. On 6/28/24 V1 (Administrator) provided a State Report dated 4/1/24 involving R1 and R2 being found with their hands in each other laps. Upon investigation into the incident on 4/1/24 an Immediate Jeopardy was Identified. The Removal Plan of the Immediacy was accepted on 4/2/24 with the facility remaining out of compliance at a Severity Level II while the removal plan implementation and effectiveness were monitored. V1 stated We just had a (Citation) for this, not three months ago. For these same two residents. V1 provided all related information. R2's Medical Record and psychiatric evaluations done after previous incident of R2 sexually abusing R1 on 4/1/24 document diagnosis of depression, posttraumatic stress disorder, and sexually inappropriate behavior. The Abatement plan dated 4/2/24 documented that R2 would be put on 1:1 supervision. The State Report dated 6/2/24 documents that at approximately 6:30 AM V3 (Certified Nurse Aide) witnessed R1's right hand up the shirt of another resident (R2). The written staff interviews from the date of the incident 6/2/24 document that V14 (Certified Nurse Aide) got R2 up and ready on 6/2/24 and left her in her room around 6:20 AM. The statements document that on 6/2/24 around 6:30 AM V3 (Certified Nurse Aide) and V14 (Certified Nurse Aide) both saw R2 wheel herself up to R1 in the lobby and put his hands on her breasts under her shirt. V14 (Certified Nurse Aide) noted that R2 stated I know I am not supposed to touch him, but it feels so good. R1's Minimum Data Set Assessment (dated 02/28/24) documents a Brief Interview of Mental Status score of 6, indicating severe cognitive impairment. R2's Care Plan last updated on 4/12/24 documents (R2) has a potential for behavior problem due to personal dynamics, false statements of staff, rejection of cares, crying, repetitive activities, attention seeking behaviors, non-compliance of cares, facility policy, manipulative behaviors towards staff, poor safety awareness, refusal to go to doctor's appointments or counselling, inappropriate behaviors, attempting to touch others. On 6/28/24 at 10:30 AM R2 was in bed, alert and oriented to time, place and situation. R2 was very upset about having a 1:1 care giver states I don't need a baby sitter. R2 confirmed that she put R1's hand on her breast. Stated It felt good, he and I are lovers and I don't care what you think. When asked if she thought R1 could consent to being touched or by being made to touch her, R2 stated I think he (R1) knows that he is a warm blooded man and he wants it. I do believe that. R2 confirmed that she understands that R1 cannot answer any simple yes or no questions for himself yet she stated she felt that he (R1) would love to feel my breast, I can tell when he (R1) wants to. On 6/29/24 at 9:00AM V2 (Director of Nursing) confirmed that she was aware of issues of R2 being found sexually abusive to R1 in the recent past (4/1/24.) V2 stated she came to work on 6/2/24, she got in verbal report that (R2) was in her room. V2 stated I then carried on about my day as normal until (V9/Certified Nurse Aide) brought R2 to me and explained that she had just witnessed R2 put R1's hands on her breasts. V2 stated When they (previous staff) said she (R2) was in her room, I assumed they meant in her bed, I didn't check, and she was actually up in her chair, and she can propel herself once up in the chair. V2 confirmed that R1 is in a reclining cushioned wheelchair that he is completely dependent on staff moving for him and that R2 can propel her wheelchair independently once she is up. V2 reported that as of 6/2/24 R2 had been changed to increase monitoring after her previous issues with R1. V2 stated that we had meetings and kind of went over her behaviors and stuff. I don't really remember when she came off of 1:1 and became increased monitoring. On 7/1/24 V1 (Administrator) stated that R2's 1:1 monitoring was discontinued as of 4/4/24 and she was on increased monitoring from 4/4/24 until the date of the second incident on 6/2/24. On 6/29/24 at 9:30 AM V1 (Administrator) stated that increased monitoring is kind of like a step down from being on 1:1, we want to always know where the resident is. For example, if a CNA took a resident that is on increase monitoring to an activity, she would stop and tell an activity member that she is leaving the resident there and for that person to keep an eye on her. V1 stated that there would be no documentation of such monitoring of an increase monitoring resident, and she also could not provide a written policy on increase monitoring. While the Immediacy was removed on 6/2/24, the facility remains out of compliance at a Severity Level II as additional time is needed to implement and evaluate effectiveness of their removal plan and quality improvement plan. 1. Immediate action(s) taken: On 6/2/2024, R2 was put on 1:1 supervision when out of bed and will continue on 1-1 supervision, that removed the immediacy. On 6/5/2024, Staff were in-serviced by LNHA(V1/Administrator) and IDT (Interdisciplinary Team) regarding facility abuse prevention and reporting policy, including definitions of abuse and immediate actions needed, identification of sexual abuse and protection of residents, and increasing supervision for a sexually aggressive resident. Psychiatric services and psychotherapy will continue, and SSD notified Psych provider on 6/4/2024 of recent behaviors. IDT revised and reviewed care plans for R2 and R1 to identify patterns in residents' behaviors and implement interventions. Care plan revisions and interventions communicated to the nursing staff, activity staff and IDT that are caring for R1 and R2. On 6/7/2024, R1 was interviewed by LNHA for any signs or symptoms of psycho-social changes and no changes were noted. R2 will not be seated near male residents during dining, activities, etc. 2. Immediate action(s) taken to ensure all abuse issues are reported and assessed: On 6/5/2024, Staff were in-serviced by Administrator and IDT regarding facility abuse prevention and reporting policy, including definitions of abuse and immediate actions needed, identification of sexual abuse and protection of residents, and increasing supervision for a sexually aggressive resident. 3. Immediate action(s) taken to ensure all abuse issues are reported and assessed: Administrator, SSD, and DON interviewed a sample of employees regarding any concerns, or reports, of resident abuse, with emphasis on inappropriate touching. On 6/5/2024 Administrator and DON educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. In the event of any future resident to resident sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. The outcomes of these evaluations will be used to determine next steps for care and treatment which could include continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. 4. Immediate action(s) taken to ensure the facility is continuing to monitor for and address any concerns regarding abuse or neglect. Director of Operations with The [NAME] will meet with department managers to educate regarding their roles and responsibilities related to abuse/neglect prevention, reporting, investigation, and follow-up. All concerns related to abuse/neglect within the facility will be reviewed by the QA team in regularly scheduled meetings, next scheduled for July 25, 2024, as well as through the QAPI process. SSD or Designee with interview 5 residents and 5 staff members, each week for 6 weeks, to ensure no complaints or concerns of abuse have been noted. Medical Director has been notified of IDPH concerns and will continue to participate in the QA process. On 7/2/24 the surveyor confirmed through observation, interview and record review the facility fully implemented all components of its abatement plan and immediacy was removed.

Based on interview observation and record review, the facility failed to adequately supervise a resident (R4) exhibiting sexually aggressive behaviors, and failed to identify and protect a resident (R5) from multiple episodes of sexual abuse reviewed for abuse in the sample of five. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 04/02/24, the facility remains out of compliance at a Severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and quality assurance program. Findings Include: The facility's Abuse, Neglect and Exploitation policy (revised 12/05/22) documents the following: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. This same policy documents, Sexual Abuse is non-consensual sexual contact of any type with a resident. This policy also documents under the section titled Prevention of Abuse, Assess, monitor, and develop appropriate plans of care for residents with inappropriate sexual behavior, whether towards staff or other residents. The facility's State Report Incident Investigation (dated 03/04/24) documents the following: On March 4, at approximately 8:20 AM, it was reported by the therapist that she had walked through the dining room and saw that (R4) was attempting to touch (R5) in the area of his lap. Both were sitting in the dining room area after breakfast and no other residents were present. (R4) was leaning in towards (R5) and (R5) was not talking and sitting quietly in his wheelchair. When the therapist intervened and questioned (R4) what they were doing, (R4) stated they were doing nothing wrong and just talking. The therapist took (R4) to the activity room. (R5) was taken to the elevator to go back upstairs to his room where a nurse assessed and found no sign of injury. On March 4, at approximately 9:00 am, Social Worker interviewed both (R4) and (R5). When (R4) was interviewed, she expressed her and (R5) were, 'in love' and doing nothing wrong in the dining room. Educated (R4) regarding the necessary cognitive ability for two residents to give consent before touching each other. (R4) verbalized that she wants (R5) to touch her, and he wants her to touch him. When (R5) was interviewed, he stated, No one touches me, I have no problems. Both POAs (Power of Attorneys) and MD (physician) were notified. On March 4, at approximately 9:40 am, Social Worker interviewed six residents with BIMS (Brief Interview for Mental Status) higher than a 10 and asked if they felt safe and comfortable in the facility and they all said 'yes'. Disposition: The facility cannot find evidence of intent to harm or any negative psycho-social outcomes. The two residents do not reside on the same hall and do not sit together at meals. They will remain separated. Care Plans were updated, and Social Services will monitor residents for any negative psycho-social outcomes. R4's Minimum Data Set Assessment (dated 02/19/24) documents a Brief Interview of Mental Status score of 10, indicating moderate cognitive impairment. R4's current care plan documents the following: (R4) has a potential for behavior problem due to current personal dynamics such as: false statements of staff, rejection of cares, crying, repetitive activities, attention seeking behaviors, noncompliance of cares/facility policy, manipulative behavior towards staff, poor safety awareness, refusal to go to doctor's appointments/hospital or counseling. 02/29/24 - inappropriate behaviors attempting to touch others. R4's Medical Practitioner Progress Note (dated 03/01/24) documents: Chief Complaint: Patient reports feeling anxious all the time with occasional panic attacks. History Of Present Illness: Female with a history of MDD (Major Depressive Disorder), Anxiety and PTSD (Post Traumatic Stress Disorder). Per staff, patient requested to go to the hospital to have, 'things removed from her vagina.' Had a stylus in vagina; nursing staff report ER (emergency room ) doctor documented patient could benefit from a vibrator/safe device to prevent recurrence of foreign objects getting stuck in patient's vagina. No records from hospital visit in EMR (electronic medical record) to review. Per staff, she has history of being inappropriate with other residents, i.e tried to grab another resident's penis in the past. (R4) is seen in her room, sitting in her wheelchair. She reports her mood is 'not good at all.' She shares about the incident. She states she struggles with hyper-arousal/hypersexuality and inserted stylus into her vagina. She states she had multiple inserted into her vagina prior to being sent to the ER. She becomes tearful. She states she has a lot of shame related to this and feels depressed. She requests something to help with her hyper arousal. She also reports feeling anxious all the time with occasional panic attacks. She denies suicidal or homicidal thoughts. She states she does not sleep well at night, because of leg pain and fear that she won't be able to walk again. Appetite is good. No manic or psychotic symptoms reported. Tolerating her medications without side effects reported. In agreement with ER doctor to allow patient to purchase appropriate item to prevent inserting inappropriate objects in her vagina and rectum. Patient is already taking the maximum dose of sertraline, discussed that SSRI/SNRI (Selective serotonin reuptake inhibitors/Serotonin and norepinephrine reuptake inhibitors) can lower libido, but she does not seem to be getting this effect. I think it's fair to trial a higher dose of buspirone to help decrease patient's anxiety and help some of her symptoms. If patient continues to be distressed by her symptoms or becomes inappropriate with another resident again, may need to trial divalproex in the future. No other concerns. On 03/27/24 at 12:45 PM, R4 was sitting in a wheelchair in the basement of the facility near the activity room. R4 was alert to person and place, but could not recall the date. R4 was questioned about recent events, and she stated the following: I am ok. Most of what's happened is my doing. I really don't want to talk about it. I am just a crazy old lady with a horrible sex drive. But I want to be with an adult that's my age and more alert. (R5) is confused. Anything we did was beautiful. He liked it too. When I see him, something sparks. It's nobody's business, and I think he (R5) enjoys sex as much as I do. R5's Minimum Data Set Assessment (dated 02/28/24) documents a Brief Interview of Mental Status score of 6, indicating severe cognitive impairment. R5's current care plan documents the following focus: (R5) is at potential risk for abuse related to Dementia, dependency on staff. On 03/27/24 at 12:30 PM, R5 was sitting in a wheelchair near the facility's front door. R5 was pleasantly confused and could answer simple questions. R5 confirmed that he had just eaten lunch, but could not recall what he had just eaten for lunch when asked. R5 could not recall any recent interactions with R4. R5 stated, yes, when asked if things were going ok, and stated no when asked if he had any issues or concerns. On 03/25/24 at 11:50 PM, V3 (Assistant Director of Nursing) stated, (R4) targets (R5). He (R5) is not cognizant. He cannot give a verbal response that he wants (R4) to do that (touching). (R4's) sexual behavior heightened about 3 weeks ago. She only behaves this way toward (R5), and she has been inappropriate with the two male CNAs (Certified Nursing Assistants) that currently work here. (R4) has been pulling her shirt up in the lobby in front of (R5). (R5) barley converses and does not like to be bothered. Every time (R4) comes out of her room she looks for (R5). We try to keep them separated, but (R4) can be quick. On 03/25/24 at 12:15 PM, V4 (Activity Director) verified the following written statement documented in R4 and R5's 03/04/24 Incident Investigation: On 03/03/24 at approximately 10:00 AM, I saw (R5) in (R4's) room and they were not talking, just sitting there. I walked in and started moving (R5) out of the room and (R4) said to me 'We are in love and in our own private room.' (R5) was in (R4's) room. I don't know how he got in there. My best guess is (R4) lured (R5) in there. He would not purposefully go into someone's room, but he would follow commands if someone gives him instructions. I removed (R5) from the room at that time. (R4) had been pursuing (R5) for about a month, and I feel like it really heightened about 2 to 3 weeks ago. I feel like it's been a situation where the more you tell her 'no' the more she wants to do it. We have been told to keep them separated, and if (R4) is out of her room, she will find (R5). (R5) is cognitively impaired, so he hasn't seemed bothered by any of this. But you wonder how much he really understands since he is impaired. I've had to separate them a few times this past month, mostly when (R4) has made herself close to (R5). On 03/25/24 at 12:50 PM, V2 (Director of Nursing) stated she has been employed at the facility since January 2024. V2 stated, (R4) has been sexually inappropriate towards (R5). We have been keeping them separated. (R5) is impaired and doesn't know what happening. (R4) does know. I have told her that (R5) doesn't understand being in love with you. He cannot consent. (R4) likes to sleep naked and does what she wants to do. She wants male staff to see her naked. One day she made the comment 'what are you supposed to do when your mind still thinks you're a size 6?' She has only been inappropriate with (R5). This has not occurred with any other male resident. (R5) has been indifferent about all of what's occurred with (R4). I don't even know if any of it has registered. I think if it bothered him, he would be swearing because he swears at staff often during cares. (R4) is attention seeking. She is monitored for behaviors, and it may not be documented as frequently as it occurs because staff has normalized her behaviors after observing her display them so often. R4's Behavior Monitoring and Interventions Report (dated 01/01/24 - 03/27/24) has no documentation of behaviors exhibited throughout this timeframe, with the exception of the following: an episode of grabbing others and public sex acts, both noted on 03/04/24; an episode of express frustration/anger at others and agitation noted on 03/09/24; and an episode of express frustration/anger at others and disruptive sounds noted on 03/17/24. V5's (Certified Nursing Assistant) witness statement noted in the facility's 03/04/24 Incident Investigation documents, (R4) wheeled herself up to (R5) at the table in the lobby. (R4) was crouched over to her side, leaning in towards (R5). I said, '(R4), keep it PG' (parental guidance, some material may not be suitable for children), and she said 'OK.' I continued with my vitals but I kept circling around and watching her and she was inching herself closer to (R5) and then I turned and looked and her shirt was up and he was grabbing her breast. I told (R4) 'that is inappropriate' so I unlocked her wheelchair and moved her closer to the TV. (R4) was upset and shouting that she can have relationships and it is her right. On 03/25/24 at 01:40 PM, V5 verified the above statement and stated this incident occurred on 03/04/24 at approximately 10:00 AM. V5 then stated, I have been on light duty and was sitting at the receptionist desk when this occurred. (R4) has been approaching (R5). She inches up to him and has been sexually inappropriate previously. (R4) will gravitate toward (R5) if she sees him. This has been happening since some time in February. (R5) doesn't get angry or really react at all. He definitely does not have the mental capacity to consent. Once you move (R4) away from him, she will find a way to return. She has said 'it's not a crime to love somebody.' I have told her that her actions out in the open are inappropriate. She has been lifting her shirt up in the front lobby when (R5) is present, and I have had to intervene a few times. I went and mentioned this to (V1, Administrator) in the beginning when it first had started. I wrote a statement about it. (R4) was always lifting up her shirt and (R5) being next to her with his hand there. She would begin touching and rubbing his hand and it would escalate to her shirt lifted up and his hand ends up on her breast. I never witnessed her shirt going up but would catch it once it was up. I would see her display the initial behavior and knew it was going to progress to her shirt up with his hand on her, so I knew to watch closely and be more aware. I never intervened when they were handsy but knew to step in when her shirt was up. She has also tried reaching in (R5's) pants. R4's Custom Alert (dated 03/04/24 and written by V5) documents the following: (R4) was addressed by multiple aides out in the hall to keep it PG and hands to herself. (R4) sneaks in the second eyes are off of her. Her breast was out with another resident's hand up her shirt while (R4) was reaching to (R5's) pants. V6's (Certified Nursing Assistant) witness statement noted in the facility's 03/04/24 incident investigation documents the following: (R4) was trying to hold (R5's) hand and I moved them apart, but she seemed to find him again and we kept an eye on her. On 03/25/24 at 02:25 PM, V6 verified the above statement and stated, She had found her way back to him and I had to separate them again. This was on 03/04/24 around 10:30 AM. (R4) is always the one approaching (R5). She has the awareness and knows she shouldn't be doing what she's doing. If she can see him, you've got to watch her. She's 100% with it and knows right from wrong. V7's (Certified Nursing Assistant) witness statement noted in the facility's 03/04/24 incident investigation documents, I was told she (R4) was trying to get her hands down his (R5) pants and asking him to do the same. On 03/25/24, V7 verified the above witness statement and then stated the following: We tried to keep them separate, but she will go back to him if you don't completely separate them, meaning not just moving her away from him in the same vicinity. She has to be moved to where she cannot see him, like she needs to be taken downstairs for activities. (R4's) behaviors started about two months ago. Initially she made comments. It went from her making these inappropriate comments to talking about doing things to herself. It continued to escalate as she began approaching (R5). On 03/25/24 at 03:05 PM, V1 (Administrator) stated facility staff started realizing that R4 had been getting close to R5, Last month. Mid-February. She was getting real close to (R5). She was whispering and began making sexual comments. She would say things like it's her right to have a boyfriend and 'We are adults. Leave us alone. We're in love.' We explained to (R4) that cognitively, (R5) doesn't understand and he cannot make this type of decision himself. I think she understands what It means for someone to be able to make decisions for themselves. (R4) tends to live in her own little world and was thinking she and (R5) were boyfriend and girlfriend. She also displays attention seeking behavior. She likes attention. She has been sneaky about this she'll look up to see if you're watching her. We had placed her on 15 minute checks after the 03/04/24 incident for 48 hours. We've never implemented one-on-one supervision, but definitely made sure she was in areas of high visibility. I think she has prompted (R5). I can totally see her manipulating the situation, especially with his impaired cognition. He does not grab at anyone else, so for his hands to be in contact with her, she's physically or verbally manipulated the situation somehow. V8's (Certified Nursing Assistant) witness statement noted in the facility's 03/04/24 incident investigation documents, (R4) sits in the lobby with her shirt up and no bra on and just sits there, and there are times family comes in to visit. I ask her to put her shirt down and she acts like she is doing nothing bad. On 03/26/24 at 09:50 AM, V8 verified her witness statement and stated the above occurred on 03/03/24, (R4's) shirt was up and I told her to stop and she said, 'Why? We're in love.' I told the nurse and she told me to separate them. I took (R5) in his room and transferred him into his recliner. All of this started in February. First (R4) was lifting up her shirt. She was sexually inappropriate and it seemed to progress to her constantly attempting to pursue (R5). You could move her to the other end of the lobby and she'd begin making her way back to him. This happened multiple times. Several staff would move (R4) away from (R5) and she would always seem to find her way back to him. I witnessed her with her shirt up twice on 03/03/24, and then again in the dining room about a week later. If (R5) physically had his hands on (R4) it is because she prompted him. (R5) will follow instruction, so I could see (R4) telling him to do things. (R5) does not grab at anyone. If that was the case, he'd be touching others as well. On 03/26/24 at 11:15 AM, V9 (Physical Therapy Assistant) stated she is the individual who witnessed the 03/04/24 incident between R4 and R5. V9 stated, I walked into the dining room and (R4) was talking to (R5). I knew they weren't supposed to be together and they were supposed to be separated. (R4) had been observed being sexually inappropriate with (R5) for a week or two prior to this day. I asked her what she was doing and she said 'nothing.' I told her to keep moving along and she did, but I continued observing. I overheard (R4) ask (R5) to put his hand in her pants, and I immediately intervened. I told her that was inappropriate and pushed her wheelchair to activities. I told (V3, Assistant Director of Nursing) about what had occurred and (V10, Social Service Director) called and spoke with me about the incident later that day, or the following day. On 03/27/24 at 10:30 AM, V11 (Certified Nursing Assistant) verified her witness statement noted on the facility's 03/04/24 incident investigation and stated, I usually work in the dementia unit. I was walking to the dining room for something and out of the corner of my eye I saw (R4) taking her shirt off. I went over and put her shirt back on and explained that she cannot be doing that in the lobby. I saw her doing it again when I was heading back the my unit, so I removed her from the area and pushed her wheelchair over by the CNA (Certified Nursing Assistant) that was working. I can't remember who was working that day. On 03/26/24 at 12:10 PM, (V10, Social Service Director) stated, I believe it was mid-February when (R4) started to approach (R5). She was getting in his personal space, and staff was instructed to separate them. She had been hypersexual and began pursuing him. (R5) is cognitively impaired and cannot consent. (R4) knows what she's doing. V10 verified that R4's care plan was updated on 02/29/24 after R4 was observed hypersexual and approaching R5 and, getting in his personal space. On 03/27/24 at 09:55 AM, V1 (Administrator) stated the 03/04/24 abuse allegation investigation regarding R4 and R5 was unsubstantiated, I did not feel like either one had the intent to be malicious. We initiated 15 minute checks on (R4) for 48 hours and placed her in areas of high visibility. I don't like doing one-on-one supervision as it can be upsetting and disruptive to the resident. We attempted to engage (R4) in more activities to redirect her focus. I would do one-on-one supervision if there were concerns about resident safety. This incident wasn't a safety concern. She (R4) wasn't going after all of the residents. (R4) and (R5) rooms are located on different hallways so we could keep them separated. The Immediate Jeopardy was identified on 04/01/24 at 07:45 AM to have begun on 02/29/24 when R4's care plan was updated for R4 displaying inappropriate behaviors of attempting to touch others. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 04/01/24 at 08:20 AM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: On 04/03/24, V1 (Administrator) provided copies of the following In-Service/Meeting Attendance Forms completed on 04/01/24 and 04/02/24 with indication that this training was administered by V1 and V2 (Director of Nursing): Abuse/Neglect Policy/Procedure and Education; Abuse/Neglect In-Service; Abuse: Who to Report Abuse to/What is Abuse; Appropriate Seating for a Resident that Displays Inappropriate Touching and Redirection Tools to Divert Attention to Positive Outcome; and Monitoring Resident Behaviors for Signs and Symptoms of Abuse or Potential for Abuse. These attendance forms confirm all staff working on 04/01/24 and 04/02/24 received the required education. An In-Service Attendance Sheet for staff members not present at the in-services on 04/01/24 or 04/02/24 was also provided and these staff members were called and the education was administered via telephone conversation. On 04/03/24, the following staff members were interviewed and could speak in detail of the recent abuse training that they had received, including the facility's abuse prevention and reporting policy, including definitions of abuse and immediate actions needed, identification of sexual abuse and protection of residents, and increasing supervision for a sexually aggressive resident: V2 (Director of Nursing); V3 (Assistant Director of Nursing); V6, V8, V15, V18, V20 and V21 (Certified Nursing Assistants); V19 (Registered Nurse); V22 (Dietary Manager); V23 (Housekeeping/Laundry); V4 (Activity Director); and V24 (Maintenance). CNAs (Certified Nursing Assistants) and Licensed Nurses elaborated on the education administered regarding documenting resident behaviors and new behavior interventions. All staff interviewed were able to elaborate on behavioral interventions to utilize with a sexually aggressive resident. On 04/04/24 at 01:27 PM, R4 was lying in bed covered with a sheet. V5 (Certified Nursing Assistant) was sitting in a chair near the doorway to R4's room providing one-to-one supervision. On 04/03/24 at 10:05 AM, R4 was in her room lying in her bed, and V21 (Certified Nursing Assistant) was providing one-to-one supervision. V21 stated, She hasn't wanted to come out of her room much since she's been on one-to-ones. If she decides to go to the dining room for lunch today, she will be seated at a table with other female residents, but I am guessing she will want to eat in her room. R4 was observed eating lunch in her room on 04/03/24 at 12:16 PM. On 04/03/24, V1 (Administrator) provided a copy of the 1:1 Staffing Sheet for R4, which documents one-to-one supervision has been provided to R4 on 04/01/24 - 04/03/24. R4's Progress Note (dated 04/02/24) documents V10 (Social Service Director) contacted psychiatric services for notification of R4's recent behaviors, and an appointment was scheduled for R4 to be evaluated on 04/09/24. R5's Progress Note (dated 04/01/24) documents the following: (V10, Social Service Director) spent some time with (R5) today. No psycho-social distress noted. (R5) was relaxing in his recliner. On 04/03/24 at 11:19 AM, V10 verified the above progress note and stated she will continue monitoring R5 for psycho-social changes. R4 and R5's current care plans were revised on 04/02/24 to reflect the recent abuse concerns, and new behavioral interventions had also been implemented at that time. On 04/03/24, V1 (Administrator) provided copies of Focused Audit Tools, which document V10 (Social Service Director) interviewed five facility staff members and five residents regarding any concerns, or reports of resident abuse, with emphasis on inappropriate touching. V1 also provided a copy of a resident roster containing all residents in the facility with a Brief Interview for Mental Status score of 8 or above, and documents V10 conducted interviews with these residents for any abuse concerns. On 04/03/24, V1 provided a copy of an In-Service Education Attendance sheet with documentation that V26 (Director of Operations) met with the facility's department managers and education regarding their roles and responsibilities related to abuse/neglect prevention, reporting, investigation and follow-up was administered. On 04/03/24, V1 stated the facility has not had any allegations of abuse reported since the allegation involving R4 and R5 on 03/04/24. V1 spoke in detail regarding the following process: In the event of any future resident-to-resident allegation of sexual abuse, the alleged perpetrator resident will immediately be placed on one-to-one supervision until primary care, nursing, and psychiatric evaluations can be completed. The outcomes of these evaluations will be used to determine next steps and treatment which could include continue one-to-one supervision for the initiation of discharge planning to a facility with focus on behavior management. The Interdisciplinary Team will review the circumstances of the allegation to assess whether a root cause can be identified, such as a physiological change. The care plans of residents involved will be updated to reflect the next steps for treatment and staff will receive education on new interventions. On 04/03/24, V1 stated the facility has integrated the focus on abuse/neglect into the facility's QAPI (Quality Assurance and Performance Improvement) process and abuse and neglect will be discussed in detail at the facility's upcoming Quality Assurance meeting, scheduled for 04/18/24. V1 also confirmed V12 (R1's Primary Physician/Medical Director) was notified of all abuse concerns on 04/02/24, and V1 stated that V12 will attend the 04/18/24 meeting, and will continue to participate in the Quality Assurance process.

Based on observation, interview and record review, the facility failed to supervise a moderately cognitively impaired high fall risk resident with known wandering and exit seeking behaviors, failed to ensure exit door alarms were on and activated at all panels in the facility to ensure the alarm could be heard throughout the facility, and failed to ensure a facility exit door that contained the facility's electronic wandering door management system was completely closed allowing the electronic wandering door management system to work as designed. These failures resulted in R1 exiting the facility without staff knowledge through two separate facility exit doors. R1 exited out of the facility, traveled approximately 330 feet, through a parking lot, into an apartment complex and up to the second floor. R1 was out of the facility for one hour and 23 minutes without staff knowledge. The facility was not aware that R1 was missing from the facility until the facility received a phone call from a resident of the apartment complex. These failures have the potential to affect 10 residents (R1-R10) who have been identified by the facility as at risk for eloping. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7/28/23, the facility remains out of compliance at a severity Level II as the facility continues to educate all staff on elopement policies, door security, and continuous monitoring of the 600 Hallway, perform door checks and door alarm audits, continues to monitor the facility's performance and compliance to ensure that corrections are achieved, and await installation of a new door alarm system. Findings include: The facility's Elopements and Wandering Residents Policy, revised 12/6/22, states, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g. the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e. an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring the effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The Interdisciplinary Team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. The Electronic Wandering Door Management System Manual dated August 25, 2020, documents when the door system receives a response from the resident's pendant, the door will lock, and an alarm will sound. This same manual documents that if the electronic wandering door management system has open contacts the magnetic lock will be disabled, and the exit will not be locked. The facility's Elopement Risk Listing documents R1-R10 as at risk for elopement. This same listing documents R1-R10 wear electronic wandering transmitter bracelets. On 7/22/23 at 8:16 AM, R1 was sitting in R1's wheelchair at a table in the main dining room eating breakfast. An electronic wandering transmitter bracelet was noted to R1's left ankle. On 7/22/23 at 8:24 AM, R1 was lying in bed in R1's bedroom. R1 stated, they said I escaped. I don't remember doing that. I got nothing to run away from. I don't know where I would have been going. On 7/25/23 at 3:03 PM, R1 was propelling R1's self in R1's wheelchair near the nurses' station and down the 300 Hallway. R1 stated, I'm just exploring. R1's Facesheet documents R1 admitted to the facility on [DATE]. This same Facesheet documents R1 with diagnoses to include but not limited to: Left Femur Fracture; History of Falling; Type II Diabetes Mellitus; Altered Mental Status; Vascular Dementia; Schizoaffective Disorder; and Major Depressive Disorder. R1's Brief Interview for Mental Status (BIMS) assessment dated [DATE] documents R1 with moderately impaired cognition, scoring an 8/15. R1's Fall Risk assessment dated [DATE] documents R1 is a high risk for falling and overestimates or forgets limits. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is moderately cognitively impaired, requires extensive assistance of two plus persons physical assist for transfers to and from wheelchair and standing position, and is not steady and only able to stabilize with staff assistance for moving from a seated to standing position and for surface-to-surface transfers, and uses a wheelchair as a mobility device. R1's Elopement Risk Assessment, dated 5/4/23, documents R1 as a high risk for elopement. This same assessment documents R1 has made one more elopement attempts in the last year. R1's Wandering Risk Assessment, dated 5/4/23. documents R1 as a moderate risk for wandering. This same assessment documents R1 is forgetful/short attention span and R1 is a known wanderer or has a history of wandering. R1's current Care Plan states, I wander/exit seek/attempt to go out of exit doors (6/18/23) with no rational purpose, seemingly oblivious to my needs or safety throughout the healthcare center. Interventions: When I begin to wander, attempt to engage me in an activity or something that will hold my interest. This same Care Plan documents R1 has poor impulse control and decision making control; moderately impaired cognitive status; poor safety awareness; and R1's discharge to the community is not feasible. R1's Social Service Assessment and History signed and dated by V17 (Social Service Director) on 4/17/23 documents R1 with Behavior Factors of wandering and exit seeking. R1's Progress Note on 4/15/23 at 4:42 PM, documents R1 was wandering in R1's wheelchair exit seeking stating that he was trying to go see his wife in the apartments. An (electronic wandering transmitter bracelet) was applied to R1's left wrist for safety. R1's Progress Note on 4/23/23 at 1:34 PM states, This nurse began looking for (R1) and was able to find (R1) in the downstairs men's restroom. (R1) was on the floor on his knees with his elbows up on the seat of the wheelchair. (R1) reports that he was trying to go to the bathroom, and he fell . R1's Physical and Occupational Evaluations completed at the local area hospital, both dated 5/2/23 documents recommendations that R1 would benefit from returning back to the skilled nursing facility due to Decreased Cognition, Poor Safety Awareness, Impaired Gait, Difficulty with Transfers, Balance Deficits, Difficulty With Bed Mobility and Decreased Ability To Perform ADLs/Activities of Daily Living. R1's Fall IDT/Interdisciplinary Note on 5/23/23 at 11:07 AM documents R1 was found on the floor in the dining room. This same note states, (R1) attempted to stand up without assistance, lost balance and fell . (R1) has poor safety awareness, unsteady gait, impulsive and impaired cognition. BIMS is 8 (moderately impaired cognition). (R1) requires one assist with transfers. R1's Geriatric Rounding Service Note signed and dated by V21 (R1's Physician) on 6/1/23 states, Plan: (R1's) Memory seems worse than I would expect right now. We are going to continue to watch (R1) and see if anything else changes. We will get a BIMS and see how he does on that, but we will need to watch. R1's Behavior Progress Note on 6/7/23 at 1:29 PM states, Behaviors Observed: Self transferring; (R1) caught twice by staff this shift transferring without assist, both times wheelchair wheels not in the locked position. (R1) has a hx (history) of non-compliance with call light system and asking staff for assistance, also (history) of falls during attempted self-transfers resulting in injuries. R1's Behavior Progress Note on 6/17/23 at 3:00 PM states, Behaviors Observed: Exit seeking, (R1) found by staff on Hall One, (electronic wandering door management system) alarming at exit door. Staff assisted resident to common area and (V3/Licensed Practical Nurse) attempted resident education about going down that hall. (R1) was not able to verbalize understanding of education. R1's Social Services Note on 7/13/23 at 5:18 PM states, (R1) is a long-term resident. (R1) has impaired cognition. (R1) is monitored for behaviors and has had some incidents recently. He is on frequent checks as he wanders and is an elopement risk. R1's Incident Report, dated 6/18/23 at 9:55 AM, documents R1 eloped from the facility. This report documents facility staff received a phone call from a tenant at nearby apartments that there was a male person looking for his sister in the apartment building. The male was described as wearing gray sweatpants and a white clothing protector. Facility staff arrived at the apartment building and R1 was on the second floor, sitting in a chair in the common area. This same report documents R1's Predisposing Situation Factors as active exit seeker; wanderer; and ambulating without assist and documents Predisposing Physiological Factors as gait imbalance; impaired memory; and confused. The facility's Initial Report to the local State Agency, undated, documents that on 6/18/23 at 9:53 AM, R1 was found in a nearby apartment building and that an investigation was initiated. The facility's Five Day Follow-Up Report to the local State Agency, undated, documents an Incident Date and Time of 6/18/23 at 9:53 AM with R1. Brief Description of Incident: (R1) exited main building of campus and was observed at campus apartments by tenant (V8). This report states, Investigation Complete. (V1/Administrator) did full walk-through to determine root cause of (R1's) ability to navigate to the apartment section of the complex. All staff on site at time of incident interviewed and it was determined that (R1) was last seen at breakfast in the dining room and then stated he was going to the Activity Room. (R1) did not enter Activity Room. (R1) wheeled down vacant rehab hallway and pushed on the door for 15 seconds until it opened. (R1) exited into another hallway and out an exit door to walkway that leads to apartments. (R1) navigated through the community room in the apartments and down a hallway. Apartment resident (V8) called nursing staff and let them know (R1) was over at the apartments. Nursing staff then retrieved (R1) and returned (R1) to the nursing home. (R1) not able to recall leaving the nursing home area of the complex due to intermittent confusion. (V7/Maintenance Director) performed a full facility check of door alarm system and (electronic wandering door management system). It was determined that a faulty door latch allowed (R1) to exit to the outside. Door latch immediately repaired. (V1) in-serviced all staff on Elopements and Wandering Residents Policy and door safety checks. Two outside vendors called to evaluate door alarm system for needs. The facility's Staff Interviews as part of V1's investigation into R1's elopement, dated 6/18/23 documents an interview with V19 (Dietary Manager). The interview states, I last saw (R1) at breakfast this morning, (R1) was fine just eating in the dining room. However, last night (R1) was in the dining room at dinner and afterwards he was trying to get out the doors down there, so I brought (R1) upstairs myself. The facility's Staff Interviews as part of V1's investigation into R1's elopement, dated 6/18/23 documents an interview with R1. R1 stated that on 6/18/23, R1 had R1's leg checked. R1 stated, I put the wheelchair in my van and drove to the Children's Hospital where they took my bandage off and checked my leg, they said everything looks great and then I put the wheelchair back in my van and drove home to (name of neighboring town). The facility's Root Cause Analysis Report, dated 6/19/23, documents a nature of violation as Resident Elopement and Wandering. This same report states, Event Description: (R1) left breakfast in the dining room around 8:20 AM stating he was going to activities. At 8:22 AM, we see (R1) heading down Hall 6 (vacant rehab hallway). At 8:30 AM, we see (R1) pushing on the door at the end of Hall 6 for 15 seconds until it opens. Door alarm sounds, but no staff or residents are currently on Hall 6 as it is vacant due to low census. (R1) proceeds to exit through the next exit door that leads outside to a small garden area and into parking lot near rehab gym. (electronic wandering door management system) alarm sounds, but door does not lock due to door was not latched. According to findings, it is assumed that (R1) then wheels around the edge of the parking lot to the next door, which is the door to the community room in the apartments. He enters through two doors into the community room, wheels through the empty community room and down a hallway through the door to the stairs. (R1) then parks his wheelchair under the stairs and proceeds to the 2nd floor. We (facility staff) are not sure if he climbed the stairs or went back down the hallway and found the elevator. (R1) then is discovered by an apartment resident (V8). At 9:53 am, (V8) calls (facility phone number) and speaks with the nurse (V3/Licensed Practical Nurse), stating she believes one of our residents is over there (at apartment complex). (6/18/23) 10:00 AM, (V3) calls Administrator (V1) to alert her of incident and to let her know (R1) is safe and uninjured. (V3) and three CNAs (Certified Nursing Assistants/V5, V9, and V10) immediately head over to the apartments to retrieve (R1). At 10:14 AM, (V3, V5, V9, V10 and R1) return through the Hall 6 door and back upstairs. (V4/Registered Nurse) performs full body assessment on (R1) with no new findings or injuries. R1's Progress Note, signed and dated by V20 (R1's Family Nurse Practitioner) on 6/20/23 states, Chief Complaint: Elopement. History of Present Illness: (R1) was seen today at (name of skilled nursing facility) to elopement. (R1) wandered outside to an apartment building and made it to the second floor before someone noticing. (R1) reports he was bored, he's a guy and he wanted to leave this place. (R1) states he will try not to escape again. On 7/22/23 at 10:18 AM, V8 (Resident of Community Apartments) stated, (On 6/18/23), I was coming down the hallway on the second floor of the apartments where I live. I saw a gentleman (R1) sitting there. I went downstairs and saw another tenant of our apartments and I told her to go upstairs and see that man (R1). I know we have had some new residents lately and I don't know everyone here, but he just seemed like he didn't belong. He stated he was trying to find his sister. I saw that he had a (clothing protector) on and then I knew he was a nursing home resident. I called over to the facility and gave the description of what he was wearing, and the girls (nursing home staff) came over right away to come get him. His wheelchair was found sitting at the bottom of the stairs that lead to the second floor. Our security cameras were struck by lightning, so our cameras were not working. I don't know how he managed to get all the way over to our building and onto the second floor. On 7/22/23 at 10:57 AM, V3 (Licensed Practical Nurse) stated, (On 6/18/23) a tenant of the apartments (V8) next to our facility called and said a man wearing gray sweatpants, a black T-shirt and a clothing protector was looking for his sister at the apartments. I talked to (V8) the whole way there so she could guide me on how to get to (R1). We found (R1) on the second floor of the apartment building, sitting in a chair by the elevator. At the time, we weren't able to locate (R1's) wheelchair. (R1) doesn't ambulate well. I couldn't understand how it happened. We found his wheelchair at the bottom of a stairwell. I guess he climbed those two flights of stairs. No alarms were sounding upstairs at the nurses' station. (R1) was last in the dining room eating breakfast and then he was going to go to activities. V3 confirmed R1 is a known wanderer and exit seeker and states, (R1) has triggered alarms before. At this time, V3 verified V3 did not know R1 was out of the facility prior to V8 calling the facility. On 7/25/23 at 1:16 PM, V3 stated that R1 is not able to make sound judgements and would not be safe in the community due to R1's cognition status. V3 stated on 6/17/23, V3 responded to alarms sounding at an exit door at the end of the 100 hallway, which is a non-resident care area. V3 stated R1 was found at the exit door and R1 was not able to state what R1 was trying to do. V3 stated, If I hear an alarm, that's the only time I run. If the alarms were on and the door was closed, (R1) wouldn't have been able to get out. V3 stated V3 has never heard an alarm sound at the facility's door alarm panel at the nurses' station because it is never on. V3 verified if the panel was on and working properly, V3 would have been able to hear an alarm that the 600 Hallway exit door had been opened. On 7/22/23 at 11:08 AM, V4 (Registered Nurse) stated, (On 6/18/23), (R1) was up and heading downstairs for breakfast. I told (R1) I needed to see him after breakfast to look at his dressing. (V3) got the call about (R1) being in the apartments, I stayed in the facility with the other residents. I was not aware that (R1) was missing from the facility prior to (V8) calling. V4 verified that V4 did not hear any alarms sounding in the facility. V4 stated, If I heard an alarm sounding, I would have investigated it right away. On 7/22/23 at 11:17 AM, V6 (Certified Nursing Assistant/CNA) stated on 6/18/23, V6 last saw R1 in the dining room eating breakfast around 8:15 AM. V6 stated that V6 stayed upstairs with the other residents but that V6 saw R1 eating when V6 was in the dining room taking another resident back upstairs. V6 denied hearing any alarms sounding upstairs. V6 denied that anyone would be able to hear the door alarms downstairs from the upstairs. V6 stated, There is a panel at the nurses' station that would tell you where the door alarm is going off, but it did not work that day. On 7/22/23 at 11:45 AM, V7 (Maintenance Director) stated, I came in (on 6/18/23) when they notified me about (R1). No alarms were sounding at the nurses' station panel. The alarms are always sounding without reason, so the alarm panel is shut off. It has been brought to Corporate's attention many times. Alarm companies provided bids to Corporate to have the system replaced. I have been at the facility for six months and the alarm system hasn't worked right since I have been here. I understand it's been like that for years. The panel would have alarmed at the nurses' desk with the location of the opened door. The second door has the (electronic wandering door management system). Since the door wasn't closed properly, the (electronic wandering door management system) couldn't work as it should. Normally the door would magnetize shut so it cannot be opened, but that function couldn't work as intended because the door was already opened. The alarms were sounding at the doors, but no one would ever hear that upstairs at the nurses station. The second door latches shut. Someone went out that door and didn't make sure to check that it closed behind them. I did tighten some hinges, but it wasn't door error, it was employee error. On 7/22/23 at 8:10 AM, V15 (Activity Assistant) stated that on 6/18/23, V15 worked in the Activity Room until 12:00 PM. V15 stated that V15 received a call from V1 (Administrator) asking if R1 was in activities. V15 stated, I guess he (R1) got out (of the facility). (R1) came to BINGO on Saturday (6/17/23) but he didn't want to come to church on Sunday. I never heard any alarms sounding (on 6/18/23) I couldn't hear those door alarms from here. On 7/22/23 at 12:20 PM, V5 (CNA) stated that on 6/18/23, R1 was down at breakfast helping feed residents in the corner. After breakfast, V5 went upstairs to chart. V5 stated the facility got the call about R1 being found at the apartments. V5 stated R1 went out of the back doors by Hall 6. V5 stated, Normally the door would have locked because of the (electronic wandering door management system) and it alarms. No alarms were heard upstairs. I went with (V3) to go get (R1) from the apartments. He was sitting in a chair on the second floor. The nurse stayed with (R1), and I went to go look for his wheelchair. We couldn't find it, so we borrowed one of theirs (apartment complex). We ended up finding it by a flight of stairs. At this time, V5 verified that V5 did not know R1 was missing from the facility prior to V8 calling. On 7/25/23 at 1:00 PM, V10 (CNA) stated that on 6/18/23, V10 saw R1 eating breakfast downstairs in the main dining room when V10 was bringing other residents down to eat. V10 stayed on the main floor helping to pass room trays, drinks, and answer call lights. V10 denied that any alarms were sounding on the main floor to alert staff that a door had been opened. V10 stated the alarm panel at the nurses' station is very loud and that if it had been on, you would have been able to hear it from anywhere upstairs. V10 stated the facility received a phone call from a resident of the apartments who saw a man with a clothing protector on who was looking for his sister. V10 stated V10 went with V3 to the apartment complex to locate R1. V10 stated, We immediately went over there (to the apartments) and found (R1) sitting in a chair in the lobby area. V10 stated R1's wheelchair was not immediately able to be found. V10 stated prior to R1's elopement from the facility, R1 would often wander and make comments about waiting to get picked up from the facility. V10 stated if the second door would have been closed, R1's (electronic wandering transmitter bracelet) would have caused the door to lock and R1 would not have been able to open it. V10 stated R1 is able to propel R1's self in R1's wheelchair but that R1 normally requires staff assistance to stand. V10 stated, (R1) is stubborn and will sometimes try and transfer himself. V10 stated R1 is not safe on R1's own outside of the facility. V10 denied being aware that R1 was missing from the facility prior to getting the phone call from V8. On 7/25/23 at 1:59 PM, V17 (Social Service Director) stated that R1 came to the facility as a transfer from another local area skilled nursing facility. V17 stated that R1's plan is long term with no plans for discharge. V17 stated that R1 is not safe in the community due to R1's lack of safety awareness. V17 stated R1 has a history of falls and requires assistance to and from the bathroom, in and out of bed, and requires cueing for mealtimes. V17 stated R1 recently began displaying sexually inappropriate behavior that is being managed by an outside psychiatric company. On 7/26/23 at 9:50 AM, V18 (R1's Power of Attorney/Spouse) stated that V18 was called and informed that R1 had gotten out of the facility (on 6/18/23) and R1 was found in a nearby apartment complex. V18 stated that R1 does have a sister who lives in a neighboring city and due to her health status, she has not been able to visit R1 in over a year. V18 stated, (R1) gets very confused. (R1) cannot take care of himself. That's how he got to be in the facility in the first place. (R1) needs around the clock care, he isn't safe on his own. I couldn't provide that for him at home. I try to get in and visit (R1) at least once a week. (R1) often makes comments about going out to get his truck and sometimes thinks we are still living in California. His brain is fried, and it happened so fast. On 7/26/23 at 10:27 AM, V19 (Dietary Cook) stated that V19 was working in the facility on 6/18/23. V19 stated, We had just served the breakfast meal and the CNAs were in the corner assisting the residents who need fed. I turned around and (R1) was just gone. It's like he just disappeared. I didn't think anything of it and assumed (R1) went back upstairs. That's what the independents do. I didn't see him leave the room. I started preparing the next meal and then next thing I know, I see (V1/Administrator) standing there. I knew something must have happened if (V1) was in on a weekend. I did not know that (R1) was missing. They said he got out (of the facility). Normally if (R1) got close enough to the doors, they would lock shut automatically because of his (electronic wandering transmitter bracelet) and the doors would alarm. We have to enter a code to get the alarms to reset. At this time, V19 denied hearing any alarms sounding on 6/18/23 when R1 exited out of the facility doors. V19 stated, You can't hear the hall 6 alarms in the dining room. V19 stated, The day before (6/17/23), he (R1) was trying to get through the exit doors in the dining room. He was talking off the wall, saying silly things like he wanted to go to [NAME] or California and that he had kids that he needed to get candy to. I told one of my co-workers that I was worried about (R1) because he was not making any sense. I took (R1) directly upstairs myself and told the nurse at the nurses' station to keep an eye on him because he was trying to leave. er On 7/22/23 at 8:42 AM, V1 (Administrator) stated that V1 was called on a weekend (6/18/23) and informed that R1 was found out of the facility. V1 stated that at the time, Hall 6 was closed for resident use due to low census and therefore, staff were not present on the hallway. V1 stated that R1 had reported to staff that he was going to Activities. V1 stated that after a review of the video camera surveillance footage, R1 instead proceeded down the 600 Hallway. V1 stated that R1 pushed the first emergency exit door for 15 seconds, allowing it to open. V1 stated the second door wasn't completely latched closed, therefore R1 was able to exit out of the door, to the outside. V1 stated that V7/Maintenance Director did tighten some hinges on the door but is unknown why the door did not latch completely close. V1 stated that no alarms were able to be heard upstairs in the facility, only at the doors themselves. V1 stated that the door alarms where R1 exited the facility from are not loud enough to be able to be heard from the Activity Room. V1 reported inquiring about the alarm volume being adjusted but was told this is not a capability of the alarm system. V1 stated that R1 was gone from the facility a little over an hour before the facility received the phone call from the apartments and staff became aware that R1 was not in the facility. V1 stated, There is an alarm system for the doors as well that would alarm at a panel at the nurses station. Unfortunately, the door alarm panel was shut off manually by someone. The alarms were always going off, even without the doors being opened and staff were always having to check the doors, and nothing was causing the alarms to go off. The wind would blow the wrong direction and trigger the alarms. It has been like that for years. It is old and needs replaced. At this time, V1 verified that if the exit door alarms were functioning appropriately and activated at the nurses' station and if the door that contained the facility's electronic wandering door management system was completely closed, R1 would not have been able to leave the facility supervised. V1 stated, (R1) wouldn't have been able to get out. On 7/22/23 at 8:57 AM, this surveyor viewed the route R1 took to exit the facility alongside V1 (Administrator). After walking out of the 600 Hallway facility exit door, a sidewalk bordered with rock walls leads to a paved parking lot. The apartment complex where R1 was located sits to the left of the parking lot, atop a small incline, 150 feet from the facility exit doors. A residential street and housing are noted to the immediate right off the parking lot. Immediately upon entering the apartment complex doors, storage boxes, tables, stacked chairs and old televisions sitting on the floor filled the room. The stairwell where R1's wheelchair was located opened to a hallway that led to the location where R1 was found. This stairwell consisted of two flights of stairs with metal railings, metal edges on the front of each step and concrete walls and floors. The distance from the facility exit doors where V1 stated R1 exited the facility to the location where R1 was located was approximately 330 feet. On 7/22/23 at 9:10 AM, V1 (Administrator) showed this surveyor the alarm panel at the facility's nurses' station. The alarm panel consisted of individual buttons, each labeled with the location of the door it correlated with. V1 stated if an emergency exit door was opened without entering a code at the door prior, the correlating button would illuminate and sound to notify staff which emergency exit door was opened. At this time, V1 verified that all alarm buttons were compressed into the off position resulting in no alarm being able to sound to alert staff that an emergency exit door anywhere in the facility had been opened. V1 turned all the alarm buttons into the on position and immediately three different buttons, labeled with the location of the door illuminated and sounded very loudly. At this time, V1 stated, This is why the alarm panel is shut off, the doors alarm without reason. It needs replaced. V1 again placed all alarm buttons on the panel back in the off position. On 7/25/23 at 3:00 PM, V7 showed this surveyor the alarm panel at the facility's nurses' station. The panel buttons were in the off position including the 600 hallway/therapy exit. At this time, V7 verified any emergency exit doors that would be opened would not be able to be heard at the nurses' station. V7 stated, This whole system is antiquated. It needs replaced. Corporate knows. The Immediate Jeopardy was determined to have begun on June 18, 2023, at 8:20 AM when the facility failed to provide adequate supervision for R1 following an attempted elopement from the facility, subsequently resulting in R1 eloping from the facility without staff knowledge and being found approximately 330 feet away from the facility in an apartment complex. R1 exited the facility at the end of an unoccupied, unstaffed resident hallway. Facility door alarm panels at the nurses' station were shut off and staff was not aware that an emergency exit door had been opened. In addition, a second door containing the facility's electronic wandering door management system was left open, not allowing the door to lock as designed. V1 (Administrator) was notified of the Immediate Jeopardy on 7/25/23 at 12:15 PM. The facility submitted the original Abatement Plan for F689 to the State Agency on 7/25/23 at 4:01 PM. Revisions were requested on 7/27/23 at 12:52 PM and 3:50 PM. The final Abatement Plan was accepted on 7/28/23 at 1:15 PM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 6/18/23, V1/Administrator initiated and completed full facility head count per policy. 2. On 6/18/23, V1/Administrator initiated 15-minute checks for R1. 3. On 6/18/23, V1/Administrator increased R1's electronic wandering transmitter bracelet checks[TRUNCATED]

Based on observation, interview and record review, the facility failed to immediately supervise a confused, wandering resident (R34) with a history of aggressive behaviors and implement new interventions after a resident to resident (R34 and R51) physical altercation occurred and failed to protect residents in the facility, including (R7, R31,R36, R46, R39, R51) who reside on the same hallway as R34, from further abuse and potential abuse during the course of an open investigation. This failure resulted in R34 having continued access to residents in the facility, including R31 who R34 physically pulled and shoved hours after R34's previous altercation with R51 on 3/19/22. This failure also resulted in R34 and R51 continuing to have bedrooms that were connected with a shared bathroom. R51 remained fearful of repeated abuse from R34. R34 continued to wander throughout the facility, including into R51's room. These failures resulted in an Immediate Jeopardy. While the Immediacy was removed on 4/14/22 the facility remains out of compliance at a severity level II while the Facility continues to monitor the effectiveness of education and training on abuse prevention, reporting, and protecting a vulnerable population including conducting an investigation. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised, 6/8/20, states, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents, consultants, contractors, volunteers or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Definitions: 2. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual deliberately, not that the individual must have intended to, inflict injury or harm. 3. Verbal abuse means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. 5. Physical Abuse includes but not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Procedure: 5. Prevention of Abuse, Neglect and Exploitation-a. Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents. b. Observe resident behavior and their reaction to other residents, roommates, tablemates. c. Place residents in accommodations and environments that help keep them calm. e. Respond to all allegations or questions of abuse by residents, family members, employees or visitors. f. Take appropriate actions when abuse, neglect, or exploitation is suspected. k. Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident's rooms, residents with self-injurious behaviors, residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff. 8. Resident Protection after Alleged Abuse, Neglect and Exploitation-The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation. Examples of ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include, but are not limited to: a. Temporary (less than 24 hours) separation from other residents if a resident's behavior poses a threat of abuse or violence. b. Temporary or permanent room or roommate change, where incompatibility creates the potential for abuse. e. Temporary one on one supervision of a resident. f. Engage a resident in diversionary activities j. increased supervision of staff and residents 9. Response and Reporting of Abuse, Neglect and Exploitation: Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the employee should: a. Respond to the needs of the resident and protect them from further incident (document). 14. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: c. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process. The facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, dated 1/1/20, states, Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Compliance Guidelines: The facility will provide resident, families and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution, and will provide feedback regarding the concerns that have been expressed. The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 7. Protection: The facility will protect residents from harm during an investigation. R34's Facesheet documents R34 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's Brief Interview for Mental Status documents R34 with severe cognitive impairment. R34's Wandering Risk Assessment, dated 12/2/21, documents R34 as a high risk for wandering. R34's current Care Plan, states, I wander with no rationale purpose, seemingly oblivious to needs or safety due to Dementia. Remove/redirect resident from other resident's rooms and/or unsafe situations or nonresident areas. This same Care Plan documents (R34) is/has the potential to be verbally/physically aggressive related to Anger, Dementia, Poor Impulse Control and on 11/23/21, 15-minute checks were initiated. R34's Nursing Notes on 3/17/22 documents R34 to be agitated and combative with staff. R34's Health Status Note on 4/1/22 at 12:14 P.M., states, (R34) becoming increasingly agitated. Took PRN (as needed) [MEDICATION(S)] approx. (approximately) 20 min. (minutes ago). (R34) hit CNA (Certified Nursing Assistant) in the face when CNA attempting to redirect d/t (due to) resident frequently trying to go into other resident's rooms. R34's initial State Report form, (undated), provided by V1/Administrator on 4/7/22, documents on 3/19/22, R34 allegedly lifted another resident's chair (R51), scaring the resident and an investigation was initiated. R34's five-day follow-up report to the local state agency states, On 4/6/22, (V1/Administrator) informed by (V4/Director of Business Office Development) of possible incident between (R34) and (R51) that occurred on 3/19/22. Reported that (R34) lifted (R51's) wheelchair and scared (R51). This same report documents on 4/7/22 around 3:00 P.M., V23 (Resident Aide) telling V1 that on second shift (R34) was in (R51's) room and (R34) tried lifting (R51's) wheelchair while (R51) was sitting in it. (V23) also stated that (R34) laid on the floor of (R51's) room and (V23) had to get a nurse to coming and help get (R34) out of (R51's) room. (V1) spoke to (V24/Certified Nursing Assistant) on 4/7/22. (V24) stated (V24) does recall helping (V23) redirect (R34) out of (R51's) room. (R34) had entered (R51's) room through the joined bathroom. (R51) had stated that (R34) lifted (R51's) wheelchair. (V1) spoke to (R51) on 4/9/22. (R51) stated that (R34) raised (R51's) wheelchair while (R51) was in the wheelchair and it scared her. (R51) says she feels safe now that (R34) has been moved to another hallway. Disposition: On 4/9/22, the IDT (Interdisciplinary Team) discussed the altercation between (R34) and (R51) and implemented intervention of staffing 1:1 (one on one) and room change for (R34). R34's initial State Report form, (undated), provided by V1/Administrator on 4/7/22, documents on 3/19/22, R34 allegedly hit another resident (R31) and an investigation was initiated. R34's five-day follow-up report to the local state agency states, On 4/6/22, (V1) informed by (V4) of possible incident between (R34) and (R31) that occurred on 3/19/22. Staff member (V23) stated that (R34) hit (R31) in the hallway. This same report states, (V1) spoke to (V23) by phone on 4/7/22 around 3:00 P.M., (V23) stated that (V23) observed (R34) hit (R31) on her back. On April 9, 2022, (V1) and (V2/Director of Nursing) watched the video footage of Hall 5 security camera from Saturday, March 19, 2022 .The camera showed that at 5:54 P.M., (R34) walks into (R31's) room, (R34) guides (R31) out of her room into the hallway, the guide was by (R31's) arms, then (R34) lightly shoves (R31's) back .There was no harm observed but the shove from (R34) was intentional. Disposition: On 4/9/22, the IDT (Interdisciplinary Team) discussed the altercation between (R34) and (R51) and implemented intervention of staffing 1:1 (one on one) and room change for (R34). Throughout the days of 4/5/22-4/8/22, R34 and R51's room were connected by a shared bathroom. On 4/6/22 at 8:32 A.M., R34 was observed in R34's room in R34's wheelchair, R34 entered the bathroom that is shared with R51. R34 then exited the bathroom on R51's side of the room and went out into the hallway out R51's doorway. At this time, R51 stated, Get her away from me, she's trying to kill me. She scares me. No staff was present in the hallway at this time. On 4/6/22 at 9:11 A.M., R51 was sitting in R51's wheelchair. A test of the door alarms with R51's electronic wandering device was being conducted alongside V18 (Certified Nursing Assistant/CNA). R51 repeatedly asked about the whereabouts of R34 and why R34 acts the way R34 does. R51 stated, I shouldn't say that I know why she does that. It just scares me. Can't (R34) get out of here? On 4/6/22 at 9:15 A.M., V18 (Certified Nursing Assistant/CNA) stated, R34 and R51 do not get along. V18 stated there was an incident approximately one month ago when R34 came and tried to lift R51 out R51's chair. V18 stated, (R34) is strong and when she's mad, it's not good. V18 verified R34 is already on 15-minute checks. On 4/7/22 at 12:45 P.M., V4 (Director of Business Development) stated that when performing staff interviews about R34 lifting R51 out of R51's chair (on 3/19/22), V4 also found that staff reported to V4 that R34 hit R31 after R31 called R34 a b***h that same day (3/19/22). On 04/08/22 at 10:11 A.M., R51 stated, I was in my room listening to my music (on 3/19/22) and (R34) came into my room and lifted the back of my wheelchair up three times. I thought (R34) was going to kill me. I was so damn scared. I went and ate with (R36) because I was so scared. I didn't want to go to the dining room without someone or be alone in my room. (R34) shouldn't still be allowed to mingle around me. It hasn't happened again since. I keep my eye on (R34). I'm sure (R34) would like to get a hold of me again. (R34) wasn't always my neighbor. People have wrote stuff down about this before, no one has done anything. I'm so scared of her. They told me she was going to be leaving, but she never does. I wish she wasn't right next to me. On 4/8/22 at 12:48 P.M., V24 (Certified Nursing Assistant/CNA) stated, I was there on 3/19/22 when (R34) tried to pick (R51) out of the wheelchair. It was probably around 3:00 P.M. or 3:30 P.M., before supper. I was at the nursing station, and I heard some commotion. I was not assigned to that hallway. I helped get (R34) out of (R51's) room. (R51) was very mad. (R51) said she didn't want to deal with that anymore and that she shouldn't have to. I believe (V23/Resident Aide) told the nurse. I don't remember who the nurse was. I did not tell (V1/Administrator) but it should be reported right away. On 4/8/22 at 3:28 P.M., V23 (Resident Aide) stated, On second shift on the weekend, (3/19/22), I was keeping an eye on (R34). I was the 1:1 for (R31). I heard (R51) yell, 'Get this B***h out before I kill her.' (R34) was grabbing (R51's) wheelchair and trying to get (R51) out of the chair. (R34) then sat in (R51's) recliner chair in (R51's) room. (R51) asked (R34) to get out of the chair and (R51) said, 'I'm not going anywhere.' It took three of us to get (R34) out of (R51's) room. We went through the shared bathroom to get (R34) back into her own room. (R51) called (R34) a B-word and I think that is what triggered her. Once (R51) said the B-word is when (R34) got aggressive. (R31) also called (R34) a B-word and (R34) smacked (R31) that same day. (R51) is scared of (R34) now because of the way (R34) picked (R51) up. Every time I go in that hallway, (R51) asks me if (R34) is around. I reported all of this to (V1/Administrator) the next day. On 4/8/22 at 4:40 P.M., R7 stated, About a month ago, (R51) was sitting in her wheelchair in (R51's) room. (R34) came over there and grabbed a hold of (R51's) wheelchair (that R51 was sitting in) and started pulling and lifting it up. (R51) started yelling for help at that time. I would say it lasted about a minute. R7's Brief Interview for Mental Status, dated 1/20/22, documents R7 is cognitively intact without memory impairments. On 4/9/22 at 10:35 A.M., V31 (Certified Nursing Assistant/CNA) stated that R34 can be violent to anyone and everyone. On 4/8/22 at 5:03 P.M., V1 (Administrator) stated, The staff should have called me right away. It says right on the outside of my door that I am the Abuse Coordinator and I even carry an abuse phone and the phone number is posted as well. We just in-serviced staff on who the abuse coordinator was and when to call in mid-February (2022). Waiting until the next day (to report potential abuse) is unacceptable. I would have come right in. I didn't know anything about this. We are going to discuss the best placement for (R34). We have to look at the census. (V4/Director of Business Development) first made me aware of this incident with (R34) the day before yesterday (4/6/22). (R34) wanders. Someone should always be with (R34). There should be some sort of documentation of (R34's) behavior in (R34's) medical record (about the 3/19/22 incident) and there is not. At this same time, V1 verified no new interventions or increased supervision had been put into place to keep other residents safe from R34 and verified that R34 and R51's rooms remain connected with a shared bathroom. On 4/9/22 at 3:30 P.M., After watching video surveillance, V1 verified on 3/19/22 that, R34 grabbed hold of the back of R51's wheelchair after wandering into R51's room, R34 wandered into R31's room, R34 shoved R31, and R34 then wandered again into R51's room. As of 4/7/22 at 3:30 P.M., R31, R34, nor R51's medical record did not contain any documentation regarding any of the above altercations on 3/19/22 occurring or any added/increased interventions being implemented. On 4/9/22 at 10:13 A.M., V4 (Director of Business Development) stated in the evening of 4/8/22, R34 was placed on 1:1 (one on one) supervision and moved from the 500 hallway to the 200 hallway. On 4/9/22 at 12:26 P.M., V1 provided written resident interviews that V1 had obtained during the course of V1's investigation into the alleged abuse between R34 and R51 on 3/19/22. This form documents R51 was interviewed on 4/9/22 at 10:44 A.M. by V1 and documents R51 told V1 that R51 does not feel safe when R34 wanders into R51's room, R34 lifted up R51's wheelchair and it scared R51, and that R51 feels safe now that R34 has been moved. On 4/9/22 at 3:55 P.M., R36 stated, It's been several weeks ago now, but I was in my room about to go out the door. (R51's) room is right across from mine, so I can see everything. I believe (R34) came into (R51's) room from the bathroom door. (R34) was behind (R51) and lifted her chair a few times where (R51) slid just about out. (R34) does impulsive things. (R51) was yelling for help and saying 'stop, stop.' (R34) finally let (R51) go. The staff came and tried to get (R34) out of (R51's) room. (R51) was so scared. (R51) didn't want to be around her. (R51) was scared that (R34) would come through her bathroom door again. (R51) went to lunch (in the dining room) with me a couple times. I think because (R51) was too scared to stay there and see (R34). R36's Brief Interview for Mental Status, dated 2/23/22, documents R36 is cognitively intact without memory impairments. On 4/11/22 at 5:10 P.M., V1 stated had V1 first been notified of the altercation between R34 and R51, V1 does not think the altercation between R34 and R31 would have occurred. V1 would have immediately instructed the staff to separate the residents and keep R34 separated from others. V1 would have immediately come to the facility and would have looked into separating and moving rooms during the open investigation. On 4/14/22 at 1:28 P.M., R51 stated, (R51) is not next to me anymore. I haven't seen her since they moved her. I thought she was going to be moving facilities, but I guess (R51) being on the other side (of the facility) is good. I feel safe now that I know she isn't next door or even in my hallway anymore. I always was scared she would come through that bathroom door again. The Immediate Jeopardy was identified on 4/12/22. The Immediate Jeopardy began on 3/19/22 when R34 wandered into R31 and R51's room; placed R34's hands on R31 and R51; and staff did not immediately report the incident to V1, and no new interventions or increased supervision was immediately implemented to protect residents from further potential abuse. On 4/12/22 at 4:25 P.M. V1 (Administrator) was notified of the Immediate Jeopardy. On 4/14/22, the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. On 4/9/22, R34 was moved to another hallway and placed on 1:1 (one to one) with staff. V1 (Administrator) and V2 (Director of Nursing) communicated altercation between R34 and R51 and R34 and R31 to floor staff and reason for implementation of 1:1 and room move. R34's Care Plan reviewed and updated with 1:1 intervention and providing redirection when approaching other residents. 2. On 4/12/22, V1 was in-serviced by V22 (Vice President of Operations) on Resident Abuse Prevention and Reporting-Protecting a vulnerable population (including completion of pre/posttest) and Abuse, Neglect, Exploitation-Conducting an Investigation in a Skilled Nursing Facility (including completion of pre/posttest). 3. On 4/12/22, the facility began in-service with all staff on Resident Abuse Prevention and Reporting-Protecting a Vulnerable Population (including completion of pre/posttest). In-service completion date of 4/14/22. 4. On 4/13/22, all managers received in-service Resident Abuse Prevention and Reporting-Protecting a vulnerable population (including completion of pre/posttest) and Abuse, Neglect, Exploitation-Conducting an Investigation in a Skilled Nursing Facility (including completion of pre/posttest). 5. All abuse reports and investigations will be discussed with and reviewed by V4 prior to submission to the local state agency to ensure completion of Abuse Investigation Protocol Checklist.

Based on observation, interview and record review, the facility failed to ensure an ambulatory resident with a history of known aggressive behaviors was monitored to prevent resident to resident verbal and physical abuse and failed to ensure residents were free of resident to resident verbal and physical abuse for three of four residents (R31, R34, R51) reviewed for abuse in the sample of 41. This failure resulted in R51 and R31 calling R34 a name using foul language, R34 wandering into R51's room and attempting to lift R51 out of R51's wheelchair resulting in R51 being fearful of R34. This failure also resulted in R34 wandering into R31's room, placing R34's hands on R31, attempting to pull R31 out of R31's room and then shoving R31 in the back. These failures resulted in an Immediate Jeopardy. While the Immediacy was removed on 4/14/22. The Facility remains out of compliance at a severity level II while the Facility continues to monitor the effectiveness of education and training on abuse prevention, reporting, and protecting a vulnerable population including conducting an investigation. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised, 6/8/20, states, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents, consultants, contractors, volunteers or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Definitions: 2. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual deliberately, not that the individual must have intended to inflict injury or harm. 3. Verbal abuse means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. 5. Physical Abuse includes but not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. R34's Facesheet documents R34 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's Brief Interview for Mental Status documents R34 with severe cognitive impairment. R34's Wandering Risk Assessment, dated 12/2/21, documents R34 as a high risk for wandering. R34's current Care Plan, states, I wander with no rationale purpose, seemingly oblivious to needs or safety due to Dementia. Remove/redirect resident from other resident's rooms and/or unsafe situations or nonresident areas. This same Care Plan states, (R34) is/has potential to be verbally/physically aggressive r/t (related to) Anger, Dementia, Poor Impulse Control. R34's Nursing Notes on 3/17/22 documents R34 to be agitated and combative with staff. R34's Health Status Note on 4/1/22 at 12:14 P.M., states, (R34) becoming increasingly agitated. Took PRN (as needed) [MEDICATION(S)] approx. (approximately) 20 min. (minutes ago). (R34) hit CNA (Certified Nursing Assistant) in the face when CNA attempting to redirect d/t (due to) resident frequently trying to go into other resident's rooms. R34's initial State Report form, (undated), provided by V1/Administrator on 4/7/22, documents on 3/19/22, R34 allegedly lifted another resident's chair (R51), scaring the resident and an investigation was initiated. R34's five-day follow-up report to the local state agency states, On 4/6/22, (V1/Administrator) informed by (V4/Director of Business Office Development) of possible incident between (R34) and (R51) that occurred on 3/19/22. Reported that (R34) lifted (R51's) wheelchair and scared (R51). This same report documents on 4/7/22 around 3:00 P.M., V23 (Resident Aide) telling V1 that on second shift (R34) was in (R51's) room and (R34) tried lifting (R51's) wheelchair while (R51) was sitting in it. (V23) also stated that (R34) laid on the floor of (R51's) room and (V23) had to get a nurse to come in and help get (R34) out of (R51's) room. (V1) spoke to (V24/Certified Nursing Assistant) on 4/7/22. (V24) stated (V24) does recall helping (V23) redirect (R34) out of (R51's) room. (R34) had entered (R51's) room through the joined bathroom. (R51) had stated that (R34) lifted (R51's) wheelchair. (V1) spoke to (R51) on 4/9/22. (R51) stated that (R34) raised (R51's) wheelchair while (R51) was in the wheelchair and it scared her. (R51) says she feels safe now that (R34) has been moved to another hallway. Disposition: On 4/9/22, the IDT (Interdisciplinary Team) discussed the altercation between (R34) and (R51) and implemented intervention of staffing 1:1 (one on one) and room change for (R34). R34's initial State Report form, (undated), provided by V1/Administrator on 4/7/22, documents on 3/19/22, R34 allegedly hit another resident (R31) and an investigation was initiated. R34's five day follow-up report to the local state agency states, On 4/6/22, (V1) informed by (V4) of possible incident between (R34) and (R31) that occurred on 3/19/22. Staff member (V23) stated that (R34) hit (R31) in the hallway. This same report states, (V1) spoke to (V23) by phone on 4/7/22 around 3:00 P.M., (V23) stated that (V23) observed (R34) hit (R31) on her back. On April 9, 2022, (V1) and (V2/Director of Nursing) watched the video footage of Hall 5 security camera from Saturday, March 19, 2022 .The camera showed that at 5:54 P.M., (R34) walks into (R31's) room, (R34) guides (R31) out of her room into the hallway, the guide was by (R31's) arms, then (R34) lightly shoves (R31's) back .There was no harm observed but the shove from (R34) was intentional. Disposition: On 4/9/22, the IDT (Interdisciplinary Team) discussed the altercation between (R34) and (R51) and implemented intervention of staffing 1:1 (one on one) and room change for (R34). On 4/6/22 at 8:32 A.M., R34 was observed in R34's room in R34's wheelchair, R34 entered the bathroom that is shared with R51. R34 then exited the bathroom on R51's side of the room and went into the hallway through R51's doorway. At this time, R51 stated, Get her away from me, she's trying to kill me. She scares me. No staff was present in the hallway at this time. On 4/6/22 at 9:11 A.M., R51 was sitting in R51's wheelchair. A test of the door alarms with R51's electronic wandering device was being conducted alongside V18 (Certified Nursing Assistant/CNA). R51 repeatedly asked about the whereabouts of R34 and why R34 acts the way R34 does. R51 stated, I shouldn't say that I know why she does that. It just scares me. Can't (R34) get out of here? On 4/6/22 at 9:15 A.M., V18 (Certified Nursing Assistant/CNA) stated, R34 and R51 do not get along. V18 stated there was an incident approximately one month ago when R34 came and tried to lift R51 out R51's chair. V18 stated, (R34) is strong and when she's mad, it's not good. V18 verified R34 is already on 15-minute checks. On 4/7/22 at 12:45 P.M., V4 (Director of Business Development) stated that when performing staff interviews about R34 lifting R51 out of R51's chair (on 3/19/22), V4 also found that staff reported to V4 that R34 hit R31 after R31 called R34 a b***h that same day (3/19/22). On 4/8/22 at 4:40 P.M., R7 stated, About a month ago, (R51) was sitting in her wheelchair in (R51's) room. (R34) came over there and grabbed a hold of (R51's) wheelchair (that R51 was sitting in) and started pulling and lifting it up. (R51) started yelling for help at that time. I would say it lasted about a minute. R7's Brief Interview for Mental Status, dated 1/20/22, documents R7 is cognitively intact without memory impairments. On 04/08/22 at 10:11 A.M., R51 stated, I was in my room listening to my music (on 3/19/22) and (R34) came into my room and lifted the back of my wheelchair up three times. I thought (R34) was going to kill me. I was so damn scared. I went and ate with (R36) because I was so scared. I didn't want to go to the dining room without someone or be alone in my room. (R34) shouldn't still be allowed to mingle around me. It hasn't happened again since. I keep my eye on (R34). I'm sure (R34) would like to get a hold of me again. (R34) wasn't always my neighbor. People have wrote stuff down about this before, no one has done anything. I'm so scared of her. They told me she was going to be leaving, but she never does. I wish she wasn't right next to me. On 4/8/22 at 12:48 P.M., V24 (Certified Nursing Assistant/CNA) stated, I was there on 3/19/22 when (R34) tried to pick (R51) out of the wheelchair. It was probably around 3:00 P.M. or 3:30 P.M., before supper. I was at the nursing station, and I heard some commotion. I was not assigned to that hallway. I helped get (R34) out of (R51's) room. (R51) was very mad. (R51) said she didn't want to deal with that anymore and that she shouldn't have to. I believe (V23/Resident Aide) told the nurse. I don't remember who the nurse was. I did not tell (V1/Administrator) but it should be reported right away. On 4/8/22 at 3:28 P.M., V23 (Resident Aide) stated, On second shift on the weekend, (3/19/22), I was keeping an eye on (R34). I was the 1:1 for (R31). I heard (R51) yell, 'Get this B***h out before I kill her.' (R34) was grabbing (R51's) wheelchair and trying to get (R51) out of the chair. (R34) then sat in (R51's) recliner chair in (R51's) room. (R51) asked (R34) to get out of the chair and (R34) said, 'I'm not going anywhere.' It took three of us to get (R34) out of (R51's) room. We went through the shared bathroom to get (R34) back into her own room. (R51) called (R34) a B-word and I think that is what triggered her. Once (R51) said the B-word is when (R34) got aggressive. (R31) also called (R34) a B-word and (R34) smacked (R31) that same day. (R51) is scared of (R34) now because of the way (R34) picked (R51) up. Every time I go in that hallway, (R51) asks me if (R34) is around. I reported all of this to (V1/Administrator) the next day. On 4/8/22 at 5:03 P.M., V1 (Administrator) stated, The staff should have called me right away. It says right on the outside of my door that I am the Abuse Coordinator and I even carry an abuse phone and the phone number is posted as well. We just in-serviced staff on who the abuse coordinator was and when to call in mid-February (2022). Waiting until the next day (to report potential abuse) is unacceptable. I would have come right in. I didn't know anything about this. We are going to discuss the best placement for (R34). We have to look at the census. (V4/Director of Business Development) first made me aware of this incident with (R34) the day before yesterday (4/6/22). (R34) wanders. Someone should always be with (R34). There should be some sort of documentation of (R34's) behavior in (R34's) medical record (about the 3/19/22 incident) and there is not. At this same time, V1 verified no new interventions or changes (after the 3/19/22 incident) have been put into place to keep other residents safe from R34. On 4/9/22 at 10:35 A.M., V31 (Certified Nursing Assistant/CNA) stated that R34 can be violent to anyone and everyone. On 4/9/22 at 3:30 P.M., After watching video surveillance, V1 verified on 3/19/22 that, R34 grabbed hold of the back of R51's wheelchair after wandering into R51's room, R34 wandered into R31's room, R34 shoved R31, and R34 then wandered again into R51's room. On 4/9/22 at 3:55 P.M., R36 stated, It's been several weeks ago now, but I was in my room about to go out the door. (R51's) room is right across from mine, so I can see everything. I believe (R34) came into (R51's) room from the bathroom door. (R34) was behind (R51) and lifted her chair a few times where (R51) slid just about out. (R34) does impulsive things. (R51) was yelling for help and saying 'stop, stop.' (R34) finally let (R51) go. The staff came and tried to get (R34) out of (R51's) room. (R51) was so scared. (R51) didn't want to be around her. (R51) was scared that (R34) would come through her bathroom door again. (R51) went to lunch (in the dining room) with me a couple times. I think because (R51) was too scared to stay there and see (R34). R36's Brief Interview for Mental Status, dated 2/23/22, documents R36 is cognitively intact without memory impairments. The Immediate Jeopardy was identified on 4/12/22. The Immediate Jeopardy began on 3/19/22 after R34 wandered into R51's room and placed R34's hands on R51's wheelchair while R51 was sitting in it and attempted to lift R51's chair. That same day, R34 then wandered into R31's room, pulled R31 out of R31's room and then R34 shoved R31 in the back. On 4/12/22 at 4:25 P.M. V1 (Administrator) was notified of the Immediate Jeopardy. On 4/14/22, the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. On 4/9/22, R34 was moved to another hallway and placed on 1:1 (one to one) with staff. V1 (Administrator) and V2 (Director of Nursing) communicated altercation between R34 and R51 and R34 and R31 to floor staff and reason for implementation of 1:1 and room move. R34's Care Plan reviewed and updated with 1:1 supervision. 2. V6 (Social Service Director) V1 or designee will meet with R51 at least three times per week for four weeks to provide psychosocial support. 3. On 4/12/22, V1 was in-serviced by V22 (Vice President of Operations) on Resident Abuse Prevention and Reporting-Protecting a vulnerable population (including completion of pre/posttest) and Abuse, Neglect, Exploitation-Conducting an Investigation in a Skilled Nursing Facility (including completion of pre/posttest). 4. On 4/12/22, the facility began in-service with all staff on Resident Abuse Prevention and Reporting-Protecting a Vulnerable Population (including completion of pre/posttest). In-service completion date of 4/14/22. 5. On 4/13/22, all managers received in-service Resident Abuse Prevention and Reporting-Protecting a vulnerable population (including completion of pre/posttest) and Abuse, Neglect, Exploitation-Conducting an Investigation in a Skilled Nursing Facility (including completion of pre/posttest). 6. All abuse reports and investigations will be discussed with and reviewed by V4 prior to submission to the local state agency to ensure completion of Abuse Investigation Protocol Checklist.

Based on interview and record review the facility failed to ensure allegations of verbal and physical abuse were immediately reported to the abuse coordinator for three of four residents (R31, R34, R51) reviewed for abuse in the sample of 41. This failure resulted in V1 (Administrator) not being able to initiate a timely investigation, which then allowed R34 to have continued access to residents in the facility. This access included R31, who R34 physically pulled and shoved hours after R34's previous altercation with R51 on 3/19/22 and resulted in R34 and R51 continuing to have bedrooms that were connected with a shared bathroom. R51 remained fearful of repeated abuse from R34. R34 continued to wander throughout the facility, including into R51's room. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised, 6/8/20, states, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents, consultants, contractors, volunteers or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Definitions: 1. The Abuse Coordinator in the facility is the Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator or designee; other Officials in accordance with State Law; State Survey and Certification agency through established procedures. Procedure: 9. Response and Reporting of Abuse, Neglect and Exploitation-Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the employee should: b. Notify Administrator or Abuse Coordinator Designee immediately (document) c. Notify the attending physician and the resident's family/legal representative. 14. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the administrator of the facility and to other official (including the State Survey Agency and Adult Protected Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law. The facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, dated 1/1/20, states, Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. R34's initial State Report form, (undated), provided by V1/Administrator on 4/7/22, documents on 3/19/22, R34 allegedly lifted another resident's chair (R51), scaring the resident and an investigation was initiated. R34's initial State Report form, (undated), provided by V1/Administrator on 4/7/22, documents on 3/19/22, R34 allegedly hit another resident (R31) and an investigation was initiated. On 4/6/22 at 9:15 A.M., V18 (Certified Nursing Assistant/CNA) stated, R34 and R51 do not get along. V18 stated there was an incident approximately one month ago when R34 came and tried to lift R51 out R51's chair. V18 stated, (R34) is strong and when she's mad, it's not good. On 4/7/22 at 9:15 A.M., V1 (Administrator) stated V1 did not know anything about the alleged abuse with R31, R34, and R51; and V1 would have expected to have been notified, especially since the alleged abuse was resident to resident. On 4/7/22 at 12:45 P.M., V4 (Director of Business Development) stated that when performing staff interviews about R34 lifting R51 out of R51's chair (on 3/19/22), V4 also found that staff reported to V4 that R34 hit R31 after R31 called R34 a b***h that same day (3/19/22). On 04/8/22 at 10:11 A.M., R51 stated, I was in my room listening to my music (on 3/19/22) and (R34) came into my room and lifted the back of my wheelchair up three times. I thought (R34) was going to kill me. I was so damn scared. I went and ate with (R36) because I was so scared. I didn't want to go to the dining room without someone or be alone in my room. (R34) shouldn't still be allowed to mingle around me. It hasn't happened again since. I keep my eye on (R34). I'm sure (R34) would like to get a hold of me again. (R34) wasn't always my neighbor. People have wrote stuff down about this before, no one has done anything. I'm so scared of her. They told me she was going to be leaving, but she never does. I wish she wasn't right next to me. On 4/8/22 at 9:30 A.M., V22 (Vice President of Operations), stated, Even with (R34's) behaviors, if (R34) does something to another resident the staff should report it immediately (to V1) so it can be handled. On 4/8/22 at 12:48 P.M., V24 (Certified Nursing Assistant/CNA) stated, I was there on 3/19/22 when (R34) tried to pick (R51) out of the wheelchair. It was probably around 3:00 P.M. or 3:30 P.M., before supper. I was at the nursing station, and I heard some commotion. I was not assigned to that hallway. I helped get (R34) out of (R51's) room. (R51) was very mad. (R51) said she didn't want to deal with that anymore and that she shouldn't have to. I believe (V23/Resident Aide) told the nurse. I don't remember who the nurse was. I did not tell (V1/Administrator) but it should be reported right away. On 4/8/22 at 3:28 P.M., V23 (Resident Aide) stated, On second shift on the weekend, (3/19/22), I was keeping an eye on (R34). I was the 1:1 for (R31). I heard (R51) yell, 'Get this B***h out before I kill her.' (R34) was grabbing (R51's) wheelchair and trying to get (R51) out of the chair. (R34) then sat in (R51's) recliner chair in (R51's) room. (R51) asked (R34) to get out of the chair and (R51) said, 'I'm not going anywhere.' It took three of us to get (R34) out of (R51's) room. We went through the shared bathroom to get (R34) back into her own room. (R51) called (R34) a B-word and I think that is what triggered her. Once (R51) said the B-word is when (R34) got aggressive. (R31) also called (R34) a B-word and (R34) smacked (R31) that same day. (R51) is scared of (R34) now because of the way (R34) picked (R51) up. Every time I go in that hallway, (R51) asks me if (R34) is around. I reported all of this to (V1/Administrator) the next day. At this time, V23 verified allegations of abuse should be reported to V1/Administrator immediately. On 4/8/22 at 5:03 P.M., V1 (Administrator) stated, The staff should have called me right away. It says right on the outside of my door that I am the Abuse Coordinator and I even carry an abuse phone and the phone number is posted as well. We just in-serviced staff on who the abuse coordinator was and when to call in mid-February (2022). Waiting until the next day (to report potential abuse) is unacceptable. I would have come right in. I didn't know anything about this. We are going to discuss the best placement for (R34). We have to look at the census. (V4/Director of Business Development) first made me aware of this incident with (R34) the day before yesterday (4/6/22). (R34) wanders. Someone should always be with (R34). There should be some sort of documentation of (R34's) behavior in (R34's) medical record (about the 3/19/22 incident) and there is not. On 4/9/22 at 2:12 P.M., During the review of video surveillance, when R34 is seen pulling R31 out of R31's room and then shoving R31, V1 stated, There was no call to me about this. I should have been called immediately. On 4/9/22 at 3:30 P.M., After watching video surveillance, V1 verified on 3/19/22, R34 grabbed hold of the back of R51's wheelchair and that R34 shoved R31. V1 stated, I should have been notified about this. I was not. I would have come in right away, so that I could interview everyone while it was still fresh in their minds and when everyone was still here. As of 4/7/22 at 3:30 P.M., R31, R34, nor R51's medical record did not contain any documentation regarding any of the above altercations on 3/19/22 occurring. On 4/11/22 at 5:10 P.M., V1 stated had V1 first been notified of the altercation between R34 and R51, V1 does not think the altercation between R34 and R31 would have occurred. V1 would have immediately instructed the staff to separate the residents and keep R34 separated from others. V1 would have immediately come to the facility and would have looked into separating and moving rooms during the open investigation.

Based on observation, interview and record review the facility failed to ensure the facility's electronic wandering door management system was in complete working order for eight (R3, R6, R17, R22, R31, R34, R47 and R51) of eight residents reviewed for wandering, failed to ensure a resident under one to one supervision was not left unattended, failed to complete neurological checks on a resident with an unwitnessed fall. In addition, the facility failed to ensure care planned interventions for falls and one to one supervision were implemented for one of seven residents (R31) reviewed for accidents in the sample of 41. This failure resulted in R31 having an unwitnessed fall that resulted in a laceration and nasal bone fractures. Findings include: 1. The facility's Fall Risk Assessment policy, revised 12/1/20, states, It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. 4. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice to reduce the risk of an accident. 5. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice. The facility's Incidents, Accidents and Supervision policy, revised 1/30/22, states, Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Definitions: Accidents refers to any unexpected or unintentional incident, which results in injury or illness to a resident. Fall refers to unintentionally coming to rest on the ground, floor, or other lower level. 3. Implementation of Interventions-using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff. d. Documenting interventions (plans of action developed by the QAPI (Quality Assurance Performance Improvement) Team or care plans for the individual resident). e. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidenced-based practice. h. Resident-directed approaches may include: i. implementing specific interventions as part of the plan of care ii. supervising staff and residents, etc. iii. facility records document the implementation of these interventions. 5. Supervision-Supervision is an intervention and a means of mitigating accident risk, The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency b. Based on the individual resident's assessed needs and identified hazards in the resident environment. R31's Face sheet documents R31 with diagnoses to include but not limited to: unspecified Dementia with Behavioral Disturbance; Alzheimer's Disease; Unsteadiness on Feet; Repeated Falls; and Cognitive Communication Deficit. R31's Fall Assessment, dated 1/6/22, documents R31 is at a high risk for falling. R31's IDT (Interdisciplinary Team) note, dated 3/21/22 and 4/7/22, documents R31's BIMS (Brief Interview Mental Status) score a of 0 (out of 15) indicating severe cognitive impairment. R31's MDS (Minimum Data Set) Assessment, dated 2/16/22, documents R31 requires limited assistance of one plus person physical assist for transfers, bed mobility, and walking between locations in R31's room. R31's current Care Plan documents the following: R31 wanders with no rational purpose, seemingly oblivious to needs or safety throughout the healthcare center and documents an intervention initiated 10/5/21, of 1:1 (one to one) supervision.; R31 requires staff supervision for transfers for safety; R31 is able to ambulate independently with staff supervision but requires limited staff assist of one for safety and direction; R31 is a high risk for falls related to incontinence and poor safety awareness due to cognitive impairment and documents interventions as Fall 3/18/22-Hazard strips to bed with a date initiated of 3/31/22. Fall 4/4/22-staff education 1:1 with a date initiated of 4/4/22. R31's Nursing Notes on 3/17/22 at 1:59 P.M., states, (R31) exhibiting behaviors almost all shift such as wandering, agitation, repetitive questioning/statements. Requiring one on one with staff for redirection. R31's Social Service Note on 2/16/22 document R31 has a one-to-one companion that monitors her. R31's Health Status notes on 3/24/22 and 4/5/22 document R31 continues to be a one-to-one supervision with staff. R31's Fall Incident Report on 3/18/22 states, (R31) fell in her room beside her bed. (R31) was found on her hands and knees over the garbage can. (R31) tripped over the bedside garbage can and landed on her hands and knees. Fall was not witnessed but (R31) denies hitting her head. (R31) complains of pain in her knees and was given Tylenol for pain. (R31) unable to give description. This same report documents no witnesses could be found. R31's IDT (Interdisciplinary Team) Note on 3/31/22 documents a root cause of R31's 3/18/22 fall as Transferring self out of bed without assistance and interventions implemented as Hazard Strips next to bed. Staff Education is documented as Monitor (R31's) gait when up walking or trying to get out of bed. R31's Post Fall Observation, dated 3/18/22 at 5:41 P.M., documents R31 was found on the floor in R31's room on her hands and knees and documents R31's fall was not witnessed but nearby staff did hear the fall occur. Detailed Description of Fall states, (R31) tripped over the garbage can at (R31's) bedside and landed on (R31's) hands and knees. R31's Fall Incident Report on 4/4/22 states, Staff entered (R31's) room after being in another resident's room. (R31) sitting on floor. Notes to have a gash in the center of forehead .Left knee noted to be swollen with raised purple area. (R31) rubbing knee stating, 'it's cold outside'. Uncertain of (R31's) cognitive status prior to fall. Pupils equal and reactive. 911 called at 0420 (4:20 A.M.). Injuries observed at time of Incident: Laceration top of scalp. Predisposing Physiological Factors: confused, gait imbalance, weakness/fainted are checked. Predisposing Situation Factors: Ambulating without Assist is checked. This same report documents no witnessed found. R31's IDT Note on 4/7/22 documents a root cause of R31's 4/4/22 fall as rolled out of bed. This same note documents R31 was last seen at 2:45 A.M. in bed, Neuro (Neurological) checks x (times) 72 hours, Monitor for signs/symptoms of injury after fall and report any abnormalities to R31's physician. R31's Initial Report to the local state agency, undated, states, (R31) BIMS (Brief Interview Mental Status) score of 0 (severe impairment); staff entered room after being in another resident's room. (R31) sitting on the floor. Noted to have a gash in the center of forehead. B/P (Blood Pressure) 136/88, p (Pulse) 100, r (Respirations) 22. Left knee noted to be swollen with raised purple area. Pupils equal and reactive. Sent to ER (emergency room ) for further evaluation. Facility received notification from ER: (R31) has a 5 cm (Centimeter) laceration to center of forehead, (R31) received sutures of forehead (laceration, concussion and has closed fracture of nasal bone. Types of injuries: Laceration of forehead, closed fracture of nasal bone, concussion/head injury. R31's five-day follow-up to the local state agency documents on 4/4/22, R31 was observed sitting on the floor with a gash in the center of R31's forehead. This report documents, (V1/Administrator) interviewed (V34/Certified Nursing Assistant) on 4/4/22. (R31) was observed in the (R31's) room at 4:00 A.M. by (V34) and (R31) was still sleeping. (V34) stated he left the room to attend to activated call light. Upon returning to the room, (V34) observed (R31) sitting on the floor. Noted to have laceration in center of forehead. Physician notified and received order to transfer to (local area hospital) by ambulance for further evaluation. POA (Power of Attorney) notified of transfer for evaluation. Facility received notification from ER (emergency room ) regarding diagnosis of 5 (five) cm (centimeter) laceration to center of forehead, concussion and closed fracture of nasal bone. Disposition: Care Plan reviewed and updated to include educate staff regarding 1:1 (one to one). (V1) sent email to (staffing) agency that (V34) is not allowed to return (to facility to work). R31's Post Fall Observation dated 4/4/22 at 5:28 A.M., documents R31's fall was unwitnessed and when staff entered (R31's) room (R31) was sitting up with legs flexed up to hip. Arms at side. R31's CT (Computed Tomography) without contrast obtained at the local area hospital on 4/4/22 documents an impression of nasal bone fractures. R31's local area hospital Emergency Department summary, on 4/4/22, states, (R31) was found on the floor of (R31's) room earlier at night with a laceration injury to forehead. This same report states, 5 (five) cm laceration sub Q (subcutaneous) lac (laceration) located in the center of (R31's) forehead. Nose: edematous (swollen) with mild deformity. This note also documents R31's forehead laceration was repaired with sutures. On 4/5/22 at 10:05 A.M., R31 was noted to be lying in bed with eyes closed. V25 (Certified Nursing Assistant) was sitting next to R31's side. V25 stated that V25 is sitting with R31 for R31's ordered one to one supervision. V25 stated that V25 has been working at the facility since September 2021 and states that R31 has been one to one supervision that whole time. At this time, R31 is noted to have purple and yellow bruising surround both of R31's eyes, a laceration to the center of R31's forehead with sutures, bruising to R31's nose, and a nasal deformity noted. At this time, no fall strips were noted to the floor next to R31's bed. On 4/7/22 at 9:02 A.M., No fall strips were noted on the floor next to R31's bed. V25 verified no fall hazard strips were on the floor next to R31's bed. R31 was lying in bed with eyes closed. R31's facial bruising, laceration with sutures, and nasal deformity remain the same. On 4/7/22 at 10:35 A.M., V2 (Director of Nursing) verified that the hazard strips had not been placed onto the floor next to R31's bed. V2 stated, They should be there. I will notify maintenance. On 4/7/22 at 11:53 A.M., V1 (Administrator) and V2 (Director of Nursing) stated that V34 (CNA/Certified Nursing Assistant), (On 4/4/22), took it upon himself to say that (V34) would do the 500 hall and also one to one (R31). Apparently, there was a call in and instead of calling (V2) who was on call, they (facility staff) made a schedule change without notifying (V2). At this time, V2 stated, I was on call that night and I did not get any notification about a schedule change or call-in. They (facility staff) know not to make changes without notifying the supervisor on call. (R34) should never have had the 500 hallway assignment and the one to one with (R31). The one to ones should never be out of sight of the resident. On 4/7/22 at 12:15 P.M., V1, V2 and V13 (Certified Nursing Assistant/Scheduler) stated, that on 3/18/22, V13 was assigned the 1:1 with R31. V2 stated that V13 had to leave R31's room to attend to another resident, so V2 sat outside R31's room in the hallway to be R31's 1:1 until V13 returned. V2 stated that V2 briefly forgot that V2 was not to leave out of eyesight from R31. V2 stated V2 began walking up the hallway and heard a noise that sounded like a bedside table falling over. V2 stated V2 ran back down into R31's room and found R31 on the floor on R31's hands and knees. V2 stated R31 had been asleep in R31's bed prior. At this time, V1, V2, and V13 verified R31 should not have been left unsupervised and that no one was with R31 at the time of R31's fall. V2 stated, One to one means 24/7. R31's Neurological Assessment Flowsheet, dated 4/4/22-4/6/22, is not finished being completed by nursing staff after R31's return from the hospital. On 4/7/22 at 12:18 P.M., V2 verified the Neurological Assessment Flowsheet (Neuro Checks) should continue to be completed after the resident comes back from the hospital if it is still within the 72 hours after the unwitnessed fall. V2 verified R31's Neuro checks were not completed and should be since R31's 4/4/22 fall was unwitnessed. Phone calls with messages left to speak with V34 (CNA) were not returned. 2. The facility's (Name of Door Management System) Installation Manual, issued 8/25/20, documents the electronic door management system monitors residents who are at risk of wandering away from a facility. This manual documents the door management system is mounted near a monitored door or exit and when the system receives a response from an elopement risk resident's pendant, it will lock the exit and/or sound an alarm and display information on the monitor's display. The exit door is normally not locked by the electronic door management system and only when a monitored pendant is detected will the exit be locked preventing escape. The facility's Elopements and Wandering Residents policy, dated 3/1/20, states, The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 1. The facility is equipped with door locks/alarms to help avoid elopements. On 4/6/22 at 10:15 A.M., V1 (Administrator) provided a list of residents in the facility who are a high risk for wandering/elopement and who wear pendants that would activate the facility's door management system. R3, R6, R17, R22, R31, R34, R47 and R51 are noted. On 4/6/22 between the hours of 10:20 A.M. and 11:48 A.M., a facility-wide check of the door management system was conducted with V26 (Maintenance Assistant). V26 stated when the resident's pendant gets within proximity of the magnetic door lock, the lock will illuminate red, and the door will lock. V26 stated on the keypad controller, the external power light should be illuminated green. On 4/6/22 at 10:20 A.M., the light on the keypad controller for the external power at the 500 wing hallway exit door alarm was not illuminated. When the pendant was brought towards the magnetic door lock and sensor, the light did not illuminate red, and the door was able to be opened. At this time, V26 stated, That needs fixed, I shouldn't be able to open the door. On 4/6/22 at 10:23 A.M., the light on the keypad controller for the external power at the 300 wing hallway exit door alarm was not illuminated. When the pendant was brought towards the magnetic door lock and sensor, the light did not illuminate red, and the door was able to be opened. On 4/6/22 at 10:26 A.M., the light on the keypad controller for the external power at the 400 wing hallway exit door alarm was not illuminated. When the pendant was brought towards the magnetic door lock and sensor, the light did not illuminate red, and the door was able to be opened. at 10:31 A.M., V26 stated, The external power is necessary. It's the main power source that's giving us our trouble. The magnet is needed to lock the door down. On 4/6/22 at 10:32 A.M., the light on the keypad controller for the external power at the multi-purpose room exit door alarm was not illuminated. When the pendant was brought towards the magnetic door lock and sensor, the light did not illuminate red, and the door was able to be opened. On 4/6/22 at 10:37 A.M., the light on the keypad controller for the external power at the 200 wing hallway door alarm was not illuminated. This door exited to a stairway to the lower level. When the pendant was brought towards the magnetic door lock and sensor, the light did not illuminate red, and the door was able to be opened. On 4/6/22 at 11:27 A.M., a set of double glass exit doors by the beauty shop were noted. The door on the left was activated and monitored with the magnetic door lock system. The door on the right was not set up with the magnetic door lock system and was unlocked. V26 stated the company did not install the magnetic door lock system on the door on the right side for an unknown reason. V26 stated the expectation was that the right door would remain locked at all times. At this time, V26 was able to open the right door due to it being unlocked. V26 stated, No one is supposed to unlock that door. If someone unlocks that then someone is out that door. On 4/6/22 at 11:44 A.M., a set of double doors were noted on the left side of the therapy room. The magnetic door lock box was partially installed on the door with parts of it disassembled and sitting in the windowsill to the right of the door. V26 stated when the door was opened, the magnetic lock box had fallen off. V26 stated, after the installers (of the door management system) were gone, we found this problem. V26 stated, The alarm is not functional right now. If we want it locked, we need to get it working. At this time, V26 verified no active alarms are placed on the double doors and that the double doors are an immediate exit to the outside. On 4/6/22 at 12:30 P.M., V1 (Administrator) verified the external power source had been tripped and that was the reason the door magnets were not working as they should.

Based on record review and interview, the facility failed to protect residents from misappropriation of resident funds for 11 of 50 residents (R1, R2, R3, R,d+[DATE], R24, R26, R35, R,d+[DATE]) reviewed for abuse in the sample of 50. These failures resulted in a total of $15,680.64 being misappropriated from resident funds, and the emotional distress of R2. Findings include: The facility's Abuse, Neglect, and Exploitation policy, dated [DATE], documents, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. The facility's Social Services Designee Job Description, dated ,d+[DATE], documents, Position purpose: Champion resident advocacy. The Social Services Designee will assist the Administrator in ensuring that staff members are knowledgeable about Resident's Rights and encourage staff to maintain and enhance each resident's dignity in recognition of each resident's individuality. The Social Services Designee will advocate for residents and assist them in assertion of their rights within the facility. Treats all residents with dignity and respect. Promotes and protects all residents' rights. Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines. The local police department police report, dated [DATE], documents, On [DATE] at approximately 1:39 pm., I (V28 Police officer) was dispatched to the facility in regards to a theft. On [DATE] at approximately 5:01 p.m., I (V28) arrived at the facility to follow up with V1 (Administrator) in regards to a meeting (V1) had with (R1). (V1) told me, (V6, Bank President) estimated there was around $6,000 taken from (R1's) bank account since [DATE]. (V1) handed me a copy of a bank account activity sheet which included all (R1's) transactions from her account. The paper showed transactions from [DATE] up until [DATE]. I (V28) went back to the police station and added up all the transactions that had (V3, Social Services Director) in the name section. Some of the transactions were for cell phone service and cable network. (R1) told me on [DATE] she does not have either of those services. The total of those transactions totaled $7,311.27. Also, there was a couple transactions for insurance (GEICO) and gas utility (Nicor Gas) (total $2,234.09) on two of the transactions, they are from (V3). On [DATE] at 3:30 p.m., I (V29 Assistant Chief of Police) spoke with (V1) on the phone regarding this case. I asked (V1) about the charges on (R1's) account for insurance and for gas utility. (V1) confirmed that those charges on R1's account are fraudulent as well. On [DATE] at approximately 5:00 p.m., I (V28) conducted an interview with (V3) at the Police Department. I asked (V3) if (R1) gave (V3) permission to use her debit card, and (V3) told me she did. I asked (V3) what she ordered with the card and she told me clothes for (R44, R1's husband). I asked (V3) if she was given permission to buy anything else and (V3) said no. I showed (V3) a copy of the bank transactions from (R1's) bank account. I asked (V3) if she had cell phone service, insurance, and gas utility, which (V3) said she did. I asked (V3) if she has used any other residents debit cards to order things and (V3) told me there were two other residents. (V3) told me (R5) and (R2). (V3) said the residents would come into her office and she would order them items they wanted from her computer. On [DATE], I received another email from (V1) regarding another person that came forward as a possible victim in this case (R3). On [DATE], I received another email from (V1) regarding this case. (V1) reported that she has located two more victims. Below is the email I received from (V1): 'I have two this evening: (R10)-V27 (R10's Power of Attorney-POA) gave an employee $30 cash to give to (V3) or the office manager, and the $30 never made it there. (R9-V23 (R9's POA) states she would put $100 in (R9's) fund, and then the balance would drop. (V23) states she reported it twice, but only to (V3) and this happened about two months ago.' On [DATE], I received another email from (V1) regarding the case. V1 advised that as their internal investigation is continuing, they are getting more residents coming forward in this case. The following is a summary of the email from (V1). 'Please add the following resident to the investigation case: (R11) is deceased but money was withdrawn from R11's account by (V3) with receipts of items listed not on (R11's) personal inventory sheet. (R45) is confused and (V3) contacted (V30 (R45's POA) approximately three weeks ago and asked to remove money from (R45's) trust account to purchase her some sweatshirts and pants. Unable to determine if anything was purchased for her.' On [DATE], I received another email from (V1) pertaining to this case. (V1) requested to add additional names to this report as more victims were found. '(R26)-There were cash withdrawals from (R26's) account per (V31 (R26's POA-Power of Attorney) totaling $48.60, but (R26) has Alzheimer's disease and cannot tell you what they are for. I (V1) have attached the statements of cash withdrawals done by (V3) that were not approved by (V31), and unknown what the cash withdrawals were for. The facility will reimburse (V30) $53.88. (R9)-As the investigation continued, I (V1) pulled all statements for 2020 and found several more without actual store receipts. Total reimbursement for 2020 will be $84.07 and for 2021 will be $188.26. (R45) -(V30-Power of Attorney) stated (V3) had contacted him to withdraw funds to purchase some clothing. (V30) was not sure if they were purchased but after conversing with him (V30) told (V1) that his brother didn't seem to think she had any new clothing. After reviewing the resident statements there are a few withdrawals with no actual sales receipt to accompany the withdrawal nor proof that all withdrawals had the permission from (V30). Therefore, the facility will reimburse this resident a total of $316.05 for the year 2020 and $64.15 for 2021.' On [DATE], I received an additional email from (V1). It says the following: 'As our investigation continues, we have a few more to add: These are the same as others with withdrawals from their resident trust account without prior approval nor receipts to justify the purchases: (R33), (R3), (R46), (R35), (R24). 1. The facility State Report, dated [DATE], documents, V6 (Bank President) contacted V1 (Administrator) to schedule an appointment with (R1) and (V1) regarding suspicious activity in (R1's) bank account. Due to information presented in this meeting (V3/Social Services Director) was immediately suspended and police were notified. (V3) had assisted (R1) with paying some bills and ordering things for her. (R1's) bank statement indicates some expenses that (R1) claims were not things of her choice or doings. On [DATE] at 2:00 p.m., V6 (Bank President) stated, (R1) normally calls the bank on a regular basis to see if her checks that she writes clear. One day (R1) called to ask about a check, and (V7 Bank Teller) told (R1) the check hadn't cleared but told (R1) her cable network had. (R1) told (V7) she didn't have a cable network account. After that, we thought something was suspicious. So, we started looking into (R1's) account. We started seeing transactions with (V3) and (V8-V3's husband) name paying bills using (R1's) account like cable network, cell phone service, and utilities. (R1) has a house in Metamora, but Nicor gas (gas company) does not service the city of Metamora. Ameren services (gas/electric company) (R1's) house, however that gas charge is in (R1's) name not (V3). So (V3) may be putting (R1's) name on things as well. Then, (V7) called (R1) that Friday ([DATE]) and wanted to speak with (R1), but (V3) was insistent she be on the call. (V7) didn't feel comfortable with that arrangement. (V7) brought it to me at that point. I called Monday ([DATE]), but (V3) answered the phone. Right away (V3) asked me if I was calling in relation to (R1's) bank issues. I didn't tell her why I was calling I just asked to speak with (V1). (V1) wasn't available. I was able to get ahold of (V1) on Tuesday ([DATE]). I called to set a meeting up with (V1). I told (V1) that (R1) had suspicious activity on (R1's) bank account, and I would like to meet with (V1) and (R1). We met on a Thursday ([DATE]) and (V1) told me that she had already let (V3) go. R1's Bank Activity Report, dated [DATE], documents the following charges made in V3's name: [DATE]:$439.32 Cell phone (Verizon); [DATE]: $461.36 Cell phone; [DATE]: $454.47 Cell phone; [DATE]: $454.47 Cell phone; [DATE]: $454.55 Cell phone; [DATE]: $120.05 Cable network (Dish Network); [DATE]: $120.05 Cable network; [DATE]: 355.65 Cell phone; [DATE]: 355.65 Cell phone; [DATE]: $40.05 Cable network; [DATE]: $355.65 Cell phone; [DATE]: $105.04 Cable network; [DATE]: $355.77 Cell phone; [DATE]: $355.77 Cell phone; [DATE]: $85.06; Cable Network; [DATE]: $95.05 Cable network; [DATE]: $443.70 Cell phone; [DATE]: $400.00 Cell phone; [DATE]: $95.05 Cable Network; [DATE]: 145.25 Cell phone; [DATE]: $316.21 Cell phone; [DATE]: $95.05 Cable Network; [DATE]: $45.31 Cell phone; [DATE]: $95.05 Cable Network; [DATE]: 315.78 Cell phone; [DATE]: $95.05 Cable network. R1's Bank Activity Report, dated [DATE], documents the following charges made in V8's (V3's Husband) name: [DATE]: $423.76 Utility payment; [DATE]: $42.01 Insurance for Renter. R1's Bank Activity Report, dated [DATE], documents the following charges made in R1's name: [DATE]: $99.63 Insurance (Geico); [DATE]: $62.22 Insurance; [DATE]: 158.70 Insurance ; [DATE]: 110.45 Insurance; [DATE]: $555.95 Gas (Nicor Gas) utility; [DATE]: $31.95 Gas utility; [DATE]: $274.53 Insurance; [DATE]: $100.68 Gas utility; [DATE]: $139.80 Insurance; [DATE]: $98.21 Gas utility; [DATE]: 145.25 Insurance; [DATE]: $98.21 Gas utility; [DATE]: $59.74 Gas utility; [DATE]: $134.80 Insurance; [DATE]: $59.81 Gas utility; [DATE]: $139.80 Insurance; [DATE]: $84.81 Gas utility. R1's Bank Activity Report, dated [DATE], documents that R1 had a total of $10,105.02 in fraudulent charges in V3's name, V8's name, and R1's name. On [DATE] at 12:00 p.m., V1 stated, On [DATE], (V6 Bank President) was scheduled to have a meeting with the two of us and (R1). That morning (V3) started acting really weird. When she left for lunch, she started texting me asking if she was fired. I asked her what this was about, and she told me it was about (R1) and the bank account. I asked (V3) to come meet with me at the facility. (V3) came back and she was suspended pending investigation. I later met with (V6) who explained the suspicious charges on (R1's) account with (V3's) name on them. I started my investigation after this meeting and sent my initial state agency report that same day. On [DATE], (V3) was terminated for misappropriation of property. On [DATE] at 9:30 a.m., V3 stated, On Tuesday ([DATE]), (R1) came to my office and said she spoke to her bank. (R1) told me about the suspicious charge of a cable network on her account. I told (R1) I didn't know how that happened, but I would pay her back all of the money. On Thursday ([DATE]), I was suspended and then let go for stealing. I think the total amount is around $10,000. On [DATE] at 11:30 am, R1 stated, I gave (V3) my trust account check each month so she must have gotten my account information from that because I never gave (V3) a debit card or my bank account information. I never gave her permission to make any purchases or use my account at any time. This makes me physically ill. I want to press charges. (V3) needs to be punished for what she did. R1's BIMS (Brief Interview for Mental Status), dated [DATE], documents a score of 15 signifying that R1 is cognitively intact. On [DATE] at 2:30 p.m., R1 confirmed that charges on her bank statement from cell phone (Verizon Wireless), Insurance (Geico), gas utility (Nicor Gas), Utility Payment, cable network (Dish Network), and Insurance Renter were not charges that she made or authorized anyone else to make. R1 also stated that she does not have a gas utility (Nicor Gas) or insurance (Geico) account in her name, however on her bank statement those charges are listed with R1's name. R1 stated, (V3) must have opened an account in my name. On [DATE] at 9:45 a.m., V10 (Vice President of Clinical Services) stated, (R1's) checkbook was also found in V3's office. This explains how (V3) did all of her transactions using (R1's) account. 2. The facility State Agency, report, dated [DATE], documents, (R2) came to (V1) [DATE] and indicated (R2) had given her debit card to (V3) to purchase some things for her. When (R2) received her statements, (R2) noticed some debits from her account were not what she had authorized. (R2) states this happened at the beginning of the year but uncertain of exact dates. This had been added to a previous allegation of the same nature with the same employee and has been given to the local police department for further investigation. (R2) is her own POA (Power of Attorney) with BIMS (Brief Interview of Mental Status Score) of 14 (cognitively intact). (R2) understands we are investigating this allegation and that the police are involved. On [DATE] at 9:15 a.m., V1 stated, On [DATE], (R2) came to me with her allegation of suspicious charges on a bank statement. On [DATE] at 1:10 PM. R2 stated, (V3) helped me make purchases using my debit card, and now I have missing money. I feel like a fool (sniffling with her words). R2 began to cry, and tears were streaming down her face. R2 stated, I let (V3) take my credit card to make purchases for me and (V3) stole from me. I trusted her and now this. It's awful. Here's one example I can show you. R2 pulled out a bank statement, dated ,d+[DATE], R2 pointed to multiple Amazon purchases and an online boutique purchase. R2 stated, I would never have purchased any of this stuff or told her that she could use my debit card for that. I didn't authorize the charges. I suspected this back at this time in ,d+[DATE], and I talked to the old administrator about it, but he did nothing. It has obviously continued. My stimulus money is gone. She wiped my account out. I can't even make my purchases I need to make if I need to buy clothes or personal items because it's all gone. I can't believe (V3) did this. I plan to press charges on her because I'm just so upset and heartbroken. You know I started to notice lately that (V3) was dressing really nice way nicer than she used to. However, with all of this coming out now I know why she dressed so nice. R2's Bank Statement, dated ,d+[DATE]-[DATE], documents a withdrawal from the account of $127.45 on [DATE]. R2's Bank Statement, dated ,d+[DATE]-[DATE], documents a charge at a Walmart in a city approximately 40 miles from the facility on [DATE] totaling $421.02. R2's Bank Statement, dated ,d+[DATE]-[DATE], documents a purchase at a local pharmacy for $161.00 on [DATE]. R2's Bank Statement, dated ,d+[DATE]-[DATE], documents the following purchases: local retail store for $155.03 on [DATE], online Amazon order for $16.99 on [DATE], online Amazon order for $96.61 on [DATE], online Amazon order for $6.36 on [DATE]. R2's Bank Statement, dated [DATE]-[DATE], documents the following purchases: Online clothing boutique for $36.28 on [DATE], online Amazon reoccurring charge of $105.95 on [DATE], online Amazon order for $47.62, online Amazon order for $42.77 on [DATE], online Amazon order for $21.64 on [DATE], online Amazon order for $32.46 on [DATE], online Amazon order for $17.31 on [DATE], online Amazon order for $66.80 on [DATE]. R2's Bank Statement, dated ,d+[DATE]-[DATE], documents the following purchases: online Amazon order for $27.04 on [DATE], online Amazon order for $17.30 on [DATE], online Amazon order for $32.31 on [DATE], online Amazon order for $10.77 on [DATE]. R2's Bank Statement, dated ,d+[DATE]-[DATE], documents an online Amazon order for $16.34 on [DATE]. R2's Bank Statement, dated ,d+[DATE]-[DATE], documents an online Amazon order for $16.11 on [DATE]. R2's Bank Statement, dated ,d+[DATE]-[DATE], documents the following purchases: online Amazon order for $64.90 on [DATE], online Amazon order for $24.89 on [DATE], online Amazon order for $48.70 on [DATE], online Amazon reoccurring charge of 105.95 three different times on [DATE], [DATE], and [DATE], online Amazon order for $31.37 on [DATE], online Amazon order for $65.00 on [DATE], Walmart for $176.31 on [DATE], online Amazon order for $14.60 on [DATE], online Amazon order for $70.31 on [DATE], online Amazon order for $109.90 on [DATE], online Amazon order for $16.23 on [DATE], online Amazon order for $30.26 on [DATE], online Amazon order for $28.13 on [DATE], online Amazon order for $14.06 on [DATE], online Amazon order for $16.15 on [DATE]. R2's Bank Statement, dated ,d+[DATE]-[DATE], documents the following purchases: online Amazon order for $10 on [DATE], online reoccurring Amazon charge for $105.95 on [DATE], online Amazon order for $18.39 on [DATE], online Amazon order for $41.76 on [DATE], online Amazon order for $15.92 on [DATE], online Amazon order for $15.89 on [DATE]. R2's Bank Statement, dated ,d+[DATE]-[DATE], documents an online Amazon order of $18.01 on [DATE]. R2's Bank Statement, dated ,d+[DATE]-[DATE], documents an online Amazon order for $11.77 on [DATE]. R2's Bank Statements listed above document a total of $2,741.51 of unauthorized charges on R2's account. On [DATE] at 12:30 p.m., V9 (Vice President of Clinical Regional Reimbursement) stated, I was in the room when (R2's) roommate was being interviewed yesterday. (R2) was heartbreaking she started crying talking about the money that had being taken from her. On [DATE] at 9:30 a.m., R2 stated that all of the charges marked on her bank statements were unauthorized charges made to her account. With tears in her eyes, R2 stated, I can't believe this. 3. A facility Resident/Family Complaint form, dated [DATE], documents an interview with V24 (R3's POA) stating, A year ago, $100 came out of R3's (trust) fund with no explanation on statement. Someone at facility told (V24) it was for clothes. (V24) asked for a (itemized) receipt but never received one. The form also documents, Unable to locate actual store receipts for the following withdraws: [DATE]-$100, [DATE]-$52.67, [DATE]-$30, [DATE]-$100. Amount to reimburse: $282.67. R3's BIMS (Brief Interview for Mental Status), dated [DATE], documents a score of five signifying severe cognitive impairment. 4. A facility State Agency report, dated [DATE], documents, (V23/R9's Power of Attorney) states she questioned and reported to (V3) a couple of times of discrepancies regarding (R9's) trust fund a couple months ago and that since then his balance is unchanged. Due to the time span of this concern, we are unable to provide proof of (V23's) approval for these withdrawals and purchases therefore facility will reimburse for all withdrawals without the actual receipt. The facility will reimburse (R9) a total of $84.07 for the year 2020 and $188.26 for the year 2021. R9's Care plan, dated [DATE], documents, (R9) has impaired cognitive function/dementia or impaired thought processes related to disease process. A facility interview form with (V23), dated [DATE], documents, (V23) would put $100 in (R9's) (trust) fund, and then the balance would drop. (V23) states (V23) reported it twice, but only to (V3). (V23) said she most recently questioned (V3) about it approximately two months ago and the balance has stayed at $32 ever since. Potential financial abuse identified. On [DATE] at 10:15 a.m., V2 (Director of Nursing) stated, I don't see (R9) needing any money to actually make purchases. His family makes all purchases of things that he may need. I've never seen him make purchases. On [DATE] at 11:30 AM, V23 stated, As soon as he was in there, we started having issues with his money. That's the only issue we had there. I brought it up to (V11 Business office manager) and (V3) several times. I don't like to call people a thief, but it was very odd. I called to express concerns of withdrawals from his account. They would tell me that (R9) was asking for money to go to the vending machine which doesn't make sense. I don't think (R9) could even work a vending machine due to his Dementia. We gave him $40 to keep in his wallet, every time we would come to visit, that $40 was still in his wallet. I said several times that I wanted an itemized statement of what the withdrawals were going towards. We buy him everything, so he would never have a reason to ask for money. I didn't believe that (R9) was asking for money withdrawals. Last time we wrote a $100 check, I told my husband we'll never deposit that much again because it was gone right away. 5. The facility's State Agency report, dated [DATE], documents, (V27/R10's POA) states she gave a staff member (unsure who) an envelope with $30 cash in it to put into her mom's fund. The money never made it to the fund. States this was back in [DATE]. States she did not report it at the time. Is reporting now because we asked. R10's BIMS, dated [DATE], documents a score of 10 signifying moderately impaired cognition. A facility interview form with (V27), dated [DATE], documents, (V27) stated she and her brother came to visit (R10) when the glass for visits was set up. (V27) estimates it was around ,d+[DATE]. (V27) stated she gave a staff member an envelope with $30 cash in it. (V27) stated it did not make it to (R10's) (trust) account. 6. A facility State Agency Report, dated [DATE], documents, (R11) is deceased . Contacted (V26/R11's family) who is listed as 1st contact to determine if the items purchased of coloring book and colors along with watch bands were ordered for (R11). (V26) gave me (R11's) sisters phone number for me to send the picture of what was purchased to the sister. (R11's) sister stated she would have to check in (R11's) belongings to see if she had a watch but did not believe (R11) did. After review of past statements, it is determined the total dollar amount to reimburse (V26) is $1115.03. Due to the time span of this concern, we are unable to provide proof of (V26) approval nor provide receipts for all items purchased for (R11) therefore facility will reimburse for all withdrawals without receipts. R11's BIMS, dated [DATE], documents a score of 8 signifying that R11 had moderately impaired cognition. 7. A facility interview form with (V25/R24's family), dated [DATE], documents, Have there been any discrepancies in items paid for on your behalf versus items received? Yes, $20 was taken out of (R24's) resident (trust) fund with no note attached on monthly statement. When (V25) called she was told it was used to get (R24) food from fast food restaurant. (V25) felt that was a lot of money to take out for one person to eat fast food. (V25) was told she did not have to be notified when they took money out of (R24's) fund because it was his money. The interview form also documents, Follow up on resident fund: Will reimburse $20 and told (V25) to report any concerns to (V1). R24's BIMS, dated [DATE], documents a score of 11 signifying that R24 has moderately impaired cognition. 8. The facility's State Agency report, dated [DATE], documents, Due to time span and facility does not have actual receipts of items purchased, nor proof of approval from (R26's) POA (V31) regarding possible unusual or unauthorized charges on resident's account. (V31) stated he questioned a few statements of cash withdrawals that were noted on his statements. He listed 4 of them since 2018 when (R26) was admitted . (V31) stated it was about $48.60. The facility will reimburse the resident in the total amount found to be in question totaling $53.88. (R26) has severe cognitive impairment and cannot tell you what the cash withdrawals are for or if she received the items purchased. A handwritten paper with (R26's) information written on it and provided by (V1) on [DATE], documents, 2018 owe $13.62 (,d+[DATE]); 2019 owe $15.00 (,d+[DATE]-$5, ,d+[DATE]-$10); 2020 owe $20 (,d+[DATE]); 2021 owe $5.26 (,d+[DATE]). Total to reimburse: $53.88. R26's BIMS, dated [DATE], documents a score of 5 signifying that R26 has severely impaired cognition. 9. A facility interview form, dated [DATE], documents that R35 was interviewed and stated, $100 was missing. Never replaced when she was on a different hall in the facility. Son reported to administrator at the time. Told (R35) he checked cameras. Reimburse $100. R35's BIMS, dated [DATE], documents a score of 9 signifying that R35 has moderately impaired cognition. 10. The facility's State Agency report, dated [DATE], documents, During a full house investigation of possible financial misappropriation of funds and/or personal property some items were purchased for (R45), but no receipts are available. (V30/R45's POA) stated V3 had contacted him to withdraw funds to purchase some clothing for (R45). (V30) did agree to the withdrawals but was not sure if anything was purchased. After interview with (V1), (V30) stated his brother who comes to visit (R45) didn't seem to think she had any new clothing but was not 100% positive. After reviewing (R45's) statements there are a few withdrawals with no actual sales receipt for clothing to accompany the withdrawal nor proof that all withdrawals had the permission from (V30). Therefore, the facility will reimburse (R45) a total of $316.05 for the year 2020 and $64.15 for 2021. R45's BIMS, dated [DATE], documents a score of 99 indicating that the assessment was unable to be completed with R45 due to her severely compromised cognition. 11. A facility Resident/Family Complaint form, dated [DATE], documents, Staff member stole $20, $400, $70, $90 ($580) per (R46). (R46) stated (V3) would purchase things for (R46). Reported money missing and no one did anything. Due to unable to determine without receipts all money reimbursed by facility. Total $580. R46's BIMS, dated [DATE], documents a score of 15 indicating that R46 is cognitively intact. On [DATE] at 3:59 p.m., R46 stated, I do not have money in the resident trust account. A couple years ago, I reported to the Administrator at that time that there was $400 missing from my purse. (V3) had brought me my purse, so I could give her money to buy me a t-shirt. (V3) saw that I had all that money in there. (V3) took my purse back to my room, when I got back into my purse, all the money was missing. I never used the resident trust account because I didn't trust (V3) from the start. On [DATE] at 12:40 p.m., R46 stated, After (V3) stole the $400 from me, it continued. I know of at least three different times that she stole $70, $90, and $20 from me. I reported it and had the ombudsman involved but it was supposedly always unfounded. I quit trusting anyone and everyone. I don't like that this is my home, and I can't trust anyone. My trust fund account only has $1.97 in it because I won't put money in it anymore especially when (V3) was responsible for the trust fund accounts. How can I trust someone to manage my money? The Social Services Director is supposed to be the person we can go to at any time and trust to help us residents. They should advocate for us. (V3) was not that whatsoever. On [DATE] at 1:40 PM, V1 (Administrator) stated, I'm not sure what all residents that (V3) assisted with making purchases nor do I know what residents have outside bank accounts. (V3) also managed all of the in house resident trust fund accounts. So, (V3) kept track of their balances. (V3) would take resident money to be deposited into their account, and also give them money out of their account if they request it. (V3) has access to all residents personal protected information in her position. On [DATE] at 1:10 p.m., V9 stated, Residents in the facility who have a trust fund within the facility were managed by (V3). A portion of (V3's) job in the facility was to manage the resident trust fund accounts. (V3) kept the facility's trust fund money box of $400 cash. Any deposits that were made to a resident's trust fund account was brought to (V3). As well, if a resident requested cash to be withdrawn from their trust fund (V3) was the person who would give them their cash. Any transaction was to have a written receipt signed by the resident (if cognitively intact) or their representatives' approval as well as (V3's) signature. If the transaction was for a purchase to be made for a resident an actual purchase receipt must be included as well. Essentially, (V3) had access to all of the resident's personal protected information including social security numbers and birthdates. (V3) would have access to their debit cards or bank accounts if she assisted them with a purchase at some point. V3's Employee application, dated [DATE], documents that V8 is V3's husband. V3's Personnel Transaction Form, dated [DATE], documents that V3 was hired at the facility on [DATE], and as of [DATE] V3 position within the facility changed from Unit Aide to Social Services. On [DATE] at 1:00 p.m., V1 provided V3's Termination/Resignation form, dated, [DATE], documents that V3 was terminated on [DATE]. V3 stated the form simply says terminated, however, V3's reason for termination was misappropriation of resident funds.

Based on interview and record review, the facility failed to thoroughly investigate a potential abuse allegation to determine other residents who could be affected and protect residents from further abuse. This had the potential to affect 42 residents (R1-R3, R6-R10, R12, R14-R43, R45-47) whose money was managed within the facility's resident trust fund account by V3 (Social Services Director). Findings include 1. The facility initial State Report, dated 12/2/21, documents, V6 (Bank President) contacted (V1/Administrator) to schedule an appointment with (R1) and (V1) regarding suspicious activity in R1's bank account. Due to information presented in this meeting (V3/Social Services Director) was immediately suspended and police were notified. The facility final State Agency report, dated 12/7/21, documents, (V3) had assisted (R1) with paying some bills and ordering things for her. (R1's) bank statement indicates some expenses that (R1) claims were not things of her choice or doings. R1's Bank Activity Report, dated 11/27/21, documents the following charges made in V3's name: 10/21/20:$439.32 Cell phone (Verizon); 11/28/20: $461.36 Cell phone; 12/17/20: $454.47 Cell phone; 1/19/21: $454.47 Cell phone; 2/17/21: $454.55 Cell phone; 2/25/21: $120.05 Cable network (Dish Network); 2/25/21: $120.05 Cable network; 3/15/21: 355.65 Cell phone; 4/7/21: 355.65 Cell phone; 4/26/21: $40.05 Cable network; 5/7/21: $355.65 Cell phone; 5/25/21: $105.04 Cable network; 6/7/21: $355.77 Cell phone; 6/24/21: $355.77 Cell phone; 6/24/21: $85.06; Cable Network; 7/15/21: $95.05 Cable network; 8/2/21: $443.70 Cell phone; 8/19/21: $400.00 Cell phone; 8/23/21: $95.05 Cable Network; 8/25/21: 145.25 Cell phone; 9/9/21: $316.21 Cell phone; 9/24/21: $95.05 Cable Network; 10/20/21: $45.31 Cell phone; 10/25/21: $95.05 Cable Network; 11/15/21: 315.78 Cell phone; 11/23/21: $95.05 Cable network. R1's Bank Activity Report, dated 11/27/21, documents the following charges made in V8's (V3's Husband) name: 9/22/20: $423.76 Utility payment; 11/1/21: $42.01 Insurance for Renter. R1's Bank Activity Report, dated 11/27/21, documents the following charges made in R1's name: 1/6/21: $99.63 Insurance (Geico); 2/16/21: $62.22 Insurance; 3/22/21: 158.70 Insurance ; 4/9/21: 110.45 Insurance; 5/3/21: $555.95 Gas (Nicor Gas) utility; 5/10/21: $31.95 Gas utility; 6/23/21: $274.53 Insurance; 7/15/21: $100.68 Gas utility; 7/19/21: $139.80 Insurance; 8/17/21: $98.21 Gas utility; 8/25/21: 145.25 Insurance; 9/8/21: $98.21 Gas utility; 9/15/21: $59.74 Gas utility; 9/27/21: $134.80 Insurance; 10/12/21: $59.81 Gas utility; 10/12/21: $139.80 Insurance; 11/15/21: $84.81 Gas utility. R1's Bank Activity Report, dated 11/27/21, documents that R1 had a total of $10,105.02 in fraudulent charges in V3's name, V8's name, and R1's name. On 12/14/21 at 11:30 am R1 stated, I gave (V3) my trust fund account check each month, so (V3) must have gotten my account information from that. I never gave (V3) permission to make any purchases or use my account at any time. This makes me ill. I want to press charges. (V3) needs to be punished for what she did. On 12/14/21 at 2:00 p.m., V6 (Bank President) stated, (R1) normally calls the bank on a regular basis to see if her checks that she writes clear. One day (R1) called to ask about a check, and (V7 Bank Teller) told (R1) the check hadn't cleared but told (R1) her cable network had. (R1) told (V7) she didn't have a cable network account. After that we thought something was suspicious. So, we started looking into (R1's) account. We started seeing transactions with (V3) and (V8-V3's husband) name paying bills using (R1's) account like cable network, cell phone service, and utilities. (R1) has a house in Metamora, but Nicor gas (gas company) does not service the city of Metamora. Ameren services (gas/electric company) (R1's) house, however that gas charge is in (R1's) name not (V3). So (V3) may be putting (R1's) name on things as well. Then, (V7) called (R1) that Friday (11/26/21) and wanted to speak with (R1), but (V3) was insistent she be on the call. (V7) didn't feel comfortable with that arrangement. (V7) brought it to me at that point. I called Monday (11/29/21), but (V3) answered the phone. Right away (V3) asked me if I was calling in relation to (R1's) bank issues. I didn't tell her why I was calling I just asked to speak with (V1). (V1) wasn't available. I was able to get ahold of (V1) on Tuesday (11/30/21). I called to set a meeting up with (V1). I told (V1) that (R1) had suspicious activity on (R1's) bank account, and I would like to meet with (V1) and (R1). We met on a Thursday (12/2/21) and (V1) told me that she had already let (V3) go. My biggest concern to discuss this with (V1) was is if (V3's) doing this to (R1), is (V3) doing this to others in her facility who are vulnerable and don't have family. Other residents could have been being taken advantage of as well. Time was of an essence to get this person stopped from doing this to anyone else. R1's facility Abuse-Investigative Protocol Checklist, dated 12/2/21, documents, Days 2-5 following incident. Action Item: Conduct interviews with an expanded sample of witnesses/staff/visitors/residents. The checklist has a box to initial and date after each action item is completed. The box for this action item is blank. On 12/13/21 at 1:40pm, V1 (Administrator) stated, I'm not sure who all this could have potentially affected. I'm not sure what all residents that V3 assisted with making purchases nor do I know what residents have outside bank accounts. V1 also confirmed that from the time that R1's allegation was reported to her on 12/2/21 to 12/7/21 when the final report was submitted to the State Agency, no other residents and/or family representatives were interviewed. 2. The facility State Agency, report, dated 12/13/21, documents, (R2) came to (V1), 12/8/21, and indicated (R2) had given her debit card to (V3) to purchase some things for her. When (R2) received her statements, (R2) noticed some debits from her account were not what she had authorized. (R2) states this happened at the beginning of the year but uncertain of exact dates. This had been added to a previous allegation of the same nature with the same employee (V3) and has been give to the local police department for further investigation. (R2) is her own POA (Power of Attorney) with BIMS (Brief Interview of Mental Status Score) of 14 (cognitively intact). R2's facility Abuse-Investigative Protocol Checklist, dated 12/8/21, documents, Days 2-5 following incident. Action Item: Conduct interviews with an expanded sample of witnesses/staff/visitors/residents. The checklist has a box to initial and date after each action item is completed. The box for this action item is blank. On 12/13/21 at 1:10 pm. R2 stated, (V3) helped me make purchases using my debit card, and now I have missing money. I feel like a fool (sniffling with her words). R2 began to cry, and tears were streaming down her face. R2 stated, I let (V3) take my credit card to make purchases for me and (V3) stole from me. I trusted her and now this. It's awful. Here's one example I can show you. R2 pulled out a bank statement, dated 12/2020, R2 pointed to multiple Amazon purchases and an online boutique purchase. R2 stated, I would never have purchased any of this stuff or told her that she could use my debit card for that. I didn't authorize the charges. I suspected this back at this time in 12/2020, and I talked to the old administrator about it, but he did nothing. It has obviously continued. My stimulus money is gone. She wiped my account out. I can't even make my purchases I need to make if I need to buy clothes or personal items because it's all gone. I can't believe (V3) did this. I plan to press charges on her because I'm just so upset and heartbroken. On 12/13/21 at 1:40pm, V1 (Administrator) stated, (As of today) I have interviewed three other residents (R2, R7, R8) on 12/8/21 and 12/9/21 total so far. I haven't interviewed any other residents at this point. I have not done a facility wide interview to question other residents or families that may have outside accounts. I'm not sure what all residents that V3 assisted with making purchases nor do I know what residents have outside bank accounts. If a resident came to (V3) and said they wanted to order something, (V3) would order it for them online or go out and shop for them. (V3) also managed all of the in house resident trust fund accounts. So, (V3) kept track of their balances. (V3) would take resident money to be deposited into their account, and also give them money out of their account if they requested it. (V3) has access to all residents personal protected information in her position. V9 (Vice President of Clinical Regional Reimbursement) was present during this interview and stated, Yes we should have done a facility wide interviewing of all of the residents to see if they may have been affected by this, but we haven't. On 12/14/21 at 12:00 p.m., V1 stated, On 12/3/21, (V3) was terminated for misappropriation of property. I sent my final report to the state agency on 12/7/21. In between this time, no other residents or families were interviewed to ask if they had any similar issues. On 12/8/21, (R2) came to me with her allegation of suspicious charges on a bank statement. There were online amazon orders, and an online boutique purchase on the statement. So, I started another investigation. I interviewed two other residents (R7 and R8) who didn't have any issues. I did not contact nor assist (R2) with contacting (R2's) bank to notify them of potential fraudulent charges. (R2's) bank still hasn't been contacted at this point. (V3) has access to all of the residents' personal info so I guess she could have still made charges outside of the facility. As of today, the only bank I have spoken to and their account was flagged is (R1). No staff member should be taking money or debit cards from residents to purchase items. I didn't even know (V3) was purchasing things for (R2). V1 confirmed that as of today (12/14/21), V1 has only interviewed an additional seven residents (R5, R34, R35, R38, R43, R49, R50) and one family representative. On 12/15/21 at 12:30 p.m., V9 stated, Instead of looking at the whole picture, (V1) just looked at the one occurrence even with our guidance. (V1) didn't do a thorough abuse investigation. On 12/16/21 at 1:10 p.m., V9 stated, Residents in the facility who have a trust fund within the facility were managed by (V3). A portion of V3's job in the facility was to manage the resident trust fund accounts. V3 kept the facility's trust fund money box of $400 cash. Any deposits that were made to a resident's trust fund account was brought to (V3). As well, if a resident requested cash to be withdrawn from their trust fund V3 was the person who would give them their cash. Any transaction was to have a written receipt signed by the resident (if cognitively intact) or their representatives' approval as well as V3's signature. If the transaction was for a purchase to be made for a resident an actual purchase receipt must be included as well. Essentially, (V3) had access to all of the resident's personal information including social security numbers and birthdates. (V3) would have access to their debit cards or bank accounts if she assisted them with a purchase at some point. On 12/15/21 at 9:30 a.m., V3 stated, On Thursday (12/2/21) I was suspended and then let go for stealing. I think the total amount is around $10,000 supposedly. V3 also confirmed that V3 assisted the following residents with purchases: R1, R2, R5, R17, R46, and R48. The facility Resident Fund spreadsheet, dated 12/9/21, document that the following residents have a facility trust fund that was managed by V3: R1-R3, R6-R10, R12, R14-R43 and R45-R47.

Based on interview and record review the facility failed to accurately transcribe a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1 receiving the wrong dose of a high-risk anticoagulant medication resulting in critical lab results and requiring R1 to receive an intramuscular injection of a reversal agent. R1 was transferred to the local area hospital for evaluation. Findings include: The facility's RN (Registered Nurse)/LPN (Licensed Practical Nurse) Charge Nurse Job Description, not dated, states, Transcribes physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Prepares and administers medications as per physicians' orders and observes for adverse effects. The facility's Physician/Practitioner Orders policy, revised 1/1/20, states, Policy: The attending physician shall authenticate orders for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. The facility's High Risk Medications-Anticoagulants policy, not dated, states, Policy: The facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety .1. Anticoagulants shall be prescribed by a physician or other authorized practitioner with clear indications for use .Risks associated with anticoagulants include: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool) b. Fall in hematocrit or blood pressure c. [CONDITION(S)]. The facility's Medication Error and Investigation Incident Report, not dated, states, Description of Medication Error: an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was not given due to a missed medication administration on 10/26/21. The error was discovered on 10/27/21 and the medication was then held. A PT/INR result for (R2) was received with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (R2) is on the same hall as (R1). It is likely that the order was placed for (R1) by mistake. History indicates (R1) had never had a dose of [MEDICATION(S)] higher than 4 mg. The facility's Quality Improvement Plan, dated 11/2/21, states, (Regarding the 10/27/21 findings) Target Area: Med Errors. Analysis: Wrong input by nurse on wrong resident, wrong dose given. 1. R2's Facesheet documents R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's current Care Plan documents R2 is on anticoagulant therapy for [CONDITION(S)] ([CONDITION(S)]) and documents an intervention as Administer anticoagulant medications as ordered by physician. R2's Laboratory Results for PT/INR, dated 10/20/21, contains a written order signed by V7 (R1 and R2's Physician) stating ([MEDICATION(S)]) 15 mg (milligram) today, then 10 mg q d (every day). Weekly [MEDICATION(S)]. This order is signed off as being completed by V9 (Registered Nurse). R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These medications have a start date of 10/14/21 and an end date of 11/4/21. R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This same MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's medical record does not document that V7's written order for [MEDICATION(S)] 15 mg one-time dose or [MEDICATION(S)] 10 mg daily dose was transcribed into R2's medical record. 2. R1's Facesheet documents R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's POS on 10/21/21 documents V9 entered R2's above written order for [MEDICATION(S)] onto R1's POS. R1's POS states, [MEDICATION(S)] Tablet 5 mg ([MEDICATION(S)] Sodium) Give one tablet by mouth one time only related to [CONDITION(S)] [CONDITION(S)] until 10/21/21 Take one tablet with 10 mg for 15 mg today only then 10 mg daily. This same POS documents R2's order for [MEDICATION(S)] Tablet 10 mg ([MEDICATION(S)] Sodium) Give one tablet by mouth one time a day related to [CONDITION(S)] [CONDITION(S)]. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This same MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . These medications are marked as given to R1 on 10/21-10/25/21. The facility's Packing Slip Proof of Delivery from the pharmacy documents the facility received seven [MEDICATION(S)] 10 mg tablets and one 5 mg tablet for R1 on 10/22/21 at 3:56 A.M. R1's Lab Results Report dated 10/27/21 documents R1 with a PT (Prothrombin Time) result of greater than 196 seconds. PT normal reference range is documented as 20.3-29.9 seconds. This result is flagged as high. This same report documents R1 with an INR (International Normalized Ratio) of greater than 22.03. R1's lab results report documents a reference INR range of 2-3 is commonly followed for prevention of venous [CONDITION(S)] and a reference INR range of 2.5-3.5 is commonly followed for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Nursing Note on 10/27/21 at 1:30 P.M., signed by V12 (Former Director of Nursing) states V7 was notified of R1's critical PT/INR results and orders for Vitamin K 5 mg IM (Intramuscular) were given. R1's MAR, dated 10/1/21-10/31/21, documents R1 received a dose of [MEDICATION(S)] Solution (Vitamin K/Reversal Agent) 5 mg intramuscularly one time on 10/27/21. R1's Nursing Note on 10/27/21 at 4:45 P.M., signed by V12 (Former Director of Nursing), states, Description of condition change: (R1's) PT/INR was critically high. (V7) initially ordered 5 mg IM Vitamin K that was immediately given by the primary nurse. After discussing the treatment and PT/INR level, (R1) made the decision that (R1) would like to go to the emergency department to be evaluated and observed for any complications that may arise from this critical level. EMS (Emergency Medical Service) contacted and will be transporting (R1) to (local area hospital). The facility's Admission/Discharge To/From Report documents R1 was transferred to the local area hospital on 10/27/21. R1's EMS Patient Care Record, dated 10/27/21, states, Called to (Skilled Nursing Facility) for a patient (R1) with a critical lab value. EMS was met by the nursing home staff and led to patient (R1). Nursing home staff stated there was a medication error with this patient's [MEDICATION(S)]. R1's local area hospital Admission History and Physical documents R1 was admitted to the hospital for continuation of INR monitoring with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/6/21 at 10:27 A.M., V3 (Licensed Practical Nurse) stated, (R1) received the wrong dosage of [MEDICATION(S)]. Someone else's (R2's) [MEDICATION(S)] order was placed in (R1's) chart. (R2) receives a large dose of [MEDICATION(S)] compared to what (R1) receives. The problem is we have a lot of agency nurses and they don't know the residents well. On 11/6/21 at 10:51 A.M. V2 (Assistant Director of Nursing) stated, On 10/27/21, (V7) had called over to the facility and stated there was a transcription error on (R1's) [MEDICATION(S)]. We investigated it and found the nurse (V9) put (R2's) order in on the wrong patient (R1). (R2's) 9 mg [MEDICATION(S)] order should have been increased according to (R2's) labs, but it wasn't. (V9) placed the order in the computer as a written order under (V7's name). (R1) was getting 10 mg, which (R1) usually gets 1-4 mg. V2 verified R1 had critical lab results which resulted in R1 needing an injection of a reversal agent. On 11/6/21 at 12:03 P.M. V9 (Registered Nurse) verified entering the [MEDICATION(S)] order on 10/21/21 into R1's chart. V9 stated V9 copied the order from the lab results that came back from V7's office. V9 verified V9 did not realize V9 had entered the orders into the incorrect resident's chart. R1's Laboratory (lab) Result form, dated 10/9/21, documents a handwritten order at the bottom that states, ([MEDICATION(S)]) 1.5 mg (milligram) x (time) day. Next draw (PT/INR) 10/14/21 per (V8/R1's Physician). R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order has a start date of 10/10/21 and an end date of 10/14/21. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This order has a start date of 10/10/21 and an end date of 10/14/21. This same MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's POS or MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/6/21 at 1:29 P.M., V2 (Assistant Director of Nursing) verified R1 was not on any [MEDICATION(S)] from 10/14/21-10/20/21 and should have been. On 11/6/21 at 2:39 P.M. V7 (R1 and R2's Physician) stated R2's written anticoagulant order was placed incorrectly into R1's chart. V7 stated R1 received too high of doses of [MEDICATION(S)] (on 10/21/21-10/25/21) which caused R1's critical lab results on 10/27/21 and caused R1 to need an injection of a reversal agent. V7 stated the critical INR level put R1 at an increased risk of bleeding/hemorrhage. V7 verified R1 should not have gone seven days without receiving anticoagulant medication (10/14/21-10/20/21). V1 stated the nurse entered the 10/9/21 order with an end date of when the next lab draw was due and since the lab didn't get drawn (on 10/14/21), the medication ([MEDICATION(S)]) did not get continued. V7 stated this has been a chronic problem at the facility and V7 has had to take residents off of [MEDICATION(S)] and switch to a different anticoagulant due to lab testing and doses being missed.

Based on interview and record review the facility failed to recognize and investigate an allegation of seclusion as possible abuse for one (R1) of six residents reviewed for abuse in a sample of six. This failure resulted in the facility not readily initiating an investigation which further led to the alleged perpetrator continuing to work in the facility and care for R1 and further subjecting all other residents (R5 and R7- R14) who came in contact with the alleged perpetrator to potential abuse. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 9/20/21 at 3:52 PM, the facility remains out of compliance at Severity Level 2 as the facility continues ongoing monitoring of all abuse reports and investigations by the Senior Administrator and the Vice President of Clinical Services prior to submission and continues to re-educate nursing staff on Abuse Prevention Programs and Policies. Findings include: The facility's Abuse Policy dated 11/1/2020 documents, V. Investigation of Alleged Abuse, Neglect and Exploitation. A) An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B) Written procedures for investigation include: 1) Identifying staff responsible for the investigation; 3) Investigating different types of alleged violations; 4) Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses's and others who might have knowledge of the allegations; 5) Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent and cause; and 6) Providing complete and thorough documentation of the investigation. R1's Current Face Sheet documents R1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Current Care Plan documents R1 is a high risk for Elopement: 7/7/21; one to one supervision with reevaluation for incremental monitoring as appropriate. The facility's Daily Assignment Sheet dated 9/12/21 documents V5/CNA worked one on one with R1 from 6:00 PM to 10:00 PM and worked on the COVID unit (700 Hall) from 10:00 PM until 6:00 AM. The facility's Resident Roster dated 9/12/21 documents R1's room as 508-B and R7's room as 703-A. V5/CNA had access to R1 and R7 during V5's 9/12/21 shift. The facility's Daily Assignment Sheet dated 9/15/21 documents V5/CNA worked in the facility on 600 Hall and COVID Unit (700 Hall) from 2:00 PM through 10:00 PM. The facility's Resident Roster dated 9/15/21 documents R5 and R7 through R14 resided on the 600 and 700 halls. V5/CNA had access to R5 and R7 through R14 during V5's 9/15/21 shift. On 9/16/21 at 11:10 AM V1/Administrator stated, The sheets show who worked and where at. If someone called in or didn't show up there would be a line through their name and the reason why not worked. On 9/16/21 at 9:30 AM V1/Administrator stated, Yes, a Certified Nurse's Assistant/CNA came up to me and (V4/Former Director of Nurses/DON), who walked out Monday (9/13/21), and said a CNA was locking (R1) in her room and blocking her doorway and cussing at her. I asked the CNA for dates and times and she couldn't give me any. She quit and no longer works here anyway. When asked if she did an investigation V1 stated, I didn't (do an investigation), the CNAs were complaining a lot that day. It is what it is. I will have to check if V4 did one. At this time V1 could not provide a copy of an abuse allegation involving R1. On 9/16/21 at 5:30 PM V4/Former DON stated, I do not work there anymore. (V1/Administrator) has only been there since 9/7/21 and is the Abuse Coordinator. Before (V1) coming (V18/Acting Administrator/Marketing Director) did the (State reportable incidents). I was being the DON and working the floor all the time, there was no way I could have done the Abuse Coordinator and DON. The Sunday before I quit, I had to work first and second shift as a floor nurse. There is no way I would have taken on the responsibility of Abuse Coordinator also. So, if they are saying I was the Abuse Coordinator, it is to cover their butts. On 9/17/21 at 12:40 PM V1/Administrator stated, So I guess the CNA (V15) that told me she heard a CNA was locking (R1) in her room and cussing at (R1) did not quit. I remembered that after I asked (V4/Former DON) if she did a report and she said she had already taken care of it. On 9/17/21 at 1:00 PM V15/Certified Nursing Assistant (CNA) stated, I had told (V4/Former Director of Nursing/DON) back on 8/1/21 that I heard (V5/CNA) was mistreating (R1). (V1) wasn't here at the time and I believe (V18/Acting Administrator/Marketing Director) was filling in as the Administrator. I don't know whose responsibility it was, but I told (V1), (V4) and (V14/Clinical Reimbursement) on 9/12/21 that I heard (R1) was being locked in her room and talked to inappropriately by (V5/CNA). The Immediate Jeopardy was identified on 9/17/21 at 9:52 AM. The Immediate Jeopardy began on September 12th, 2021 when V15/CNA reported to V1/Administrator an allegation of abuse from V5/CNA to R1 and no investigation was initiated, and V5/CNA continued to have access to R1, R5 and R7-R14. V1/Administrator was notified of the Immediate Jeopardy on 9/17/21 at 1:24 PM. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: Actions completed by V1/Administrator, V2/Assistant Director of Nurses/ADON, V17/Corporate Administrator and V20/Vice President of Clinical Services: On 9/16/21, V1/Administrator initiated an abuse investigation involving R1. The alleged perpetrator (V5/CNA) was suspended. On 9/17/21 V1/Administrator was in-serviced on abuse, conducting a thorough abuse investigation and reporting abuse. On 9/17/21 the facility immediately began employee in-servicing with staff on abuse reporting. In-servicing was completed with all staff regarding abuse on 9/20/21. On 9/20/21, all facility managers received in-servicing on the Abuse policy, Abuse reporting and Abuse investigations.

Based on observation, interview and record review, the facility failed to evaluate each resident fall to determine the root cause analysis and implement interventions to reduce the risk of future falls for one of three residents (R4) reviewed for falls in the sample of 33. This failure resulted in R4 falling on 1/17/21 and landing on her face, which resulted in the following facial fractures: mildly displaced anterior and posterior maxillary sinus wall fractures, mildly displaced left lateral orbital wall and orbital floor fractures, and a zygomatic arch fracture. Findings include: The Facility's Incident's Accidents and Supervision policy dated 1/1/20, states The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s); 2. Evaluating and analyzing hazard(s); 3. Implementing interventions to reduce hazard(s) and risk(s); 4. Monitoring for effectiveness and modifying interventions when necessary. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Data collection includes documents that are for review of the Quality Assurance and Performance Improvement (QAPI) Committee only; Risk Management Report, Post Fall Huddle Summary, etc. b. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as day, location, etc. C. Both the facility-centered and resident-directed approaches include evaluation hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk; d. Evaluations also look at trends such as time of day, location, etc. Implementation of Interventions- Using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes: a. communicating the interventions to all relevant staff; b. Assigning responsibility; c. Providing training as needed; d. Document interventions (such as plans of action developed by the QAPI Team or care plans for the individual resident); e. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence based practice. R4's Fall Scale dated 2/12/20, documents R4 is at high risk for falls. R4's Minimum Data Set assessment dated [DATE], documents R4 has severely impaired cognitive skills, requires assistance with transfers and ambulation, and had two falls since the previous assessment. R4's Fall Report dated 11/5/20 at 2:11 p.m., documents R4 fell while ambulating outside and tripped over her feet. R4's medical record did not document the root cause analysis or implementation of new interventions to reduce the risk of future falls. R4's Fall Report dated 12/7/20 at 11:43 a.m., document R4 fell forward to the ground while standing by a chair. R4's medical record did not document the root cause analysis or implementation of new interventions to reduce the risk of future falls. R4's Fall Report dated 1/17/21 at 9:40 a.m., documents R4 was found on the floor face down. R4 was sent to the hospital where X-rays dated 1/17/21, revealed R4 had the following facial fractures: mildly displaced anterior and posterior maxillary sinus wall fractures, mildly displaced left lateral orbital wall and orbital floor fractures, and a zygomatic arch fracture. R4's Medical Record did not document any further investigation into R4's falls on 11/5/20 and 12/7/20. On 2/18/21 at 10:21 a.m., V2 (Acting Director of Nursing) stated I don't have any evidence that we discussed (R4's) falls on 11/5/20 and 12/7/20. I don't know if we missed them or what. I usually have my own documentation also but I don't have a follow up on either of those falls. I know we should evaluate and analysis each fall and try to determine the cause to help prevent it from happening again. I'm not sure what happened with (R4's) falls. I do understand (R4) had a fall with serious injury on 1/17/21. The two prior falls should have been addressed.

Based on observation, interview and record review the facility failed to ensure all facility doors were properly alarmed and ensure an electronic wander management transmitter bracelet was in working order for one resident (R1). In addition, the facility failed to provide adequate supervision and revise/develop an elopement plan of care for two severely cognitively impaired residents at risk of elopement for two (R1, R2) of three residents reviewed for elopement risk in the sample of four. These failures resulted in R1, a severely cognitively impaired resident with the [DIAGNOSES REDACTED]. The facility was unaware of R1 missing until the police located R1 and contacted the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity Level II as the facility continues to educate all staff on elopement policies, perform wander management transmitter bracelet audits and quality assurance audits, and revises policies and procedures. Findings include: The facility's Elopements and Wandering Residents policy dated [DATE] documents, Policy: The facility ensures that resident who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering and elopement risk. Definition: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Policy explanation and compliance guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risk, and monitoring of effectiveness and modifying interventions when necessary. 4. Monitoring and managing residents at risk for elopement or unsafe wandering. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team. b. The interdisciplinary team will evaluate the unique factors to contributing the risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. The effectiveness of interventions will be evaluated and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. The wander management transmitter bracelet manufacturer's instructions (undated) document, A 90-day device is stamped with the activate by date which indicates the last date the device can be activated to permit approximately 90 days of use. Record the date in the resident's records. The one-year device is stamped with a replacement date which indicates the last date the device will work. Do not keep the device on a resident past this date. On [DATE] at 11:20 AM, R1 was sitting in her room. R1 was pleasantly confused and was unaware of date, time, and place. R1 stated that she is currently living in (a neighboring town). R1's Medical Record from [DATE] through [DATE] does not include documentation of the wander management transmitter bracelet's date of expiration or date that it was applied. R1's physician's orders [REDACTED]. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired and experiences occasional wandering. This same MDS Assessment documents R1 requires oversight/supervision with walking in her room, walking in the corridor, locomotion on the unit, and locomotion off of the unit. R1's physician progress notes [REDACTED]. R1's Wander Care Plan dated [DATE] documents, Focus: (R1) wanders with no rational purpose, seemingly oblivious to needs or safety throughout the healthcare center. Goal: (R1) will wander safely within the facility by next review (target dated [DATE]). Interventions: Administer medications. Avoid over-stimulation. Convey an attitude of acceptance towards (R1). (R1) wears a wander management transmitter bracelet. Please check the wander management transmitter bracelet routinely to ensure (R1's) safety. Maintain a calm environment and approach (R1) from the front. When (R1) begins to wander, attempt to engage (R1) in an activity or something that will hold (R1's) interest. When (R1) begins to wander, provide comfort measures for basic needs. Date initiated [DATE] (R1) is on 30-minute safety checks until further notice. R1's Elopement Care Plan dated [DATE] documents, Focus: (R1) is at risk for elopement due to impaired cognition and dementia. Goal: (R1's) safety will be maintained through the review date and (R1) will not leave the facility unattended through the next review date ([DATE]). Interventions: Assess for fall risk. Distract (R1) from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. Monitor (R1) for fatigue and weight loss. Provide structured activities such as toileting, walking inside and outside, and re-orientation strategies including signs, pictures, and memory boxes. Wander guard to be checked for placement every shift and function daily. R1's Wandering Risk assessment dated [DATE] documents R1 is forgetful, has a short attention span, does not understand surroundings, experiences feelings of anger and fear of abandonment, is independent with mobility, is a known wanderer with a history of wandering, and has a [DIAGNOSES REDACTED]. R1's Progress Notes dated [DATE] at 7:15 PM and signed by V6 (Licensed Practical Nurse/LPN) document, (R1) was found trying to exit hall two. Wander management transmitter bracelet system went off and the button was shut off. This writer re-directed (R1) to common area. R1's Progress Notes dated [DATE] at 1:24 AM and signed by V5 (Registered Nurse/RN) document, (R1) eloped from hall one around 8:56 PM (On [DATE]) after being re-directed in hall two from an elopement attempt. (R1) was found approximately 150 yards from the facility and the sheriff's department was notified. The Sheriff and EMS (Emergency Medical System) responded and returned (R1) to facility after elopement. EMS and nursing staff assessed resident and found no abnormalities, vital signs were stable, and (R1) could not recall where she went or the details of the incident. R1's Police Report #21l-,[DATE] dated [DATE] at 9:17 PM and signed by V4 and V16 (Police Officers) documents, On [DATE] around 9:17 PM (V4 and V16) were dispatched to 112 Clinton Drive on a female yelling for help. On arrival (V4 and V16) found a frail [AGE] year-old female, later identified as (R1), sitting on the curb in front of 112 Clinton Drive, Eureka. (R1) was shivering and stated she was very cold. (R1) had wet pants on from sitting in the snow and ice. The temperature outside was approximately 25 degrees Fahrenheit. (R1) was not wearing a winter hat, winter coat, or winter gloves. (R1) was wearing thin shoes and socks, a pair of thin slacks, and a thin shirt. (R1) stated that she had fell and could not get up off the ground on her own. Paramedics called to check (R1) for injuries and hypothermia. While speaking to (R1), (R1) could not remember her date of birth and thought she was in Creve Coeur, Illinois. (R1) stated she was just going for a walk and had just left her house when she slipped and fell on the snow and ice. (R1) did not know how long she had been outside. I asked dispatch to call (the nursing home) to see if (R1) was a patient there. Dispatch made the call and confirmed that (R1) was missing from the facility. (V5) stated that he was responsible for resident health care for wings four, five, and six but had primarily been on wing six, which is located downstairs and is not the wing that (R1) resides on. (V5) also confirmed that (R1) has Dementia and Alzheimer's (disease). The facility staff also informed (V4) that they are grossly understaffed and have four managers sitting at home doing nothing that could help take some of the work load off. The staff also stated that the facility's upper management has been made aware of the staffing issues numerous times but have failed to resolve the issue. Once we (V4 and V16) exited the main entrance, (V4) could hear a loud beeping alarm noise going off at the northern most entrance of the facility. (V6/LPN) met us at the door from within the facility and was able to disarm the alarm and open the door. Alarm could not be heard at the main entrance within the facility. It is possible that (R1) exited the facility through that door. It is unknown how (R1) was able to walk past staff members, other residents, video surveillance, and a locked door that requires a code. R1's Elopement Care Plan dated [DATE] through [DATE] and R1's Wander Care Plan dated [DATE] to [DATE] do not include any documentation of R1's elopement from the facility on [DATE], or a revision of R1's goals/interventions to prevent R1 from future elopements. V13's (Assistant Director of Nursing) investigation notes regarding R1's [DATE] elopement document R1's wander management transmitter bracelet was not working, and door alarms were shut off at the panel. These same notes document R1 left the building at 8:56 PM. On [DATE] at 9:30 AM V17 (Community Witness) stated, On [DATE] at 9:00 PM, I was in my living room and had just turned the television off. I heard someone outside yelling 'Help me. Help me.' I looked out the window and saw an elderly women sitting on the curb facing route 117. The woman did not have on a hat, gloves, or coat and there was snow and ice on the ground. I immediately called 911 and two police officers and an ambulance came and helped the woman. I looked at my phone that night and my phone said it was 28 degrees Fahrenheit outside. On [DATE] at 2:10 PM V4 (Police Officer) stated, On [DATE] at 9:17 PM we received a 911 call from V17 (Community Witness) stating that a women was outside of (V17's) apartment screaming for help. (V16/Police Officer) and I immediately went to the scene. (R1) was sitting on a curb and stated she had fallen. (R1) was sitting on a curb facing route 117. Route 117 is a very busy roadway. (R1) was around 500 feet away from the nursing home and was out of sight of the nursing home. (R1) had no hat, gloves, or coat on and was shivering. (R1's) pants were soaked with water. (R1) only had on a light shirt and pants. (R1) stated she had fallen and could not get up. It was 25 degrees Fahrenheit outside and it had just started to snow. The ground was covered in ice and snow. (R1) knew her name but was not sure where she lived. I called EMS (Emergency Medical Services) and they came to the sight and assessed her. (R1) did not have hypothermia. Dispatch called the nursing home (the facility) and staff were unaware that (R1) had left the facility. The staff did confirm that the name (R1) gave me was a resident of theirs. Me and (V16) returned (R1) to the nursing facility. When we got to the facility an alarm was sounding outside at the 100-hallway door. When we took (R1) inside there was no alarm sounding at the main entrance or at the nurse's station. The staff told me that they are inadequately staffed. (R1) would have died outside had (V17) not heard (R1) yelling for help. On [DATE] at 11:05 AM V1 (Administrator) stated, It was reported to me that (R1) exited the facility at the end of 100 hallway. (R1) is ambulatory and has very severe Dementia. On [DATE] at 11:50 AM V13 (Assistant Director of Nursing) stated, The staff called me about (R1) leaving the facility and I went to the facility immediately. The facility's surveillance cameras showed (R1) walking back and forth on 100 hallway. On the third trip down 100 hallway at 8:56 PM, (R1) left the building out of the 100-hallway door. (R1) pushed the door for 15 seconds and then the door opened. (R1) tried to open the door back up to go back inside the building but was unable to get the door open. (R1) then turned around and left. Earlier that night (R1) had tried to go out of the 200-hallway door and was re-directed by staff. (R1)'s wander management transmitter bracelet was checked and did not work. (V14/Director of Operations) came in around 10:00 PM and went to the alarm panel behind the nurse's desk. (V14) noticed that two or three alarms shut off at the panel, so the door alarm would not have alarmed at the desk. No residents reside on 100 hall, and the hall has doors that close in the middle of the hall. Staff would not be able to hear an alarm at the door. (R1) is confused to time, place, and family. (R1) has poor safety awareness and would not know where to go if she were to get outside of the building. There are times (R1) does not know how to get back to her room. On [DATE] at 12:05 PM V14 (Director of Operations) stated, I came into the facility on [DATE] around 10:00 PM. The alarm to 100 hallway had been shut off at the nurse's station. The staff informed me that the alarm had not went off at the nurse's station panel. The alarm at the door on 100 hall was alarming. The alarm at the 100 hallway is very faint. On [DATE] at 6:15 PM V5 (Registered Nurse/RN) stated, On Saturday [DATE] I was (R1's) nurse and I was working downstairs on a different floor from where (R1) resides. I had not been told that (R1) tried to open the 200-hallway door earlier that night. When the police returned (R1) to the facility we checked (R1's) wander management transmitter bracelet and it was not working. I was not aware that a wander management transmitter bracelet had an expiration date. I never have checked to see if (R1's) wander management transmitter bracelet was expired. No alarms were sounding at the nurse's station when (R1) had left the facility. Two CNAs (Certified Nursing Assistant) is not enough staff to take care of all the residents on the 200, 300, 400, and 500 hallways. We did not have enough staff and that is why (R1) was able to elope unnoticed. On [DATE] at 1:00 PM, V8 (CNA) stated, On [DATE] Me and (V7/CNA) were the only two CNAs working after 8:00 PM on the 200, 300, 400, and 500 hallways. Sometime before 8:00 PM that night, (R1) tried to leave out of the 200-hall door. I re-directed (R1) to turn around and walk back up towards the nurse's station. The alarm to the 200-hall door had alarmed at the door and the nurse's station. I turned the alarm off at the door and (V7) turned the alarm off at the nurse's station. (R1) continued to wander on all hallways that night. I did not see (R1) go down 100 hall and did not know (R1) exited the building. There were not alarms going off at the 100-hall door or the nurse's station. When the police brought (R1) back to the facility I checked (R1's) wander management transmitter bracelet. (R1's) bracelet was expired and did not work with the transmitter tester. I am not aware of what residents are elopement risks. Two CNAs is not enough to take care of and supervise all of the residents upstairs (200, 300, 400, and 500 hallway). On [DATE] at 1:30 PM, V6 (LPN) stated, I worked on [DATE] from 6:00 PM to 10:00 PM. That night (R1) had went down 200 hallway door and pushed the door setting off the alarm on the panel at the nurse's desk and at the door. (V8 and V7) were the only CNAs working on the main floor that night. There was no actual CNA working on 500 hall (hallway R1 resides on) after 8:00 PM. At the time (R1) left the building, (V7) was working 200 hall and (V8) was working 400 hall. (R1) tried to leave the building all day. I was busy with medication pass that night and was unable to help the CNAs. The last time I saw (R1) was when she tried to exit out 200 hall door. I did not inform (V5/R1's Nurse) that (R1) tried to exit out of the 200-hallway door. The alarms were not sounding at the nurse's station when (R1) exited out the 100-hallway door. On [DATE] at 1:40 PM V9 (CNA) stated, I worked until 8:00 PM on [DATE]. I was (R1's) CNA until 8:00 PM. No one told me that (R1) tried to leave out of the 200 hall door. If I would have known, then I would have monitored (R1) closer. On [DATE] at 4:55 PM V7 (CNA) stated, On [DATE] there were only two CNAs after 8:00 PM working the 200, 300, 400, and 500 halls. (R1) tried to elope out of the 200-hallway door earlier that night. (V6) re-directed (R1). I did not do anymore supervision of (R1) after (R1) tried to leave through the 200-hallway door. I pressed the button behind the nurse's station to turn off the alarm. I did not know that I had to re-press that same button to turn the alarm back on. I did not know that (R1) had left the building that night. There were no CNAs available to supervise residents on 500 hall that night from 8:00 PM to 10:00 PM. There was not enough staff to supervise (R1) and that is why (R1) left the facility without staff knowing. (V1/Administrator and V2/Director of Nursing) are fully aware of the staffing issues at the facility and when I report the staffing issues, they tell the staff to 'stay positive.' I have resigned from the facility due to not having enough staff to take care of the residents. On [DATE] at 11:25 AM V15 (LPN) stated, (R1) is confused to time and place. (R1) only knows her name. (R1) wanders throughout the facility daily and wanders into residents' rooms at times. (R1) always says she wants to go home. (R1) has no safety awareness and would not be safe to outside by herself. (R1) would have no idea where to go if she got outside unattended. I was never aware that wander management transmitter bracelets have an expiration date. I have never checked wander management transmitter bracelets for expiration. On [DATE] at 2:45 PM V21 (LPN) stated, I did not know that there was an expiration date to the wander management transmitter bracelets . (R1's) medical record does not include the expiration date to (R1's) wander management transmitter bracelet. (R1) has always wandered and is not safe to go outside by herself. (R1) has been wandering more often and has been more agitated since her husband has not been able to visit. On [DATE] at 1:45 PM V12 (CNA) stated, (R1) has very poor safety awareness. If (R1) left the building she would not know where she was going or what she was doing. On [DATE] at 1:00 PM V3 (Care Plan Coordinator) stated, (R1's) care plan has not been updated to include (R1's) elopement from the facility on [DATE]. On [DATE] at 3:45 PM V10 (RN) stated, I was not aware that wander management transmitter bracelets expire or have expiration dates stamped on them. I never check to see if wander management transmitter bracelets are expired. (R1) wanders around the facility and has tried to open the main entrance a couple of times. On [DATE] at 12:55 PM V11 (Maintenance Director) stated, I have never checked the wander management transmitter bracelets. Third shift nurses are responsible for checking the wander management transmitter bracelets. 2. R2's physician's orders [REDACTED]. R2's MDS assessment dated [DATE] documents R2 is cognitively moderately impaired and requires extensive assistance of two-person physical assistance to transfer and walk in R2's room and the corridor. This same assessment documents R2 requires supervision of one staff physical assistance to move off and on the unit and is not steady with walking unless stabilized. R2's Care Plan dated [DATE] documents R2 has a communication problem and does not always understand or is not always understood. R2's Behavior Monitoring Logs dated [DATE] through [DATE] documents R2 has had four wandering attempts. R2's Care Plan dated [DATE] does not include a plan of care or interventions to address R2's wandering and elopement attempts. R2's Medical Record dated [DATE] (date of admission) to [DATE] does not include an assessment of R2's wandering/risk of elopement. R2's Progress Notes dated [DATE] at 3:35 PM and signed by V10 (RN) document, Call received from (V20/R2's Power of Attorney). (V20) states that she received two calls from (R2) so far today and was checking on him to see if he was agitated. (V20) stated the first time (R2) hung up on her during the conversation and then second time she hung up on him. (V20) stated after speaking with (R2), (R2) stopped speaking. Both times (R2) commented to (V20) that he wanted to come home and also said he wanted a friend. (V2) tried to reeducate (R2) about placement in the nursing home being long term, but (R2) is having hard time accepting this. (V20) also updated on elopements times four today. (R2) stated he was wanting to go home as the reason for leaving the building. On [DATE] at 1:40 PM R4 stated, About a month or two ago I was in my room and saw (R2) walking down the hill of the driveway unattended. I hollered at (V9/CNA) and then V9 went after (R2). On [DATE] at 1:40 PM V9 stated, Sometime in the morning on [DATE] (R4) yelled at me and told me (R2) was outside unattended. I found (R2) in the driveway of the facility. I could not get (R2) re-directed. I called the facility two times for help before I got an answer. (R2) was walking towards the road. The FedEx driver tried to help me. I finally got ahold of (V6/RN) and she helped me to get (R2) back into the facility. I was so upset that day and had notified (V1) of (R2) leaving the facility unattended and not wanting to go back inside. On [DATE] at 1:30 PM V6 (RN) stated, (V9) saw (R2) walking outside unattended on ([DATE]). (V9) called into the facility and asked me to help her with getting (R2) to go back inside. (R2) was in the middle of the facility's driveway. The front door alarm was alarming at the time. Me and (V9) were able to get (R2) back into the facility. I do not think I charted anything about the incident in (R2's) chart or notified (R2's) family or physician. On [DATE] at 3:45 PM, V10 stated, On [DATE] (R2) tried to elope four times that day. I was not at the facility for all of those attempts. I think (R2) might have gotten outside once unattended. I cannot remember all the specifics. (R2) wanders around in his wheelchair. On [DATE] at 4:05 PM, V20 (R2's Family) stated, I have never been notified about (R2) trying to leave the facility, or actually leaving the facility. I should have been informed if he is attempting to leave the facility. (R2) had to be admitted to the facility for supervision. (R2) had [MEDICAL CONDITION] and Dementia and could not take care of himself at home. On [DATE] at 1:45 PM V1 and V2 stated that (R2's) medical record does not include any documentation of R2 leaving the building unattended on [DATE]. V1 also stated the facility has not investigated R2 leaving the building unattended on [DATE]. On [DATE] at 1:50 PM V2 (Director of Nursing) stated, Wandering assessments are to be done quarterly when the MDS assessments are due. On [DATE] at 1:00 PM V3 stated, (R2) has not had a wandering or elopement care plan. (R2) has never had a wandering/elopement risk assessment done. The Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy began on [DATE] at 7:15 PM when the facility failed to provide adequate supervision to R1 following an attempted elopement from the facility, subsequently resulting in R1 eloping from the facility, falling, and being found sitting on the ice-covered ground 500 feet away from the facility. V1 (Administrator), V2 (Director of Nursing) and V14 (Director of Operations) were notified of the Immediate Jeopardy on [DATE] at 9:10 AM. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Immediate action(s) taken to ensure electronic wander management bracelets in proper working order include: a. On [DATE], V2 (Director of Nursing) and V13 (Assistant Director of Nursing) replaced all wander management bracelets with new bracelets with expiration dates clearly marked on the devices. b. On [DATE], V2 and V13 documented placement of the new bracelets in the resident's progress notes. 2. Immediate action(s) taken to ensure all exterior doors are properly alarmed include: a. On [DATE], V11 (Maintenance Director) inspected all exterior door alarms, and alarms were found to be in proper working order. b. On [DATE], the facility's corporate team re-educated all staff on the facility elopement and wandering policy and procedure including proper management of the redundant door alarm system. 3. Immediate action(s) taken to ensure all residents were assessed for risk for elopement include: a. On [DATE], V3 (Care Plan Coordinator) completed an Elopement Risk Assessment for R1 and R2. b. On [DATE], V3 audited the clinical record of all residents at risk for elopement and wandering to ensure each resident had a current Elopement Risk Assessment on record. 4. Immediate action(s) taken to ensure the facility is providing adequate supervision include: a. On [DATE], V2 and V13 reviewed the nursing staffing schedule to ensure there was sufficient staffing for adequate supervision. b. On [DATE], V2 and V3 re-educated nursing staff on notifying the nursing management of all staffing shortages. c. On [DATE] the corporate team reviewed with nursing management the facility's procedure for staffing and policy for emergency staffing. 5. Immediate action(s) taken to ensure the facility has developed an elopement risk care plan and evaluated elopement risk interventions for effectiveness include: a. On [DATE], V3 reviewed and revised care plans for R1 and R2 to ensure an elopement risk care plan was developed and effective interventions were in place. b. On [DATE], the facility's corporate staff re-educated the interdisciplinary team on assessing elopement risk interventions for effectiveness. c. On [DATE], V3 reviewed the care plans of all other residents at risk for elopement to ensure care plans and effective interventions were in place.

Based on observation, interview, and record review the facility failed to attempt to manage resident behavior within the facility prior to issuing an emergent involuntary discharge, failed to assist family with finding appropriate alternate living arrangements, failed to ensure that an involuntary discharge was not based on the resident's condition at the time of transfer, and failed to ensure that the resident was being transferred to an appropriate environment for one of five residents (R15) reviewed for involuntary discharge in the sample of 29. This failure resulted in R15 being discharged to an unsafe environment, experiencing severe emotional distress and increased confusion. Findings include: The facility's Admission Criteria policy, dated 3/2019, documents Our facility admits only residents whose medical and nursing care needs can be met. The Facility assessment dated [DATE] documents List the common diagnosis, conditions, physical and cognitive disabilities of the residents the facility cares for to determine the types of human and physical resources needed. Common Diagnoses: [REDACTED].), Impaired Cognition, Mental Disorder, Depression, [MEDICAL CONDITION] Disorder (Mania/Depression), [MEDICAL CONDITION], Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], Non-Alzheimer's Dementia, [MEDICAL CONDITION] Disorders, [MEDICAL CONDITION], Stroke, Traumatic Brain Injuries, [MEDICAL CONDITION], Down's Syndrome, Autism, [MEDICAL CONDITION]'s Disease, [MEDICAL CONDITIONS]. This Assessment documents Each resident is evaluated by the Director of Nursing and nursing staff to ensure the potential residents can be properly cared for and the resources necessary are on site or can be acquired externally. If it is developed in house the resident is evaluated for the need and we acquire the necessary equipment and/or resources to properly care for the resident. This Assessment also documents, Services and Care we offer based on our residents' needs: Mental health and behavior: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/[MEDICAL CONDITION], other psychiatric diagnoses, intellectual or developmental disabilities. The facility's (undated) Abuse, Neglect, Exploitation Prevention, Investigation, reporting policy documents Residents who allegedly mistreated another resident will be removed from contact with that resident during the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of other resident and employees of the facility. A room change or staffing change may be indicated but should not be interpreted as a restriction of rights or liberties. Residents will be protected from service interruptions, restrictions, and any other form of retaliation. R15's Admission Record face sheet dated 7/30/19, documents R15 was admitted to the facility on [DATE]. This sheet documents R15 has [DIAGNOSES REDACTED]. R15's physician order [REDACTED]. R15's Minimum Data Set assessment (MDS), dated [DATE], documents R15's cognitive skills for daily decision making are severely impaired. This assessment also documents R15 has fluctuating behaviors of inattention and altered level of consciousness and has continuous behaviors of disorganized thinking. R15's current (undated) care plan documents I wander with no rational purpose, seemingly oblivious to my needs or safety throughout the (facility). When I begin to wander, attempt to engage me in activity or something that will hold my interest. This care plan also documents I (R15) have behavioral symptoms present as evidence by yelling/ screaming/ hitting/ kicking/ scratching/ biting and throwing things. Monitor me for wandering as I will go in other residents' rooms and take their personal items and yell at them to get out of my house. The same care plan also documents The resident (R15) is/has potential to be physically and verbally aggressive related to dementia with behavioral disturbance and anxiety. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later. R15's progress note, dated 4/30/19 at 2:17 PM, documents (R15) became agitated with another resident in the multi-purpose room. This writer (V4 Social Service Director) was able to redirect (R15) to the common area. With no further incident. R15's final abuse investigation, dated 5/6/19, documents At approximately 1:30 PM on 4/30/19 (R15) and (R12) were in the resident dining room, (R15) became agitated and slapped (R12) on the chin. This investigation also documents (R12) was assessed and had no injuries and did not express any pain or injury. Upon investigation, (R15) has dementia and was upset because she believed (R12) to be in her house and could not understand why she was not leaving when she asked her to. (R15) was maintained on a one to one visual contact the remainder of the evening as well as monitored for agitation and behaviors with none other noted that evening. R15's final abuse investigation, dated 6/12/19, documents at 5:00 PM on 6/12/19 (R15) became agitated with staff and other residents while sitting in the main living room of the facility. (R15) was upset that other residents were In her house. (R15) went around staff and pushed (R29), causing (R29) to lose her balance and fall to the floor. This investigation also documents R15 was maintained on one to one visualization for the remainder of the night and that V27 (R15's Physician) Reviewed (R15's) medications and ordered to change the timing of the administration of (R15's) antianxiety medication to earlier in the afternoon, to minimize behaviors in the late afternoon and evening. R15's progress note, dated 7/8/19 at 4:28 PM, documents Attempted to take (R15) to the bathroom, (R15) agitated at each attempt. R15's progress note, dated 7/8/19 at 5:16 PM, documents (R15) ambulated down the hallway agitated but not aggressive just talking. (R15) ambulated into another resident's room and without cause walked up to (R9) and slapped her across the face. (R9) had not even spoke to (R15) and she did it. Both progress notes were documented by V10 (Registered Nurse) On 7/31/19 at 11:15 AM, R9 was sitting in a wheelchair in her room. R9 stated On the evening of 7/8/19, (R15) came in my room through the bathroom and started yelling at me that I was keeping her baby awake and then she slapped me and hit my face. One other time she came flying through the bathroom door and started yelling at me while I was watching television. I don't use the bathroom at all. I have told staff to lock it, but they don't. I always would yell for staff whenever (R15) was in my room. They (staff) were always aware. I just never knew when (R15) may come in here and start on me. On 7/30/19 at 1:30 PM, V10 (Registered Nurse) confirmed working on the evening shift of 7/8/19. V10 stated (R15) has dementia, Alzheimer's and has had agitation. She could go from being pleasant to picking stuff up and throwing it or shoving you. She had her bad times of the day. When she first admitted I noticed a pattern that by 1:30-2:00 PM, she would get more agitated. Some of it would do with the change of shift. The incident on 7/8/19 is one that (R15) has done in the past. (R15) went into (R9's) room. She would do that sometimes, if she could hear that someone was in the room on the other side of the bathroom door, (R15) would go in the other room and try to kick them out, thinking it was her house to do so. She had done that several times. I didn't see the actual incident. (V25, Certified Nursing Assistant (CNA)) and (V26, CNA) reported it to me and I'm not sure how much they saw of it. When I went down, (R9) said (R15) had slapped her across the head. We got (R15) out of the room and I got on the phone with (V2, Director of Nursing (DON)) and (V1, Administrator). We had to do one on one monitoring with (R15) after that. When she was admitted she was confused from the get go. She was on [MEDICATION NAME] since admission. My next step that day was that I was instructed by (V2) to contact (V27, R15's physician) and get an order for [REDACTED]. dementia. (V27) offered to get (R15) more [MEDICATION NAME]. But I explained that I was told by the (V2) and (V1) that we need to involuntarily discharge (R15). (V27) said What am I supposed to do? Throw her out on the street? We didn't leave her side. We took turns walking with her. On 7/30/19 at 1:50 PM, V25 (CNA) and V26 (CNA) both confirmed working the night that R15 was discharged . V25 stated We were both coming out of a room across the hall when (R15) was leaving (R9's) room. We could hear (R9) screaming. (R9) was yelling and saying (R15) hit her and she was calling the police. (R15) has hit other residents in the past. She has knocked (R29) down before and she smacked (R12) across the face. Those were recent episodes. In the beginning when (R15) was admitted she was confused but not aggressive. (R15) has become more physical in the last 6-8 months. (R15) would often yell out this is my house, get out. Normally (R15) liked seeing us and we could re-direct her. She felt bad that night (7/8/19) but didn't know why. We took her out to the lobby area and she calmed down a lot. When (V23/R15's family member) got here (R15) was calm. (R15) used to have a pattern of behaviors like typical sundowners (worsened confusion in the evening hours). They were getting more frequent lately. Interventions for (R15) would be distraction. This event occurred before supper in the evening time. On 7/31/19 at 10:10 AM, V28 (CNA) stated (R15) mood would just depend on the day. Sometimes she could be cooperative and other times she'd put up a fight. Sometimes (R15) would go into other resident's rooms and be physical and yell or be mad. (R15's) Alzheimer's and dementia has just progressed and it made her have more aggressive behaviors, you'll have that with that disease. On 7/30/19 at 12:00 PM, V23 (R15's family member) stated On (MONTH) eighth at 7:45 PM, I received a phone call that there was an incident and (R15) needed to be removed from the facility. I met with the (V1, Administrator), (V2, DON), and had (V27, R15's physician) on speaker phone. I was told that (R15) went into another room and hit another resident and they were unable to care for her anymore. When we asked for more time to figure things out, the administrator said that this has already been done right now and they could give us no time and that (V15, the facility's medical director) had signed off on it. So, at 9:00 PM they made me wake up my sleeping mother and take (R15) to my home which was in no way equipped to handle her and put her in great danger. (R15) had lived almost three years in the facility. She had had other altercations with residents and they never spoke about something like this. At every care plan meeting they always told me she is so re-directable. I was told this incident happened between 5-5:30, the nurse saw her walking down the hall and she never stopped her or tried to re-direct her. When we got (R15) to my house she was extremely difficult to manage. She didn't want to get out of the car. She was upset and tearful and did not know where she was or what we were trying to do for her. We had to do everything we could to get her into the house and ready for bed. The bed is high off the floor and we have stairs. (R15) was not safe in my home. The facility never contacted me to help me find another placement. I have not heard anything from them since she left on (MONTH) eighth. There was no witness to the incident itself. No one saw it or was in there besides (R15) and the other resident (R9). When (R15) was admitted to the facility she had no idea that she was being admitted to a facility. She thought she was in her mother's house. We had to bring her to the facility in the first place because she was so confused. (R15) believed that from the day she was admitted until the day I took her home. They (the facility) did injustice to (R15) and it's not ok. On 7/31/19 at 2:15 PM, V4 (Social Service Director) stated A lot of (R15's) behaviors were in the evening so I wasn't in there for those times. (R15) had a lot of sundowner symptom. I don't recall any talk of getting (R15) out of the facility prior to her discharge on (MONTH) eighth. I know we never said that she would need to find alternate placement. We talked some about her medications in care plan meetings with her family but we (the facility) never said we can't handle her here. On 7/31/19 at 9:40 AM, V2 (DON) stated The night she was discharged I got a call from staff telling me what had happened, and I came back in a little after 5:00 PM. The police officer talked with (R15), but she was fine and calmed down by then and of course made no sense. When (V1, Administrator) got here we both sat down and talked. When we talked to (V27, R15's physician), she wouldn't send (R15) to the emergency room for a psychiatric evaluation. (V27) said (R15) didn't need it and she wouldn't give us an order. (V1) and I decided that evening that we need to involuntary discharge on (R15). (V15, medical director) is our medical director and he gave us the order for (R15) to be involuntarily discharged . (R15) was aggressive hit or miss at times. She's had about three incidents since October. When we called both (V27 and V15) we asked for an order for [REDACTED].>On 7/31/19 at 9:50 AM, V1 (Administrator) stated The reason (for involuntary discharge) was for safety of other residents. It was a matter of us trying several different things and at that point we had exhausted all other options. (V27) told us This is just (R15), this is the way she is, and this is what she does. So, a psychiatric evaluation wasn't an option. We do have other residents here with Alzheimer's and dementia. Aggression and agitation do go with dementia and Alzheimer's and it is a part of the disease process. We talked to (V23) that night about locked units and other facilities. After the last incident (prior to 7/8/19) we had made some changes to (R15's) medications and she was doing OK, then out of nowhere (R15) walked into another residents room and hit her. No-one was in the room to witness the incident. No staff saw what happened between the two residents. I gave the family and (V23) the involuntary discharge notice within hours of the incident. We have not talked with the resident's family since they left that night, aside from (V23) calling us to get medical records. On 7/31/19 at 11:00 AM, V15 (Facility's Medical Director) stated (R15) is not my patient but she physically assaulted another resident and that resident is my patient. I did give (the facility) an order to discharge (R15). I am not her primary physician. Aggression and agitation are part of Alzheimer's and dementia. I do feel like the staff are more than capable of taking care of residents with Alzheimer's, dementia and aggressive behaviors related to the [MEDICAL CONDITION] process. The staff are very careful and capable, and they are capable of handling residents with behaviors, agitation and aggression. On 7/31/19 at 12:45 PM, V27 (R15's physician) stated (R15) has severe dementia. When (R15) comes in with (V23) to her appointments. She can't answer you when you ask her who (V23) is. (R15's) clarity and confusion is severe. So, when they (the facility) called me with this episode of her hitting another resident, to me obviously (R15) is confused and lashed out because she was scared or whatever. (The facility) wanted me to give an order to immediately discharge (R15) and release her. If you're a facility that deals with dementia and residents like this then why can't you handle this? If it was a problem with another resident maybe move (R15's) room or maybe eventually move (R15) to another facility. I didn't feel the immediacy of the discharge or putting (R15) in a hospital where her symptoms would get worse. If (R15) had violence with other residents, they didn't make me aware. I don't recall ever being told (R15) had a pattern of violence. They (the facility) never reached out and said she might need a higher level of care or a special unit until this night (7/8/19). Taking (R15) to (V23's) home which is unfamiliar, that could make her confusion related to dementia even worse and possibly make her have more behaviors, without trained staff there to help. (R15) didn't need to be thrown out that night. (The facility) certainly wanted to get the resident out that night. (V23) offered to come in and pay for someone else to come in and stay with (R15) and give her time to find placement, even a day or two longer to let (V23) find another facility. (V23) was actually being very reasonable with (the facility) and they wouldn't have it. On 8/1/19 at 11:20 AM, V2 (DON) stated We were always to redirect (R15). After she pushed (R29) down in June, we did some medication changes with (R15's) [MEDICATION NAME]. It helped for a while but even (V27), the night we sent her out, said this is how (R15) is. I get that, and I understand it's part of (R15's) disease process. If (staff) saw (R15) walking down a hall and looking agitated they should re-direct her, offer her a coffee or just get her mind distracted. (R15) would go in (R9's) room here and there, she would go through the adjoining bathroom sometimes. (R9) did tell me that (R15) had went in during the night at times and would yell at her. (R9) does not use that bathroom, she uses a bed pan. We (the facility) never thought about locking the bathroom door on (R9's) side. When we changed her [MEDICATION NAME] in (MONTH) (V27) said we could go up with medication if needed, but since the actual event was more than just agitation, that wasn't what we (the facility) wanted. If we had the amount of staff to give her one to one attention that possibly could have helped, but we're not equipped to provide one on one care. (R15's) behaviors were that of sundowners and events happened on second shift usually. We don't have enough Certified Nursing Assistants or staff to provide more in (R15's) area. V2 confirmed that in the past a room change for R15 with a private bathroom was mentioned, but never happened. V2 also confirmed the facility did not try any further interventions on the night of 7/8/19 before making the decision to involuntarily discharge R15.

Based on interview, and record review, the facility failed to ensure physical abuse did not occur for three of three residents reviewed for abuse (R1, R3 and R9) in the sample of 12. This failure resulted in a hematoma on R1's left temple and bruising on top of R1's hand, as well as R1's left wrist being swollen, discolored and tender to touch. Findings include: The facility policy for Abuse, Neglect, Exploitation last revised 1/2017 documents, This facility affirms the right of our resident to be free from exploitation, abuse or neglect and misappropriation of resident property. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. Abuse is a willful infliction of injury, unreasonable confinement, intimidation, or punishment with results physical harm, pain, or mental anguish. Willful: means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse: refers to the infliction of injury on a resident that occurs other than by accidental means this includes but is not limited to, hitting, slapping, pinching and kicking. 1. On 6/12/2019 R1's Nursing progress notes document, Pushed down by another resident (R3) (and) landed on the floor hitting left temple area and left hip. Large hematoma to left temple. Ice applied. Crying 'ow'. The Progress notes document R1 was sent into the emergency room for evaluation, returning later the same day. The 6/12/19 Facility Abuse investigation summary documents, On 6/12/19 (R3) became agitated with staff and other residents while sitting in the main living room of the facility. Staff intervened and attempted to redirect (R3) out of the area. (R3) was upset that the other residents were 'in her house'. As the nurse was trying to calm down (R3), (R3) went around the nurse and pushed (R1) causing (R1) to lose her balance and fall to the floor causing a hematoma on (R1's) left temple and bruising on top of (R1's) hand. The physician was made aware and ordered R1 to be sent to the ER (emergency room ) for evaluation. On 6/13/19 at 4:16PM R1's progress notes document, Radiology here to take X-ray of left wrist. At 5:36pm the nurse documented, Follow up to previous fall finds new injury to left wrist. Wrist swollen and discolored red/purple. Tender to touch. Large hematoma to left temple with bruising extending toward forehead. Favors left leg with ambulation. Will continue to monitor. 2. The Facility Abuse investigation summary dated 5/6/19 documents, On 4/30/19 (R9) was sitting in the dining room and another resident (R3) became agitated and slapped R9 in the chin. Staff intervened and removed (R9) from the activity. R9's physician's orders [REDACTED]. R9's 4/9/19 Quarterly Minimum Data Set assessment (MDS) documents R9 as cognitively intact with no behaviors. R9's 4/30/19 Progress notes document R9 was not injured. On 6/21/19 at 3:15PM R9 stated, I did get hit by someone right here (pointing to her upper left chest) and it hurt!

Based on observation, record review, and interview, the facility failed to ensure proper incontinence care was provided and follow Urology recommendations for the prevention of Urinary Tract Infections, for one of three residents (R1) reviewed for incontinence in a sample of 22. This failure has resulted in R1 not being on a scheduled toileting program, not being cleansed appropriately after incontinence, developing recurrent Urinary Tract Infections over the course of 5 months and chronic [MEDICAL CONDITION] in the groin area. Findings include: The facility policy, titled Incontinence Care, Peri-care (11/15), documents, The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The policy instructs staff, for a female resident, a. Use incontinence wipes or wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (1.) separate labia and wash area downward from front to back. (2.) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward [MEDICAL CONDITION]. Do not reuse the same wipe or washcloth or water to clean the urethra or labia. (3.) If using a washcloth, rinse the perineum thoroughly in the same direction, using fresh water and a clean washcloth. (4.) Gently dry perineum. Admission Records, dated 6/10/19, document R1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A Minimum Data Set assessment, dated 3/28/19, documents R1 as occasionally incontinent, requiring the extensive assistance of one staff member for toileting, and having no cognitive impairment. An Order Listing Report documents R1 was treated with antibiotics for a Urinary Tract Infection on 1/14/19. R1's Plan of Care was updated on 4/04/19, to identify R1 as high risk for skin breakdown due to decreased mobility, incontinence and requiring staff assistance for toileting, and advises staff to keep R1 dry as possible and minimize skin exposure to moisture. Physician Office Visit Notes, dated 3/11/19, document R1 was seen by Urology for recurrent Urinary Tract Infections [MEDICAL CONDITION], Urinary Incontinence, and blood in the urine. The 3/11/19 Office Visit Notes document R1 reported to the Urologist that she did not get cleansed by facility staff in a timely manner when she was incontinent of urine. The 3/11/19 Office Visit Notes instruct nursing home staff to do the following: return for follow up in six weeks, start medication (D-[MEDICATION NAME]) for prevention of UTIs, timed urination every two hours - get patient up out of chair every 2-3 hours to toilet on commode with assistance, and change patient's (incontinence brief) immediately if wet. Wetness/incontinence is increasing her chances of recurrent UTI. An Order Listing Report documents R1 was treated with antibiotics for a Urinary Tract Infections again on 3/20/19, 4/08/19 and 5/26/19. Nursing Progress Notes, dated 5/01/19, document R1 was prescribed [MEDICATION NAME] Powder twice per day, for persistent redness to her groin area. Physician Office Visit Notes, dated 5/30/19, indicate R1 saw Urology for continued recurrent UTIs, and documents, (R1) states the nursing home will not clean me up when she urinates in her (incontinence brief). I am wet up to my back and I am just sitting in a wet diaper with wet sheets and they don't wipe me. I am raw in the groin area, there is a cream they should be using but they are not. (My) groin area is red and irritated. The Urologist Office Follow Up Instructions for 5/30/19 instruct facility staff to do the following: Timed toileting every two hours - get up to commode or use bedpan, Wash skin with soap and water after urinary leakage before applying dry (incontinence brief), wake (R1) up at night to urinate - do not let her sleep and soak the bed, Apply [MEDICATION NAME] powder to the groin area twice daily and as needed. R1's current Plan of Care, printed 6/06/19, fails to contain any of the instructions for incontinence following both the 3/11/19 and 5/30/19 Urologist appointments. On 6/06/19 at 11:00 am, R1 was in an activity in the upstairs dining room. R1 was continuously observed at 15-minute intervals. At 11:42 am, R1 left the upstairs dining room and was waiting for the elevator to go downstairs for lunch. At 11:45 am, R1 was in the main dining room for lunch, where she remained until 2:00 pm and was taken to her room. At that time, R1 stated she was last given incontinence care before the morning activity, so sometime prior to 11:00 am. R1 stated she was incontinent of urine and could tell that she was currently wet but indicated it wouldn't matter if she told the staff she needed incontinence care, because they will just get to me when they do. R1 stated she does know at times, but not all the time, when she needs to urinate and is supposed to be on a scheduled toileting program, but staff won't do it for her. R1 stated her groin area is red, and sometimes staff don't wipe her at all when they change her brief, and simply put a clean brief on her without cleansing. R1 also stated she would prefer to use a bed pan at night, but the staff on third shift make her just wet her diaper and then she will have to lay in the urine. R1 stated staff are to be putting [MEDICATION NAME] powder on her groin, but they don't routinely. R1 stated she had a full list of instructions from her doctor regarding her incontinence care, but it's never been followed by the staff. R1 was visibly upset when talking about her care and stated she is increasingly frustrated because she isn't getting the care she needs, even though she has repeatedly complained to staff. On 6/06/19 at 2:17 pm, R1 was taken by V5 (Certified Nursing Assistant) to the toilet for peri care. R1's incontinence brief was saturated with urine, V5 (Certified Nursing Assistant) confirmed and stated R1 was pretty wet. V5 also stated, R1 takes diuretics and drinks a lot, so she is frequently wet. After leaving R1 on the toilet for a few minutes, V5 had R1 stand and V5 wiped R1 with a packaged cleansing wipe from front to back on the back side, and with another wipe in the upper groin area on both sides. V5 did not use soap and water, or cleanse near the urethra, folds of the labia or upper thighs. R1 did have visible redness in the groin area and inner upper thighs, and V5 applied a barrier cream to that area. V5 indicated that she routinely uses the wipes on R1 for incontinence care. On 6/10/19 at 12:41 pm, V8 (Licensed Practical Nurse) stated when she came on shift 6/09/19 (day shift) that she found R1 soaked with urine in her bed. R1 reported to V8 that staff had not been in to give her incontinence care since 1:00 am. V8 stated R1 has also told her that staff won't cleanse her after finding her incontinent, but just put a dry brief on her. V8 stated she has reported all of this to management, because R1 has frequent UTIs. On 6/10/19 at 12:05 pm, V7 (Care Plan Coordinator) stated R1 has voiced complaints to her about not receiving proper incontinence care, that the CNAs are not cleaning her appropriately and this has been reported to management. V7 stated R1 is alert and knows how her care is to be given. V7 stated R1 was not currently on a toileting program, but R1 would be a perfect candidate for one, as she is often aware of when she needs to void. V7 stated R1 gets frequent Urinary Tract Infections, which is another reason toileting her would be in her best interest. V7 stated it was her understanding that the facility did not utilize any kind of toileting programs, as she had inquired about that for certain residents and was told they don't have one. V7 stated there is no reason staff could not honor R1's request to use a bedpan at night and that would be better for her, rather than laying in urine. V7 concluded that R1's urinary incontinence needs and high risk for UTI's has not been incorporated into her plan of care and V7 was unaware of the Urologist recommendations on 3/11/19 and 5/30/19. On 6/10/19 at 2:08 pm, V2 (Director of Nursing) stated the facility is just now initializing a toileting program for residents; however, if a resident asks to be toileted, staff should toilet them as requested. V2 indicated R1 would be a good candidate for scheduled toileting. V2 confirmed that R1 has reported to her the CNAs are not cleansing her properly, and she has discussed this with them. V2 stated staff should not be making R1 void in her depend at night and should honor her request for a bed pan. On 6/11/19 at 9:45 am, V10 (Advanced [MEDICATION NAME] Registered Nurse for Urology) stated R1 has been her patient for some time now and during R1's last few check-ups, R1 has been very upset with the care she is receiving at the facility. V10 stated she saw R1 two weeks ago and R1 informed her that the facility staff were not following any of her instruction from her last visit, which included toileting R1 routinely and to wash her perineum with soap and water, after episodes of incontinence. V10 stated, due to R1's increased risk for developing UTIs, R1 needs peri care as soon as she becomes wet and therefore she stressed having R1 on a routine toileting program back in (MONTH) 2019. V10 stated R1 told her that staff will sometimes not even cleanse her skin and simply just take the wet incontinence brief off and replace it with a clean one. V10 stated, after her 5/30/19 appointment, she gave two sets of instructions for R1's care, one to R1 and another to the facility staff. V10 stated she even called V2 to ensure her recommendations were being followed, but V2 did not return her call. V10 stated R1 already has a chronic [MEDICAL CONDITION] on her groin, which is from constantly being wet with urine and not receiving proper incontinence care; however, V10's biggest concern is R1's recurrent UTIs, which are the direct result of poor and improper peri care and R1 not being routinely toileted.

Based on record review, and interview, the facility failed to ensure all residents were kept free from physical, and mental abuse, for one of 11 residents (R1) reviewed for abuse, in a sample of 22. This failure resulted in R1 being forced to wear clothing that she voiced to V3 (Certified Nursing Assistant) she did not want to wear, V3 throwing clothes at R1, yelling at R1 and slamming the door on R1, making R1 cry and feel humiliated. Findings include: The facility policy, titled Abuse, Neglect, Exploitation - Prevention, Investigation, Reporting (1/2017), documents, This facility affirms the right of our residents to be free from exploitation, mistreatment, abuse or neglect and misappropriation of resident property. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat residents' medical symptoms. Residents must not be abused by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the facility, staff of other agencies serving the resident, family members, resident representative, legal guardians, friends, volunteers or other individuals. This facility has established an environment that is as homelike as possible and includes a culture and environment that treats each resident with dignity and respect. The facility provides care and services in a person-centered environment in which all individuals are treated as human beings. Treating any resident in a manner that does not uphold a resident sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetuates a disrespectful and/or potentially abusive attitude towards the resident(s). The policy further documents, under Definitions, that Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment, resulting in physical harm, pain or mental anguish. The policy defines Emotional/Mental Abuse as, humiliation, harassment, threats of punishment or deprivation, or offensive physical contact that results in mental or emotional suffering. Mental abuse may occur through verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. On 6/06/19 at 2:00 pm, R1 stated the morning of 5/27/19, V3 (Certified Nursing Assistant) helped her get up and ready for the day. R1 stated V3 picked out clothing for her to wear that did not belong to R1. R1 stated she told V3 that the shirt she chose for her to wear wasn't hers and was too small for her, but V3 put the shirt on her anyway. R1 had to go down for breakfast wearing the shirt that was too tight, making her uncomfortable. R1 described the situation as embarrassing and humiliating. R1 stated she returned to her room after eating and immediately took off the shirt V3 put on her. V3 came into R1's room and yelled at her You shouldn't have done that! and threw the sweatshirt R1 originally wanted to wear at R1 and slammed the door. R1 stated she was upset and crying after the incident and felt intimidated, because she didn't know why V3 would treat her that way. R1 stated other staff observed her crying, asked what was wrong and she reported what happened. According to R1, V3 apologized to her the next day, so she believes someone must have said something to her about it. On 6/10/19 at 1:09 pm, V9 (Registered Nurse) stated R1 reported to her on 5/27/19, during lunch, that V3 was dressing her that morning and put a shirt on R1 that she did not want to wear. R1 told her V3 indicated she had to wear it anyway. V9 stated R1 told her she removed the shirt herself, then V3 got a different shirt and threw it at her, yelled at her for taking it off and slammed the door. V9 stated R1 was still upset over the incident at lunch, several hours after it occurred. On 6/10/19 at 12:41 pm, V8 (Licensed Practical Nurse) stated the previous Monday (5/27/19) R1 reported to V9 (Registered Nurse) that V3 had made R1 wear a shirt that was too small and didn't belong to her, when R1 took off the shirt R1 reported that V3 got out a different shirt, threw it at her face and yelled at her.

Based on observation, interview, and record review the facility failed to perform skin assessments, follow a turning, and repositioning schedule, ensure pressure reduction devices were in place, revise pressure reduction interventions, follow physician's orders [REDACTED]. These failures resulted in R40 developing an unstageable pressure ulcer to the left buttock and additional open wounds developed to the cleft between the right and left buttocks less than one week later. These failures also resulted in R20 developing an unstageable pressure ulcer to the left buttock which progressed to a stage IV pressure ulcer. Findings include: A Prevention of Pressure Ulcers/Injuries policy dated 7/2017 states to perform a pressure ulcer risk assessment upon admission and to repeat the risk assessment weekly, and upon any changes in condition. This policy also instructs to inspect residents' skin daily and to keep the skin clean and free of exposure to urine, and fecal matter. The policy further states to reposition residents who are chair-bound, or bed bound every hour and more frequently based on the condition of the skin. The policy instructs to review the pressure ulcer prevention interventions and strategies for effectiveness on an ongoing basis. This policy also instructs to select the appropriate support surfaces based on the resident's mobility, continence, skin moisture, perfusion, and overall risk factors. This same policy states to review the pressure ulcer prevention, treatment interventions, and strategies for effectiveness on an ongoing basis. A Repositioning policy dated 5/2013 states, Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. The policy also states, Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. This policy further states, 4. For residents with a stage I or above pressure ulcer, every two-hour (q2 hour) repositioning schedule is inadequate. 5. Residents who are in a chair should be on every one-hour (q1 hour) repositioning schedule. 6. If ineffective, the turning and repositioning frequency will be increased. This policy also instructs to document in the medical record the position in which the resident was placed. R20 and R40's Wound specialist pressure ulcer information sheet (undated)states, Pressure ulcers (also called decubitus ulcers or bedsores) develop when there is injury to the skin and underlying tissue due to pressure for an extended period. This constant pressure reduces the blood supply to that area, preventing the delivery of vital nutrients and oxygen. Pressure ulcers most commonly occur in patients confined to a wheelchair or a bed. A Dressings, Dry/Clean policy dated 9/2013 states that prior to performing pressure ulcer dressing changes, 5. Wash and dry your hands thoroughly. 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 1. R20's Minimum Data Set (MDS) assessment date 1/31/19 documents R20 requires extensive assistance for bed mobility, transfers, and toilet use. This same MDS documents R20 has functional limitation in range of motion to one upper and lower extremity and is occasionally incontinent. R20's Braden Scale for Predicting Pressure Sore Risk dated 1/31/19 documents that R20 is chairfast but otherwise at a low risk for the development of pressure ulcers. R20's nurse's note dated 3/10/19 documents that R20 has increased, difficulty manipulating w/c (wheelchair) with paralysis from stroke. R20's nurse's note dated 3/15/19 documents R20 developed a 2cm (centimeters) DTI (Deep Tissue Injury) which had a 1cm fluid filled blister over the top of it. This same note documents R20 also had a second DTI to the bottom of his left foot. R20's nurse's note dated 4/3/19 documents R20 developed an unstageable pressure ulcer to the left upper buttock on that date. R20's Wound Evaluation and Management Summary dated 4/3/19 documents that R20's physician ordered for R20 to have a gel cushion in R20's chair/wheelchair, and a cream applied to R20's left upper buttock wound then covered with a water proof adhesive gauze every day for wound healing. R20's care plan dated 5/23/18 states that R20 is at risk for pressure ulcer development related to immobility. The care plan further instructs for R20 to use a pressure reduction cushion in his wheelchair and instructs staff to follow facility policies for prevention, and treatment of [REDACTED]. On 4/7/19 at 10:00a.m. V17 (Certified Nurse Aide/ CNA) stated that R20 has taken a decline in his strength over the past month. V17 stated that R20 can no longer self-propel in the wheelchair and needs more assistance with mobility because of increasing weakness. V17 also stated that R20 cannot use his right arm at all, has an amputation to his right leg, and a cushioned boot to his left leg. V17 stated that R20 is supposed to be transferred to bed and provided incontinence care after meals. On 4/8/19 at 10:08a.m. R20 was in his room seated in a wheelchair, which did not have a pressure reduction cushion in place, next to his bed. R20 had a cushioned boot to the left lower leg and had an above the knee amputation to the right leg. R20 stated that he had been seated in the wheelchair since 7:00a.m. and had been waiting a long time after breakfast for staff to transfer him back to bed. R20 stated he wanted to lay down because his buttocks were sore because of having a pressure ulcer. R20 stated that he is supposed to lay down after meals, but he always must wait a long time for staff to assist him. R20 stated that sometimes when he pushes his call light, so staff can help him with toileting, R20 will have to wait up to one- and one-half hours for someone to answer which causes R20 to soil himself. R20 stated that he had a pressure reduction cushion for his wheelchair at the time of his admission in 5/2018 but that staff removed it a long time ago and R20 doesn't know where it went. R20 stated that he had become much weaker lately and could no longer adjust himself or propel himself in the wheelchair. R20 stated his right arm was paralyzed because of a stroke and he now has a new onset of weakness in his left arm which is the arm he used to propel the wheelchair. At 10:15a.m. V13 (CNA) and V6 (CNA) entered R20's room to transfer R20 to bed. V13 and V6 wrapped a safety belt around R20's waist and, using extensive assistance, lifted R20 from the wheelchair into the bed. V6 verified that R20 does not use a pressure reduction cushion in his wheelchair. V13 and V6 left R20's room without offering to toilet R20 or check and change R20's incontinence brief. On 4/8/19 at 10:59a.m. V14 (Licensed Practical Nurse) stated that R20 does not have any pressure ulcers besides the wounds to R20's left foot. V14 reviewed R20's physician's orders [REDACTED]. V14 entered R20's room to examine R20's buttocks wounds. V14 loosened the tape from R20's incontinence brief which was full of fecal material and assisted R20 to turn to the side. R20's left buttocks had an open wound which did not have a dressing in place and which measured approximately 1.5cm (centimeters) long x 1.2cm wide x 0.3cm deep with a tannish pink wound bed. R20 also had two new open wounds to the cleft between the right and left buttocks. V14 reapplied R20's soiled incontinence brief over R20's open wounds. V14 asked V15 (Registered Nurse) to check R20's wound documentation to see if R20 was supposed to have a dressing to R20's buttocks wounds. V15 stated that R20's wound physician had documented R20'a left buttock wound on 4/3/19 and had ordered a cream and adhesive dressing to be applied daily. V15 stated that those orders were not transcribed into R20's electronic physician's orders [REDACTED]. V15 stated R20's wound specialists notes did not identify any other wound to R20's buttocks. V14 also verified that R20 does not use a pressure relief cushion to R20's wheelchair. R20's Treatment Administration Record (TAR) dated 3/2019 to 4/8/19 does not document that nursing staff perform skin assessments to monitor for skin breakdown for R20. These same TARs do not show documentation that R20's physician ordered left buttock pressure ulcer treatment was administered from the time the wound developed 4/3/19 to 4/8/19. On 4/10/19 at 9:15a.m. and 10:20a.m., V2 (Director of Nurses) verified that R20's care plan dated 5/23/18 instructs for R20 to have a pressure reduction cushion in R20's wheelchair. V2 stated that the facility disposed of R20's original cushion at the time R20 was admitted because the cushion was soiled. V2 verified that R20's physician ordered a new pressure reduction cushion on 4/3/19 after R20 developed an unstageable pressure ulcer to the left buttock. V2 stated that the cushion had been ordered but had not arrived as of 4/10/19. V2 stated that nursing staff do not currently perform skin assessments on residents to detect and prevent pressure ulcers. V2 stated that R20 is chair bound but states she believes he can reposition independently and therefore, is not on a turning and repositioning program. V2 stated residents should be turned and repositioned every two hours and should be checked for incontinence and their incontinence briefs changed at that time. V2 could not provide any pressure ulcer prevention measures that were implemented after R20 developed an unstageable pressure ulcer to the left buttock on 4/3/19 in order to prevent the pressure ulcers from developing in the cleft between R20's right and left buttock. On 4/10/19 at 12:45p.m. V20 (R20's Physician) stated that R20's unstageable left buttock pressure ulcer and pressure wounds between the right and left buttock could have been avoided if R20 had been using a pressure reduction cushion in his wheelchair and if he had been turned and repositioned at least every two hours. 2. R40's MDS assessment dated [DATE] Section G, Functional Status, documents R40 requires extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. This same section also documents that R40 has no functional limitation in range of motion to the upper or lower extremities. Section M, Skin Conditions, documents R40 did not have any pressure ulcers. R40's annual MDS dated [DATE] Section G, Functional Status, documents R40 is totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. This same section also documents that R40 has a functional limitation in range of motion to both upper extremities. Section M, Skin Conditions, documents R40 has one unstageable pressure ulcer. R40's care plan dated 3/28/19 documents that R40 is at risk for further skin breakdown related to immobility, current pressure ulcers, bowel incontinence, and because R40 requires assistance from staff for cares. R40's care plan interventions of lay down after breakfast and lunch to offload, pressure reducing cushion for chair and/or wheelchair, treatments/dressings as ordered by the physician, and pressure reducing mattress were all initiated between 1/2017 and 10/2017. R40's intervention to use a pressure reducing cushion to the chair was added a second time on 1/30/19. On 4/7/19 at 10:55 V16 (Licensed Practical Nurse) stated that R40 had a stage IV pressure ulcer to R40's left buttock but that it was healed and no longer required a treatment and dressing. On 4/9/19 at 10:51a.m. R40 was seated in a specialized wheelchair with no pressure relief cushion in place. V17 (Certified Nurse Aide/CNA) and V6 (CNA) entered R40's room to transfer R40 to bed. V17 stated that R40 had been seated in the wheelchair since 8:00a.m. that morning when V17 assisted her with morning cares. V17 stated that R40 is supposed to be turned and repositioned every two hours. V17 and V6 used a mechanical lift to transfer R40 from the wheelchair to the bed. R40 did not move her arms or legs at any time during the transfer. Once R40 was in the bed, V17 and V6 proceeded to removed R40's soiled incontinence brief to provide care. There was an open wound to R40's left buttock which was covered with fecal material and which measured approximately 1.5cm (centimeters) long x 0.5cm wide x 0.3cm deep. V17 stated she thought there was supposed to be a dressing to R40's wound but that V16 (Licensed Practical Nurse) had told V17 that R40's wound was healed and didn't need a dressing. V17 verified that R40's wheelchair did not have a pressure relief cushion in place stating that R40 does not use one. On 4/9/19 at 11:10a.m. V28 (Licensed Practical Nurse) stated that R40 does not have any pressure ulcers. V28 looked through R40's physician's orders [REDACTED]. 3/27/19. R40's Treatment Administration Records (TAR) dated 3/2019 to 4/9/2019 document that R40's stage IV left buttock pressure ulcer has not received R40's physician ordered wound treatment by nursing staff since 3/27/19. On 4/10/19 at 11:25a.m. V5 (MDS) Coordinator verified that R40 had a significant change in condition sometime following her MDS assessment on 9/13/18 and before her annual MDS assessment on 12/6/19. V5 stated that R40's significant change was not recognized and therefore, a significant change in status assessment was not conducted. V5 stated that if R40's significant change in status had been recognized, R40's care plan would have addressed R40's increased risk for skin break down with additional interventions to prevent the development of pressure ulcers, such as increased turning and repositioning. V5 verified that R40's care plan did not include any new interventions since 10/2017. R40's wound physician's note dated 12/5/19 documents R40 was initially assessed for the development of a new unstageable pressure ulcer to the left buttock on that date. R40's wound physician's note dated 3/6/19 documents that R40's wound had deteriorated to a stage IV pressure ulcer. On 4/10/19 at 9:15a.m. and 10:20a.m., V2 (Director of Nurses) verified that R40's current pressure ulcer risk reduction care plan does not include any new interventions since (YEAR) to address R40's increased pressure ulcer risk following the development of a stage IV pressure ulcer. V2 stated that R40's pressure ulcer developed on 11/30/18 as an unstageable pressure ulcer then progressed to a stage IV pressure ulcer in 1/2019. V2 verified that R40's care plan instructs for R40 to have a pressure reduction cushion to R40's wheelchair. V2 also verified that R40 was not provided with a pressure relief cushion. V2 stated that nursing staff do not currently perform skin assessments on residents to detect and prevent pressure ulcers. V2 stated that R40 is chair bound and requires turning and repositioning every two hours. V2 could not provide any pressure ulcer prevention measures that were implemented after R40 developed an unstageable pressure ulcer to the left buttock on 11/30/18 in order to prevent that pressure ulcer from progressing into a stage IV pressure ulcer on 3/6/19. V2 stated that R20 does have a pressure reduction air mattress which was not offered by the facility but instead was purchased by R40's family at the end of 1/2019. On 4/10/19 at 1:31p.m. V25 (R40's physician) stated that R40 has taken a significant decline. V25 stated that R40's stage IV left buttock pressure ulcer could have been avoidable if staff had used the pressure relieve cushion in R40's wheelchair as ordered. V25 stated that he expects that R40's pressure ulcer treatment is provided by nursing staff as ordered. 3. R9's current Physician order [REDACTED]. 04/09/19 09:23am, V7, RN (Registered Nurse) washed his hands, applied gloves, then removed R9's soiled dressing from his right heel. V7 then cleansed the wound and changed his gloves. V7 then applied the medicated dressing to R9's wound and wrapped it with a gauze dressing. V7 then removed R9's soiled dressing from his left heel, cleansed the wound then changed his gloves, applied the medicated dressing and wrapped it with gauze. V7 did not perform any hand hygiene during R9's pressure ulcer cares. V7 stated that he did not have anywhere to perform hand hygiene during R9's care, so he did not do it. V7 also verified that there is a sink in the room a few feet away from where R9's wound care was being done. V7 stated that he does not know the policy, because that is to many details. On 4/10/19 at 9:00am, V2, Director of Nursing, verified that hand hygiene is to be performed when moving from a soiled area to a clean area.