Every finding on record at Maple Ridge Rehabilitation and Nursing

Based on interview and record review, the facility failed to protect each resident's right to be free from neglect for 1 of 19 residents. Specifically, facility staff failed to provide the necessary care and supervision required to maintain a safe environment for a resident with known impulsivity and severe cognitive impairment. This failure occurred when a Registered Nurse (RN) left a medication cart unlocked and unattended, in direct violation of facility policy and the resident's specific care plan interventions dated 9/17/25. This breach in safety protocols allowed the resident to access the unsecured cart and ingest multiple medications not prescribed to him. This resulted in a significant change in the resident's condition, including an altered mental status and life-threatening electrolyte imbalances, which required emergency medical transfer and admission to a Medical Intensive Care Unit (MICU). This will be cited at a harm level. Resident Identifier: 32.Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included human immunodeficiency virus, paranoid schizophrenia, and schizoaffective disorder.Review of resident 32's medical record was completed on 6/1/26 through 6/4/26.A Quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 32 had a Brief Interview of Mental Status (BIMS) score of 0 which indicated severely impaired cognition. On 3/13/26 at 12:10 PM, an Event Note Template revealed the following: Event Date/Time: 3/4/26 @ [at] 1130 [11:30 AM] Event Description: Staff found medication cards in residents [sic] room, staff immediately notified nursing and management. A medication error occurred involving the above-named resident. The resident accessed the medication cart after it was left unlocked and unattended. The resident was able to obtain and self-administer medications without staff supervision. Shortly thereafter, the resident exhibited signs of altered mental status (AMS), including confusion and decreased level of awareness. The resident also demonstrated an unsteady gait, increasing fall risk . A thorough search of the resident's room was conducted, which resulted in the discoveryof [sic] multiple medication cards in the resident's possession .DON [Director of Nursing] and provider were notified immediately. Emergency medical services (EMS) were activated due to change in condition. Resident was transferred to the emergency department for further evaluation and treatment . Root cause: Resident was able to access unlocked and unattended medication cart and took med cards and pills . Preventative Measures in Place Prior to Incident: Educated staff to ensure back is never turned to resident while pulling medication, re educated [sic] nurses that they are not to leave meds with residents, med audits will be completed on all nurses.A review of the inpatient admission notes from 3/4/26 through 3/12/26 revealed the following: [resident 32] was brought in by EMS [Emergency Medical Services] from his care facility after they found empty sheets of blister packs for abilify 2mg [milligrams], Eliquis 5mg, desmopressin dose unknown, atorvastatin 40 mg, metoprolol XL100 mg, doxycycline 20 mg, melatonin dose unknown, and zofran dose unknown. It is unclear how much of any of these medications he may have taken, could have taken none, could have taken several of each individual medication. Apparently these were in bubble packs on a cart near his room. This was not discovered unto [sic] some time after ingestion but timing is unclear. He was admitted to MICU [Medical Intensive Care Unit] for management of hyponatremia, (initially 117) with increased urine output likely 2/2 [secondary] to that ingestion. Patient was placed on a 1:1 sitter, sodium has been uptrending without intervention to 130, and patient's home medications for schizophrenia have been restarted. Still holding BP [blood pressure] meds due to some softer BP readings . Upon my interview [resident 32]was awake and alert but minimally interactive. He reported having right arm pain and right foot numbness. When asked why he was in the hospital he did endorse taking medications but did not respond when asked if this was in an effort to self harm or commit suicide, additionally, he was unable to answer whether or not he was having thought [sic] of self harm/suicidal ideation/ homicidal ideation. A review of the resident's medical record indicated that Resident 32 did not have active medication orders for the following:Abilify 2 mgEliquis 5 mgDesmopressinAtorvastatin 40 mgMetoprolol XL 100 mgDoxycycline 20 mgMelatoninZofranOn 2/21/25, a care plan for resident 32 was initiated and the focus was, Resident has mental health diagnoses of anxiety and schizophrenia and requires the use of psychotropic medications with an intervention added on 9/17/25, resident is extremely impulsive, position medication cart so the nurses back is never towards the residents.On 3/4/26 the facility initiated a Critical Incident Response Plan. The Quality Assurance and Performance Improvement (QAPI) Performance Improvement Plan (PIP) Action Plan documented the following: The facility failed to ensure medications were securely stored and failed to maintain a hazard-free environment when a medication cart was left unlocked and unattended. As a result, a resident accessed and ingested medication, resulting in actual harm that required transfer and admission to the hospital. Identified Concern: Failure to Maintain a Hazard-Free Environment (F689). Medication cart left unlocked and unattended. Resident was able to independently access and remove medication. Lack of adequate supervision to prevent access to hazardous substances. Failure to Secure Medications (F761) Medications were not stored in a locked compartment. Controlled access safeguards were not maintained. Failure to follow facility policy regarding medication cart security. Potential Risk to Patient. Resident ingested medication not prescribed to them. Sent out for emergency transfer to hospital for evaluation and treatment. Required hospital admission, with possibility of adverse outcome. Systemic Risk to Other Residents. Potential for additional residents to access unsecured medications. Possible pattern of noncompliance if carts are routinely left unsecured. Inadequate staff education and/or competency validation regarding medication security. Root Cause Identified: The root cause of this incident was a systemic failure in the facility's medication management and oversight processes, including staff noncompliance with medication cart security policy and ineffective competency validation and supervisory monitoring to ensure sustained adherence to required medication storage standards.On 3/16/26 at 1:21 PM, a MD Progress Note revealed the following, Note Text: admission history and physical cc [chief complaint]: Are you going to give me meds HPI [History of Present Illness]: [Resident 32] is a [AGE] year old male with a history of HIV [Human Immunodeficiency Virus] and paranoid schizophrenia who was admitted to the [name redacted] hospital 3/4 [2026] after ingesting meds that were not prescribed to him. He was admitted to the MICU [medical intensive care unit]. He had a sodium level of 117. His condition stabilized and then he was admitted to the psychiatric unit as he told hospital staff he wanted to die at the time he took the meds. He told the psychiatrist he was no longer suicidal.On 6/4/26 at 11:37 AM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that if she ever saw the medication cart unlocked she would lock it or stay near it until the nurse returned. CNA 3 stated that as a CNA she knows not to leave the medication cart unlocked and unattended because it only takes seconds for something to happen, especially in a facility that takes care of residents with mental health needs. On 6/4/26 at 11:52 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that when the medication cart is unattended it should always be locked. LPN 1 stated that the population of residents served in the facility would make it very unsafe to leave any type of medication unattended.On 6/4/26 at 1:23 PM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that when resident 32's room was being cleaned, multiple medication blister packs were found. The RDCS stated it was discovered that the Registered Nurse (RN) had left the medication cart unlocked and unattended, at which time resident 32 removed multiple blister packs from the cart. The RDCS stated that resident 32 presented with an altered level of consciousness, EMS was notified, and the resident was transported to the emergency department. The RDCS stated that the RN's employment with the facility was terminated due to a violation of facility policy regarding leaving a medication cart unlocked and unattended.

Based on interview, record review, and facility policy review, the facility failed to store all medications in a locked compartment and limit access only to authorized staff. Specifically, for 1 of 19 sampled residents, a resident was able to access the medication cart that was unlocked and unattended in a public hallway, allowing the resident to obtain multiple medications blister packs, and possibly ingest of unauthorized medication. This resulted in a finding of harm. Resident Identifier: 32.Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included human immunodeficiency virus, paranoid schizophrenia, and schizoaffective disorder.Review of resident 32's medical record was completed on 6/1/26 through 6/4/26.On 3/13/25 at 12:10 PM, an Event Note Template revealed the following: Event Date/Time: 3/4/25 @ [at] 1130 [11:30 AM] Event Description: Staff found medication cards in residents [sic] room, staff immediately notified nursing and management. A medication error occurred involving the above-named resident. The resident accessed the medication cart after it was left unlocked and unattended. The resident was able to obtain and self-administer medications without staff supervision. Shortly thereafter, the resident exhibited signs of altered mental status (AMS), including confusion and decreased level of awareness. The resident also demonstrated an unsteady gait, increasing fall risk . A thorough search of the resident's room was conducted, which resulted in the discoveryof [sic] multiple medication cards in the resident's possession .DON [Director of Nursing] and provider were notified immediately. Emergency medical services (EMS) were activated due to change in condition. Resident was transferred to the emergency department for further evaluation and treatment . Root cause: Resident was able to access unlocked and unattended medication cart and took med cards and pills . Preventative Measures in Place Prior to Incident: Educated staff to ensure back is never turned to resident while pulling medication, re educated [sic] nurses that they are not to leave meds with residents, med audits will be completed on all nurses.A review of the inpatient admission notes from 3/4/26 through 3/12/26 revealed the following: [resident 32] was brought in by EMS [Emergency Medical Services] from his care facility after they found empty sheets of blister packs for abilify 2mg [milligrams], Eliquis 5mg, desmopressin dose unknown, atorvastatin 40 mg, metoprolol XL100 mg, doxycycline 20 mg, melatonin dose unknown, and zofran dose unknown. It is unclear how much of any of these medications he may have taken, could have taken none, could have taken several of each individual medication. Apparently these were in bubble packs on a cart near his room. This was not discovered unto [sic] some time after ingestion but timing is unclear. He was admitted to MICU [Medical Intensive Care Unit] for management of hyponatremia, (initially 117) with increased urine output likely 2/2 [secondary] to that ingestion. Patient was placed on a 1:1 sitter, sodium has been uptrending without intervention to 130, and patient's home medications for schizophrenia have been restarted. Still holding BP [blood pressure] meds due to some softer BP readings . Upon my interview [resident 32] was awake and alert but minimally interactive. He reported having right arm pain and right foot numbness. When asked why he was in the hospital he did endorse taking medications but did not respond when asked if this was in an effort to self harm or commit suicide, additionally, he was unable to answer whether or not he was having thought [sic] of self harm/suicidal ideation/ homicidal ideation. A review of the resident's medical record indicated that Resident 32 did not have active medication orders for the following:Abilify 2 mgEliquis 5 mgDesmopressinAtorvastatin 40 mgMetoprolol XL 100 mgDoxycycline 20 mgMelatoninZofranOn 3/4/26 the facility initiated a Critical Incident Response Plan. The Quality Assurance and Performance Improvement (QAPI) Performance Improvement Plan (PIP) Action Plan documented the following: The facility failed to ensure medications were securely stored and failed to maintain a hazard-free environment when a medication cart was left unlocked and unattended. As a result,, a resident accessed and ingested medication, resulting in actual harm that required transfer and admission to the hospital. Identified Concern: Failure to Secure Medications (F761) Medications were not stored in a locked compartment. Controlled access safeguards were not maintained. Failure to follow facility policy regarding medication cart security.Potential Risk to Patient. Resident ingested medication not prescribed to them. Sent out for emergency transfer to hospital for evaluation and treatment. Required hospital admission, with possibility of adverse outcome. Systemic Risk to Other Residents. Potential for additional residents to access unsecured medications. Possible pattern of noncompliance if carts are routinely left unsecured. Inadequate staff education and/or competency validation regarding medication security. Root Cause Identified: The root cause of this incident was a systemic failure in the facility's medication management and oversight processes, including staff noncompliance with medication cart security policy and ineffective competency validation and supervisory monitoring to ensure sustained adherence to required medication storage standards.On 6/4/26 at 11:37 AM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that if she ever saw the medication cart unlocked she would lock it or stay near it until the nurse returned. CNA 3 stated that as a CNA she knows not to leave the medication cart unlocked and unattended because it only takes seconds for something to happen, especially in a facility that takes care of residents with mental health needs. On 6/4/26 at 11:52 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that when the medication cart is unattended it should always be locked. LPN 1 stated that the population of residents served in the facility would make it very unsafe to leave any type of medication unattended.On 6/4/26 at 1:23 PM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that when resident 32's room was being cleaned, multiple medication blister packs were found. The RDCS stated it was discovered that the Registered Nurse (RN) had left the medication cart unlocked and unattended, at which time resident 32 removed multiple blister packs from the cart. The RDCS stated that resident 32 presented with an altered level of consciousness, EMS was notified, and the resident was transported to the emergency department. The RDCS stated that the RN's employment with the facility was terminated due to a violation of facility policy regarding leaving a medication cart unlocked and unattended.

Based on interview, record review, and facility policy review, the facility failed to ensure that the transfer and discharge process was properly documented and that the required notifications were sent to the Office of the State Long-Term Care Ombudsman. Specifically, for 3 of 19 residents who were reviewed, the facility failed to maintain evidence that a copy of the written transfer notice was sent to the Ombudsman at the time of the transfer. Resident Identifiers: 2, 20, and 40.1. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute respiratory failure with hypoxia, schizophrenia, and acquired absence of lung. A review of resident 20's progress notes revealed the following hospital transfers:4/24/26 at 5:13 AM, a health status note documented, Resident was c/o [complaining of] 10/10 burning stomach pain. He started vomiting. He notified me that yesterday he had dark red stool. He stated he wanted to go to the hospital. He left via EMS [emergency medical services] to [name readacted]. Provider notified.5/11/26 at 4:37 AM, a discharge summary documented, Resident discharge location: [name redacted] HospitalResident 20's medical record was reviewed from 6/1/26 through 6/4/26. There was no documentation in the record that the facility had sent a copy of the written transfer notice to the Ombudsman.2. Resident 40 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified intracranial injury without loss of consciousness and dementia with mood disturbance.A review of resident 40's progress notes revealed the following hospital transfers:10/20/25 at 5:18 AM, a transfer to hospital summary documented, Resident was observed yelling throughout the night, more than usual.Staff immediately called 911, and the resident was transported via EMS to [name redacted] Hospital in Salt Lake for further evaluation and treatment. The provider, Director of Nursing, Administrator, and family were notified.11/13/25 at 9:46 AM, a discharge summary documented, Discharge/transfer location:: [name redacted] ED [emergency department], Mode at transportation at time of discharge/transfer:: [name redacted] EMS, Reason for Transfer/discharge: Labored breathing, Rhonchi and wheezing throughout lobes. Decreased responsiveness11/25/25 at 12:37 PM, a discharge summary documented, Discharge/transfer location:: [name redacted] ED, Mode at transportation at time of discharge/transfer:: [name redacted] EMS, Reason for Transfer/discharge: Fell out of WC [wheelchair] Onto [sic] dining room floor receiving a laceration above left eyebrow.Resident 40's medical record was reviewed from 6/1/26 through 6/4/26. There was no documentation in the record that the facility had sent a copy of the written transfer notice to the Ombudsman.3. Resident 2 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, unspecified dementia, major depressive disorder, borderline personality disorder, and sepsis.On 6/1/26 at 10:39 AM, an interview was conducted with resident 2. Resident 2 stated that she had been transferred to several emergency rooms since she was admitted to the facility. A review of resident 2's progress notes revealed the following hospital transfers:On 7/16/25 at 11:16 PM, a health status note documented, Resident approached me wanting to go to the ER [emergency room] for pain unrelieved with current analgesics. She is c/o [complaining of] pain on her left hip that radiates down to her stump. Resident wanting an mri [magnetic resonance imaging] and to go to hospital. [Name redacted] notified and [name redacted] . On 8/17/25 at 10:27 AM, a discharge summary documented, Patient is complaining of nausea and vomiting. Patient is refusing to take any prescribed medications, insulin, blood glucose checks, or vitals. Patient is requesting to be transferred to the hospital due top [sic] her nausea.On 9/22/25 at 11:35 PM, a transfer to hospital summary documented, Resident called 911 and was transferred to [local hospital] due to complaints of sharp, burning pain in the bladder area and right leg. On 9/28/25 at 5:44 PM, a discharge summary documented, Pt [patient] requested to go to the ER for her persistent N/V [nausea and vomiting] and pain. Pt assessed and neurological status is normal, Respirations normal, and BG [blood glucose] is 236. Providers notified. On 10/6/25 at 12:30 AM, an alert note documented, pt went to the ED [emergency department] due to break through pain that was not managed with the medication she is currently prescribed. she came back after two hours and is now going to bed.On 10/14/25 at 12:30 AM, a transfer to hospital summary documented, Resident reported experiencing significant pain in her back and bladder and stated she wanted to go to the hospital. Resident refused PRN [as needed] pain medication when offered. Staff explained that she would need to wait for the physician's order for hospitaltransfer [sic], but the resident declined and independently called 911. On 10/17/25 at 10:43 PM, a health status note documented, The resident reported experiencing pain in her right foot on a scale of 8/10 and requested a lidocaine external patch. Provider was notified, and an order was placed for the patch. after an hour of using the patch, resident returned, stating that her pain had not improved and that she would call 911.the Resident decline [sic] to take her PRN pain pill and insisted on being sent to the hospital. Staff explained that she should wait for the providers advice, but refused and proceeded to call 911.On 10/20/25 at 1:50 AM, a transfer to hospital summary documented, Resident reported significant pain during urination and expressed a desire to go to the hospital. PRN pain medication was offered but refused by the resident. Staff explained that a physician's order would be required for hospital transfer; however, the resident declined to wait and independently called 911.On 10/25/25 at 12:50 AM, a nurses note documented, Late Entry: At 0020 [12:20 AM] 0n [sic] 10/25/25, resident came asking for BG check two hours after administering her 35 unit glargine. The BG level was 415. Staff informed resident to wait for the providers order since resident requested .[sic] short acting insulin. Resident insist (sic) on not waiting for the on-call provider's order. She immediately called 911 to be sent to the hospital. Pt was asymptomatic and denied any symptom related to hyperglycemia.On 11/3/25 at 12:10 AM, a transfer to hospital summary documented, Resident complained of intense right leg pain and stated a desire to go to the hospital. PRN pain medication was offered but declined. Staff explained that hospital transfer required a physician's order, but the resident opted not to wait and independently called 911. EMS [emergency medical services] responded, and the resident was transported to [name redacted] for further assessment and care.On 11/11/25 at 7:30 PM, a transfer to hospital summary documented, At approximately 19:25 [7:25 PM], the resident called 911, reporting nausea and stating that she did not feel well. Emergency Medical Crew arrived, and the resident was transported from the room via stretcher. On 11/12/25 at 2:32 PM, a nurses note documented, pt reported nausea and abdominal pain. gave prn zofran and reglan. pt reported no relief. encouraged fluids. pt requested to be sent to ER. NP [nurse practitioner] was in building and assessed pt. pt still requested to be sent out. pt reported feeling like she was in DKA [diabetic ketoacidosis].On 11/25/25 at 10:50 PM, a transfer to hospital summary documented, Resident reported experiencing intense left leg pain and expressed a desire to be transferred to the hospital. PRN pain medication was offered but the resident declined. Staff explained that a hospital transfer would require a physician's order; however, the resident chose not to wait and independently contacted 911. The resident was transported. On 12/18/25 at 6:45 AM, a health status note documented, Resident returned from [name redacted] with EMS. AAO [awake, alert, and oriented] to person, place, time and situation. No SOB [shortness of breath], chest pain or acute distress.On 12/28/25 at 8:45 PM, a health status note documented, Late Entry: Resident returns from ED visit. No new orders were given.On 2/8/26 at 12:08 AM, a transfer to hospital summary documented, Resident c/o 10/10 right knee pain. She iitially [sic] stated that all prns would not be effective and she wants to go to the hospital. She then did agree to take tylenol but then stated she wanted to go to the hospital. Spoke with provider and called EMS.On 2/8/26 at 11:37 PM, a health status note documented, Patient continued to complain of knee pain following an unwitnessed fall outside. Patient is alert and oriented x4. Patient was sent to [name redacted] Hospital. On 2/13/26 at 11:30 PM, a transfer to hospital summary documented, Resident stated she wants to go to the ER due to UTI [urinary tract infection] s/s [signs and symptoms] and pain.On 2/19/26 at 9:35 PM, a transfer to hospital summary documented, Resident left via ambulance to [name redacted] hospital d/t [due to] right knee pain. Provider approved transfer.On 2/21/26 at 12:36 AM, a transfer to hospital summary documented, Resident was taken to the [name redacted] hospital vis [sic] ambulance. Provider notified.On 3/2/26 at 9:47 PM, a health status note documented, Resident called 911 and was transported to [name redacted] Hospital via ambulance on stretcher.Resident 2's medical record was reviewed from 6/1/26 through 6/4/26. There was no documentation in the record that the facility had sent a copy of the written transfer notice to the Ombudsman.On 6/4/26 at 12:50 PM, an interview was conducted with the Administrator (ADM). The ADM stated that staff filled out a discharge summary before residents were transferred to the hospital. The ADM stated that he was unable to locate any notifications that were made to the Ombudsman in regards to hospital transfers, but it was part of their process.

Based on interview and record review, the facility failed to ensure that an allegation of resident neglect was reported to the State Survey Agency and other required officials within the mandatory federal timeframe. Specifically, after a medication cart was left unlocked and unattended, and a resident ingested multiple medications from the unlocked medication card, the facility failed to report this allegation of neglect and misappropriation to the State Survey Agency within 2 hours of discovery. Resident Identifier: 32Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included human immunodeficiency virus, paranoid schizophrenia, and schizoaffective disorder.Review of resident 32's medical record was completed on 6/1/26 through 6/4/26.On 3/13/25 at 12:10 PM, an Event Note Template revealed the following: Event Date/Time: 3/4/25 @ [at] 1130 [11:30 AM] Event Description: Staff found medication cards in residents [sic] room, staff immediately notified nursing and management. A medication error occurred involving the above-named resident. The resident accessed the medication cart after it was left unlocked and unattended. The resident was able to obtain and self-administer medications without staff supervision. Shortly thereafter, the resident exhibited signs of altered mental status (AMS), including confusion and decreased level of awareness. The resident also demonstrated an unsteady gait, increasing fall risk . A thorough search of the resident's room was conducted, which resulted in the discoveryof [sic] multiple medication cards in the resident's possession .DON [Director of Nursing] and provider were notified immediately. Emergency medical services (EMS) were activated due to change in condition. Resident was transferred to the emergency department for further evaluation and treatment . Root cause: Resident was able to access unlocked and unattended medication cart and took med cards and pills . Preventative Measures in Place Prior to Incident: Educated staff to ensure back is never turned to resident while pulling medication, re educated [sic] nurses that they are not to leave meds with residents, med audits will be completed on all nurses.A review of the inpatient admission notes from 3/4/26 through 3/12/26 revealed the following: .[resident 32] was brought in by EMS [Emergency Medical Services] from his care facility after they found empty sheets of blister packs for abilify 2mg [milligrams], Eliquis 5mg, desmopressin dose unknown, atorvastatin 40 mg, metoprolol XL100 mg, doxycycline 20 mg, melatonin dose unknown, and zofran dose unknown. It is unclear how much of any of these medications he may have taken, could have taken none, could have taken several of each individual medication. Apparently these were in bubble packs on a cart near his room. This was not discovered unto [sic] some time after ingestion but timing is unclear. He was admitted to MICU [Medical Intensive Care Unit] for management of hyponatremia, (initially 117) with increased urine output likely 2/2 [secondary] to that ingestion. Patient was placed on a 1:1 sitter, sodium has been uptrending without intervention to 130, and patient's home medications for schizophrenia have been restarted. Still holding BP [blood pressure] meds due to some softer BP readings . Upon my interview [resident 32] was awake and alert but minimally interactive. He reported having right arm pain and right foot numbness. When asked why he was in the hospital he did endorse taking medications but did not respond when asked if this was in an effort to self harm or commit suicide, additionally, he was unable to answer whether or not he was having thought [sic] of self harm/suicidal ideation/ homicidal ideation. A review of the resident's medical record indicated that Resident 32 did not have active medication orders for the following:Abilify 2 mgEliquis 5 mgDesmopressinAtorvastatin 40 mgMetoprolol XL 100 mgDoxycycline 20 mgMelatoninZofranOn 6/4/26 at 1:23 PM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that when resident 32's room was being cleaned, multiple medication blister packs were found. The RDCS stated it was discovered that the Registered Nurse (RN) had left the medication cart unlocked and unattended, at which time resident 32 removed multiple blister packs from the cart. The RDCS stated that resident 32 presented with an altered level of consciousness, EMS was notified, and the resident was transported to the emergency department. The RDCS stated that the RN's employment with the facility was terminated due to a violation of facility policy regarding leaving a medication cart unlocked and unattended.On 6/4/26 at 1:23 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he conducted an investigation regarding the incident involving Resident 32 on 3/4/26. The ADM stated that resident 32 was not harmed, was treated for hyponatremia, and was then placed on a psychiatric hold. The ADM confirmed that he did not submit an incident report to the State Survey Agency regarding the resident's medication ingestion.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, 4 out of 19 residents, resident 32 obtained medications independently from an unsecured, unlocked medication cart. This will be cited at a harm level. In addition, the facility failed to implement new or revised interventions after consecutive falls. Resident 40 will also be cited at a harm level. Resident Identifiers: 2, 26, 32, and 40.HARM1. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included human immunodeficiency virus, paranoid schizophrenia, and schizoaffective disorder.Review of resident 32's medical record was completed on 6/1/26 through 6/4/26.A Quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 32 had a Brief Interview of Mental Status (BIMS) score of 0 which indicated severely impaired cognition. On 3/13/26 at 12:10 PM, an Event Note Template revealed the following: Event Date/Time: 3/4/26 @ [at] 1130 [11:30 AM] Event Description: Staff found medication cards in residents [sic] room, staff immediately notified nursing and management. A medication error occurred involving the above-named resident. The resident accessed the medication cart after it was left unlocked and unattended. The resident was able to obtain and self-administer medications without staff supervision. Shortly thereafter, the resident exhibited signs of altered mental status (AMS), including confusion and decreased level of awareness. The resident also demonstrated an unsteady gait, increasing fall risk . A thorough search of the resident's room was conducted, which resulted in the discoveryof [sic] multiple medication cards in the resident's possession .DON [Director of Nursing] and provider were notified immediately. Emergency medical services (EMS) were activated due to change in condition. Resident was transferred to the emergency department for further evaluation and treatment . Root cause: Resident was able to access unlocked and unattended medication cart and took med cards and pills . Preventative Measures in Place Prior to Incident: Educated staff to ensure back is never turned to resident while pulling medication, re educated [sic] nurses that they are not to leave meds with residents, med audits will be completed on all nurses.A review of the inpatient admission notes from 3/4/26 through 3/12/26 revealed the following: [resident 32] was brought in by EMS [Emergency Medical Services] from his care facility after they found empty sheets of blister packs for abilify 2mg [milligrams], Eliquis 5mg, desmopressin dose unknown, atorvastatin 40 mg, metoprolol XL100 mg, doxycycline 20 mg, melatonin dose unknown, and zofran dose unknown. It is unclear how much of any of these medications he may have taken, could have taken none, could have taken several of each individual medication. Apparently these were in bubble packs on a cart near his room. This was not discovered unto [sic] some time after ingestion but timing is unclear. He was admitted to MICU [Medical Intensive Care Unit] for management of hyponatremia, (initially 117) with increased urine output likely 2/2 [secondary] to that ingestion. Patient was placed on a 1:1 sitter, sodium has been uptrending without intervention to 130, and patient's home medications for schizophrenia have been restarted. Still holding BP [blood pressure] meds due to some softer BP readings . Upon my interview [resident 32] was awake and alert but minimally interactive. He reported having right arm pain and right foot numbness. When asked why he was in the hospital he did endorse taking medications but did not respond when asked if this was in an effort to self harm or commit suicide, additionally, he was unable to answer whether or not he was having thought [sic] of self harm/suicidal ideation/ homicidal ideation. A review of the resident's medical record indicated that Resident 32 did not have active medication orders for the following:Abilify 2 mgEliquis 5 mgDesmopressinAtorvastatin 40 mgMetoprolol XL 100 mgDoxycycline 20 mgMelatoninZofranOn 3/4/26 the facility initiated a Critical Incident Response Plan. The Quality Assurance and Performance Improvement (QAPI) Performance Improvement Plan (PIP) Action Plan documented the following: The facility failed to ensure medications were securely stored and failed to maintain a hazard-free environment when a medication cart was left unlocked and unattended. As a result, a resident accessed and ingested medication, resulting in actual harm that required transfer and admission to the hospital. Identified Concern: Failure to Maintain a Hazare-Free Environment (F689). Medication cart left unlocked and unattended. Resident was able to independently access and remove medication. Lack of adequate supervision to prevent access to hazardous substances. Potential Risk to Patient. Resident ingested medication not prescribed to them. Sent out for emergency transfer to hospital for evaluation and treatment. Required hospital admission, with possibility of adverse outcome. Systemic Risk to Other Residents. Potential for additional residents to access unsecured medications. Possible pattern of noncompliance if carts are routinely left unsecured. Inadequate staff education and/or competency validation regarding medication security. Root Cause Identified: The root cause of this incident was a systemic failure in the facility's medication management and oversight processes, including staff noncompliance with medication cart security policy and ineffective competency validation and supervisory monitoring to ensure sustained adherence to required medication storage standards.On 6/4/26 at 1:23 PM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that when resident 32's room was being cleaned, multiple medication blister packs were found. The RDCS stated it was discovered that the Registered Nurse (RN) had left the medication cart unlocked and unattended, at which time resident 32 removed multiple blister packs from the cart. The RDCS stated that resident 32 presented with an altered level of consciousness, EMS was notified, and the resident was transported to the emergency department. The RDCS stated that the RN's employment with the facility was terminated due to a violation of facility policy regarding leaving a medication cart unlocked and unattended.2. Resident 40 was admitted to the facility on [DATE],readmitted on [DATE], and discharged [DATE] with diagnoses which included unspecified intracranial injury without loss of consciousness and dementia with mood disturbance.Review of resident 40's medical record was completed on 6/1/26 through 6/4/26.A Quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 40 had a Brief Interview of Mental Status (BIMS) score of 0 which indicated severely impaired cognition.A review of resident 40's care plan focus dated 6/7/24 documented, [Resident 40] is at risk for falls r/t [related to] UNSPECIFIED INTRACRANIAL INJURY WITHOUT LOSS OF CONSCIOUSNESS, SEQUELA; MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER; UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH MOOD DISTURBANCE.A review of resident 40's medical record revealed the following:a. On 8/18/25 at 10:09 AM, an event note documented, on 7/10/25 at 12:30 PM, the resident was found on the floor in the dining room by another resident. Interventions for this fall included: The current plan of care reviewed will continue to follow.b. On 8/18/25 at 10:09 AM, an event note documented, on 8/10/25 at 6:04 PM, Certified nurse assistant (CNA) notified the nurse that the resident had an unwitnessed fall. Upon the arrival the nurse witnessed the resident on the floor lying on their left side and was on top of their fall mat.Interventions for this fall included: Reviewed care plan, interventions remain in place.c. On 9/8/25 at 4:59 PM, an event note documented, on 8/28/25 at 3:00 PM, CNA notified the nurse that the resident had rolled over his bed and was found on the floor mattress.Interventions for this fall included: Reviewed care plan, interventions remain in place.d. On 9/8/25 at 3:06 PM, an event note documented, on 9/3/25 at 6:30 PM, a CNA found resident 40 lying on the floor beside the bed.Interventions for this fall included: Reviewed care plan, interventions remain in place.e. On 9/17/25 at 4:06 PM, an event note documented, on 9/9/25 at 10:18 AM, CNA found resident on his hands and knees on floor mat next to bed.Interventions for this fall included: maintain the current plan of care.f. On 9/18/25 at 10:24 PM, an alert nursing note documented, patient is on alert charting due to a witnessed fall. Interventions for this fall included: It should be noted no interventions were located for this incident.g. On 9/23/25 at 11:35 AM, an event note documented, on 9/12/25 at 4:20 PM, Resident had an unwitnessed fall at 4:14 PM. Residents were yelling and staff came running to find the patient on his left side lying on the ground. The patient's head was not on the ground nor were there any signs he hit his head according to fellow residents and the normal skin assessment findings.Interventions for this fall included: Referred resident to be seen by psych Nurse Practitioner she recommended order changes Medical Doctor approved and orders have been updated.h. On 9/23/25 at 11:38 AM, an event note documented, on 9/12/25 at 4:20 PM, the nurse had just got done giving another patient medication, then the nurse came back to the med cart and looked up and the patient was crawling out of his chair and fell on the floor. The nurse then picked the patient up and put him back in his wheelchair Interventions for this fall included: refer resident to wheelchair supplier to evaluate the need for a new wheelchairi. On 9/23/25 at 11:40 AM, an event note documented, on 9/20/25 at 5:14 PM, the resident had an unwitnessed fall at 5:15 PM. Staff heard thud and ran over to see the patient on the floor on his right side. The patient had a laceration to right eyebrow which was bleeding. A bandage was put on the wound after being cleaned. Interventions for this fall included: the resident had 2 falls within the same nature in 2 days, refer resident to wheelchair supplier to evaluate the need for a new wheelchair. j. On 9/30/25 at 10:47 PM, an alert note documented, the resident sustained a witnessed fall this evening. He slid from his wheelchair to the floor, coming to rest in a seated position. There was no head impact, and no injuries were noted upon assessment. The resident was assisted back into his wheelchair without difficulty. Interventions for this fall included: It should be noted no interventions were located for this incident.k. On 10/3/25 at 10:44 AM, an health status note documented the patient is on alert charting following a witnessed fall.Interventions for this fall included: It should be noted no interventions were located for this incident.l. On 10/5/25 at 12:07 PM, an alert note documented the patient on alert charting for fall yesterday. Interventions for this fall included: It should be noted no interventions were located for this incident.m On 11/5/25 at 12:36 PM, an event note documented, on 9/26/25 at 7:45 PM, the nurse was giving medications to another client and then the nurse heard another client say [resident 40] is on the floor. The nurse then came out and helped the patient back into his wheelchair and did a head to toe assessment. The patient did not have any new wounds. The patient was placed on neuro checks and alert charting.Interventions for this fall included: medication review with psych Nurse Practitioner.n. On 11/5/25 at 12:41 PM, an event note documented, on 9/27/25 at 2:52 PM, the patient experienced a witnessed fall from his wheelchair. The patient fell forward, hitting forehead on the floor. No loss of consciousness observed. Staff immediately assisted the patient back into the wheelchair. Interventions for this fall included: medication review with psych Nurse Practitioner.o. On 11/5/25 at 12:51 PM, an event note documented, on 10/4/25 at 7:30 AM, nurse heard a thud, then came out of another resident's room and then the nurse picked up the patient, then cleaned up his eyebrow that had been split open. The patient was taken to the hospital. Interventions for this fall included: Resident was sent to the emergency room for a computed tomography (CT) scan and treatment for laceration.p. On 11/9/25 at 7:50 PM, an incident note documented the Resident experienced an unwitnessed fall this evening in the hallway. The Resident was found lying on his left side on the floor, reportedly falling from his wheelchair. Interventions for this fall included: It should be noted no interventions were located for this incident.q. On 11/25/25 at 12:03 PM, an alert note documented the resident was on the dining room floor near his wheelchair. The resident was awake responding with a low muffle sound and did not make eye contact. The resident held his head up approximately 25% from the floor. Assessed for injuries as staff supported the resident's head. The resident received a laceration just above left eyebrow with mild bleeding that was controlled. Called EMS and reported with them about the resident incident.Interventions for this fall included: It should be noted no interventions were located for this incident.On 6/4/26 at 12:55 PM, an interview was conducted with the RDCS. The RDCS stated that it was difficult to come up with new interventions to resident 40's fall care plan. The RDCS stated that they approached resident 40 about a possible room change closer to the nursing station and he had refused. The RDCS stated that it was like resident 40 had locked-in syndrome, there was never enough they could do for him. They did try one on one with him at one time but that seemed like that caused him more agitation, so they would just try and keep eyes on him at all times. POTENTIAL FOR HARM3. Resident 26 was admitted to the facility on [DATE] and discharged on 5/31/26 with diagnoses which included traumatic hemorrhage of cerebrum.Review of resident 26's medical record was completed on 6/1/26 through 6/4/26.A Quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 26 had a Brief Interview of Mental Status (BIMS) score of 7 which indicated severely impaired cognition.A review of resident 26's care plan focus dated 6/16/20 documented, [Resident 26] is at risk for falls r/t [related to] impaired gait and balance, poor muscle control/coordination that results in spastic movements, dementia with associated cognitive deficits including poor safety awareness and judgment, seizures, cataracts, myopia, refusal of care, noncompliance.a. On 1/7/26 at 12:03 PM, an event note documented, on 12/31/25 at 2:30 PM, The Pt [patient] had an unwitnessed fall at approximately 1430 [2:30 PM] which he states happened in the bathroom. He was found by a CNA [certified nursing assistant] in his bed with blood all over his face.There were no other skin issues found other than above his L [left] eyelid which has a large open wound which would require stitches. The patient is refusing to receive any kind of care including stitches, repeatedly stating no, DON [director of nursing] was present and asked the pt as well and he continued to refuse. Interventions for this fall included: Will review fall incidents and adjust interventions as needed. b. On 3/6/26 at 8:46 AM, an event note documented, on 2/27/26 at 12:15 PM, Resident found on the floor next to the bathroom. Resident when questioned states he didn't fall, but it is apparent he did. Found next to his wheelchair. States the floor is slippery [sic] Resident unable to state what happened other than the floor is slippery.Interventions for this fall included: Educate staff to ensure resident has proper nonslip foot wear. It should be noted that an intervention on 3/28/25 states, Education provided to resident on importance of having shoes on and adequately tied prior to transfers.c. On 3/27/26 at 12:05 PM, an event note documented, on 3/21/26 at 4:20 PM, Found resident in room sitting up on the floor between his WC [wheelchair] and bed. BM [bowl movement] on floor around resident. Resident has history of refusing briefs and assistance with toileting. Resident stated he did not remember what he was doing. Assessed resident for injuries. Small abrasion approximately 1 cm [centimeter] to right hand 3rd knuckle and right lateral foot.Interventions for this fall included: Provide frequent reminders for resident to ask for assistance. It should be noted that an invention on 3/28/25 states, Education provided to resident for utilizing staff to assist with transfers when needed.d. On 4/13/26 at 10:46 PM, a health status note documented, Resident noted to have a bruise on the right forehead. When asked about the injury, the resident stated he does not know what happened and does not recall the cause.It should be noted no interventions were located for this incident.e. On 5/8/26 at 1:49 PM, an event note documented, on 4/24/26 at 4:20 PM, Cut near his eye.Refused treatment to clean wound.Pt [patient] stated that he fell off his bed and received that cut near his eye from the floor.Interventions for this fall included: Anticipate and meet resident's needs. Be sure call light is within reach and encourage resident to use it for assistance as needed. It should be noted that an invention on 4/26/25 states, Be sure [resident 24's] call light is within reach and encourage the resident to use it for assistance as needed.f. On 5/8/26 at 1:59 PM, an event note documented, on 4/27/26 at 11:30 AM, Resident had an unwitnessed fall at 1135 [11:35 AM] today. He was found in his room on the floor by the CNA [certified nursing assistant]. He appeared to have a large open wound on the left side of his forehead, no other injuries noted .Pt was unable to state how he fell or what happened to cause the incident.Pt [patient] education was provided for fall precautions.Interventions for this fall included: Anticipate and meet resident's needs. Be sure call light is within reach and encourage resident to use it for assistance as needed.On 6/4/26 at 12:55 PM, an interview was conducted with the RDCS. The RDCS stated that resident 26 would frequently refuse the interventions that had been care planned for him. The RDCS stated that with resident's 26 recent fall on 5/32/26 they moved him closer to the nursing station for an intervention. 4. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, non-pressure chronic ulcer of foot and acquired absence of right foot.A review of resident 2's care plan focus dated 5/28/25 documented, The resident is at risk for falls r/t [related to] Dementia, diabetes with neuropathy, right diabetic foot ulcer, left below the knee amputation, use of left lower leg prosthetic, anemia, incontinence, use of medications that increase risk for falls, chronic pain. A review of resident 2's medical record revealed the following:On 2/8/26 at 10:25 PM, an incident note documented, Patient had an unwitnessed fall outside while attempting to stand from a chair. Patient denies head strike. No visible injuries noted. Patient reports knee pain. Interventions for this fall included: Encourage resident to ask for help and wait until getting balance when ambulating.On 2/19/26 at 3:44 PM, an alert note documented, Found resident sitting on floor next to bed. Resident said that she was sitting on her bed reaching down to adjust her sock (right leg) and she slid off of the bed landing on her buttox. [sic] Assessed resident for injuries. No bruising, abrasions or new injuries noted.Interventions for this fall included: Educated staff to ensure they are anticipating needs for resident.On 2/20/26 at 8:51 PM, a health status note documented, Resident was found on the floor in between bed and wheelchair. She was in the fetal position on her right side. She stated she was stransferring [sic] from bed to wheelchair and the wheelchair brakes were not on. She c/o [complaining of] right hip and head pain. Neuros started.Interventions for this fall included: Resident was assessed for pain.On 2/21/26 at 12:36 AM, a transfer to hospital summary documented, Resident was taken to the [name redacted] hospital vis [sic] ambulance.Interventions for this fall included: Resident was assessed for pain. It should be noted that this intervention was used for the fall on 2/20/26.On 3/29/26 at 12:40 AM, a health status note documented, Resident had an unwitnesed [sic] fall in her room. She stated the brakes on her wc were not locked and she fell onto her buttocks. She was found on her buttocks in front of her wc. Assessed for pain and injury. Interventions for this fall included: Re-educated resident to ask for assistance and re-educated staff to anticipate needs. It should be noted that these interventions were used for the falls occurring on 2/8/26 and 2/19/26.On 3/29/26 at 1:35 AM, a health status note documented, Resident had and [sic] unwitnessed fall in her room. She stated swhe [sic] was getting onto the toilet and slipped on her pant leg. She stated she hit her head on the sink. Assessed for pain and injury. Interventions for this fall included: Re-educated resident to ask for assistance and re-educated staff to anticipate needs. It should be noted that these interventions were used for the falls occurring on 2/8/26, 2/19/26, and 3/29/26.On 6/3/26 at 9:54 AM, an interview was conducted with Certified Nursing Assistant (CNA ) 1. CNA 1 stated that resident 2 was a fall risk because she was an amputee. CNA 1 stated that the only fall intervention that she knew of for resident 2 was to keep her room clutter free. On 6/3/26 at 1:45 PM, an interview was conducted with the Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 2 could be a fall risk and that she had fallen in the past. LPN 1 stated that she could not remember if resident 2 had gotten injured from any of her falls. LPN 1 stated that she did not know of any fall interventions that resident 2 had. On 6/3/26 at 2:12 PM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that resident 2 had a history of falls and was someone who could not care for themselves. The RDCS stated that resident 2 had a few falls where resident 2 grabbed for things and tried to self-transfer. The RDCS stated that resident 2 was able to be educated, but oftentimes over-estimated her abilities. The RDCS stated that fall interventions should not be repeated and assessments were not interventions for falls. On 6/3/26 at 2:28 PM, an interview was conducted with the Administrator (ADM). The ADM stated that if a resident fell then they should have a unique intervention for each fall and interventions should not be repeated even if multiple falls occurred on the same day.

Based on interview, record review, and facility policy review, the facility failed to ensure that the pharmacist's monthly drug regimen review recommendations were documented and acted upon. Specifically, for 1 out of 19 residents reviewed the facility failed to ensure that the pharmacist's March 2026 recommendation to update order from as needed to a scheduled medication was addressed. This resulted in a three-month delay until June 2026 without any medication update. Resident Identifier: 13.Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included radiculopathy, lumbosacral region and major depressive disorder.Review of resident 13's medical record was completed on 6/1/26 through 6/4/26.On 3/16/26, a physician recommendation provided by the pharmacist revealed the following, [Resident 13] has an order for sodium fluoride toothpaste to be used as needed. This toothpaste is recommended to be used daily. Recommend changing the order to scheduled daily instead of as needed. A review of the facility's Medication Regimen Review Policy implemented on 4/11/25 revealed the following: Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.A review of ordered medication reviewed the following:On 2/10/26, Sodium Fluoride Gel 1.1 % 1 application dental every 12 hours as needed for sensitivity was started and discontinued on 6/2/26.On 6/3/26, Sodium Fluoride Gel 1.1 % 1 application dental every day shift for dental care, was started.On 6/4/26 at 12:55 PM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that the Director of Nursing (DON) was responsible for any follow-up regarding the pharmacist's monthly recommendations, which includes updating any physician orders to reflect the recommendation. The RDCS stated that the previous DON was not following the facility's policy regarding pharmacy recommendations.

Based on interview and record review it was determined the facility did not provide or obtain laboratory services to meet the needs of the residents. Specifically for 2 out of 19 sampled residents a resident did not have his Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lipid Panel and a Valproic Acid level drawn every 6 months and another resident did not have their monthly CBC lab drawn. Resident Identifiers: 12 and 27.1. Resident 12 was admitted [DATE], readmitted [DATE] with diagnoses including, but not limited to schizophrenia, chronic diastolic (congestive) heart failure, and unspecified intracranial injury. Resident 12's medical record was reviewed from 6/1/26 through 6/4/26.A physician's order dated 9/29/25 stated, Draw CBC [complete blood count] monthly r/t [related to] clozaril use. This order was discontinued 3/6/26.A physician's order dated 3/6/26, stated, Draw CBC monthly r/t clozaril use. This order was still active during the dates the resident's medical record was reviewed. There were no monthly CBC laboratory results in the resident's medical record for the months of June 2025, July 2025, August 2025, February 2026, April 2026, and May 2026.On 6/3/26 at 10:47 AM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that laboratory results should be uploaded under the Documents tab or the Results tab in the electronic medical record. The RDCS stated that if laboratory results were not uploaded under either of these tabs, then it was likely that the facility did not have a record of the labs being completed. 2. Resident 27 was admitted to the facility on [DATE] with diagnoses which included, cerebral infarction, generalized anxiety disorder, adjustment disorder with depressed mood, and insomnia.A physician's orders dated 2/6/24 documented, Routine labs: Draw CBC, CMP [Comprehensive Metabolic Panel], Valproic Acid Level q [every] 6 Months in February and August. Draw Lipid Panel in February.Labs drawn in February 2026 were not located in resident 2's medical record.On 6/3/26 at 11:09 AM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that valproic acid levels should be drawn every 6 months on residents. The RDCS stated that resident 27's valproic acid level was drawn on 5/28/26. On 6/4/26 at 1:17 PM, a follow-up interview was conducted with the RDCS. The RDCS stated that there were standing orders for routine labs. The RDCS stated she had completed an audit of residents and found out that many residents were not getting routine labs drawn. The RDCS stated that she informed the previous Director of Nursing (DON) that resident 27 had not had his labs drawn in February and instructed him to notify the medical provider to see if she still wanted labs drawn. The RDCS stated that there was not a progress note documenting that the previous DON contacted the medical provider. The RDCS stated that the labs drawn in May 2026 for resident 27 were supposed to be the labs that needed to be drawn in February 2026. [Cross refer to F773]

Based on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner, or clinical nurse specialist. Specifically for 2 out of 19 sampled residents, a resident had a complete blood count (CBC), comprehensive metabolic panel (CMP), valproic acid level, and lipid level collected without a physician's order. Additionally, a resident had a glycated hemoglobin (HgbA1C), CMP, CBC with differential, prolactin, valproic acid, and lipid panel collected without a physician's order. Resident identifiers: 19 and 27.1. Resident 27 was admitted to the facility on [DATE] with diagnoses which included, cerebral infarction, generalized anxiety disorder, adjustment disorder with depressed mood, and insomnia.On 5/28/26 at 5:32 PM, a health status note documented, Late Entry: CBC w/Diff [differential] and CMP results received and reviewed by provider.It should be noted that an order for lab tests was not located in resident 27's medical record. On 6/4/26 at 1:17 PM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that there were standing orders for routine labs. The RDCS stated she had completed an audit of residents and found out that many residents were not getting routine labs drawn. The RDCS stated that she informed the previous Director of Nursing (DON) that resident 27 had not had his labs drawn in February and instructed him to notify the medical provider to see if she still wanted labs drawn. The RDCS stated that there was not a progress note documenting that the previous DON contacted the medical provider. The RDCS stated that the labs drawn in May 2026 for resident 27 were supposed to be the labs that needed to be drawn in February 2026. 2. Resident 19 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, unspecified convulsions and diabetes mellitus due to underlying condition with diabetic neuropathy.Review of resident 19's medical record was completed on 6/1/26 through 6/4/26.On 5/28/26 the following laboratory results were located in resident 19's medical chart:Hemoglobin A1C [HgbA1C]CMP CBC with differentialProlactinValproic Acid LevelLipid PanelIt should be noted that an order for lab tests was not located in resident 19's medical record. On 6/4/26 at 12:55 PM, an interview was conducted with the RDCS. The RDCS stated that a physician's order is needed in order to draw labs. The RDCS stated that she was unable to find an order for resident 19 for the labs that were drawn on 5/28/26.

Based on interview and record review, the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, for 2 out of 19 sampled residents a resident had an incorrect medical diagnosis and another resident had an incorrect diagnosis for a medication given. Resident identifiers: 6 and 27.1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease, adult failure to thrive, mild cognitive impairment, and major depressive disorder.A review of resident 6's Minimum Data Set, dated [DATE] documented that resident 6 had a diagnosis of Schizophrenia. A review of resident 6's medical record revealed that resident 6 did not have a Preadmission Screening and Resident Review (PASRR) level 2 with a diagnosis of Schizophrenia.On 6/3/26 at 1:29 PM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that resident 6 was screened out for a PASRR 2 because he did not have any mental health issues. The RDCS stated that she would have to have the schizophrenia diagnosis removed from resident 6's MDS because she was unable to remove them.2. Resident 27 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, insomnia, muscle weakness, dysphagia, generalized anxiety disorder, adjustment disorder with depressed mood, aphasia, cognitive communication deficit, and essential hypertension. A review of resident 27's orders revealed a physician's order started on 7/9/25 for Bromocriptine Mesylate Oral Tablet 2.5 MG (milligrams) Give 20 mg by mouth two times a day for DM (diabetes mellitus). It should be noted that resident 27 did not have a diagnosis for diabetes mellitus.On 6/3/26 at 10:53 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 27 did not have diabetes and did not take any medications for diabetes.On 6/3/26 at 10:56 AM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that resident 27 did not have a diagnosis for diabetes mellitus and was unsure why he was taking bromocriptine. On 6/3/26 at 11:05 AM, a follow-up interview was conducted with the RDCS. The RDCS stated that resident 27 was admitted with the medication for diabetes and she would continue to look into why he was taking the medication.

Based on observation, interview, and record review it was determined that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 2 of 19 sampled residents, Enhanced Barrier Precautions [EBP] were not being implemented as ordered. Resident identifiers: 2 and 27.1. Resident 2 was admitted on [DATE] with diagnoses which included, non-pressure chronic ulcer of foot, sepsis, and acquired absence of right foot.On 6/1/26 at 9:02 AM, an observation and interview were conducted with resident 2. There was no observed EBP signage or Personal Protective Equipment (PPE) available for use in the resident's room. Resident 2 was observed to have her right foot wrapped in a bandage. Resident 2 stated that she required assistance from staff with showering and staff did not wear a gown when assisting her.A review of resident 2's physician orders started on 3/11/26 documented, ENHANCED BARRIER PRECAUTIONS: PPE required for high direct care resident contact activities. Indication for use: wounds every shift.On 6/3/26 at 9:54 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 2 was mostly continent, but there were times that she did have incontinent episodes and that she needed to have her brief changed. CNA 1 stated that the CNAs performed about 75% of the work when showering resident 2. CNA 1 stated that resident 2 was not on EBP and that she did not wear a gown when assisting resident 2. On 6/3/26 at 1:45 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 2 had a wound on her foot that was being managed by podiatry. LPN 1 stated that resident 2 only needed EBP when her dressing was changed, but that was done at the podiatrist's office. On 6/3/26 at 2:29 PM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that resident 2 should be on EBP because she had a chronic wound. The RDCS stated that staff should be wearing a gown and gloves when providing high contact care and there should be signage on her door.2. Resident 27 was admitted to the facility on [DATE] with diagnoses which included, venous insufficiency, non-pressure chronic ulcer of right lower leg, and non-pressure chronic ulcer of left lower leg.On 6/1/26 at 9:44 AM, an observation was made of resident 27. Resident 27 had swollen legs with red marks and open areas. Resident 27 had red marks and scabs to his upper left arm and shoulder. Resident 27 was bleeding from a scratch behind his right ear and neck. There were no visible bandages on resident 27's open areas of the skin. There was no EBP signage on the door and no PPE available for use in his room.A review of resident 27's physician orders revealed the following orders: Open area on left leg: Cleanse with wound wash and pat dry. Apply collagen, alginate, and cover with border dressing. Date started: 12/6/25 Wound care to left shoulder: cleanse with wound wash, pat dry. Apply skin prep and cover with border dressing. Change daily and PRN [as needed] for soiling or accidental removal. Start date: 1/24/26 Open area on right buttock: Cleans (sic) with wound wash and pat dry. Apply collagen and cover with protective dressing. Date started: 4/14/26 ENHANCED BARRIER PRECAUTIONS: PPE required for high-contact direct care activities R/T [related to] (wounds). Start date: 6/1/26On 6/3/26 at 9:54 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 27 had wounds to his body from scratching. CNA 1 stated that resident 27 needed a Hoyer lift for transferring and was unable to move himself. CNA 1 stated that resident 27 was incontinent. CNA 1 stated that she only wore gloves when assisting resident 27.On 6/3/26 at 10:56 AM, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that resident 27 had chronic wounds and had an active order for EBP. The RDCS stated that resident 27 should have signage that stated he was on EBP. On 6/4/26 at 9:41 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 27 was fully dependent on staff for his activities of daily living. CNA 2 stated that resident 27 used a Hoyer lift and was incontinent. CNA 2 stated that resident 27 had open wounds on his legs and left shoulder and had them for some time. CNA 2 stated that resident 27 scratched at his wounds. CNA 2 stated that she needed to wear a gown and gloves when caring for resident 27.

Based on interview and record review, it was determined for 1 of 19 sampled residents, that the facility did not ensure that laboratory results were filed in the resident's clinical record. Specifically, the facility did not include 6 monthly physician ordered complete blood counts in a resident's medical record. Resident Identifier: 12Resident 12 was admitted [DATE], readmitted [DATE] with diagnoses including, but not limited to schizophrenia, chronic diastolic (congestive) heart failure, and unspecified intracranial injury. Resident 12's medical record was reviewed from 6/1/26 through 6/4/26.A physician's order dated 9/29/25 stated, Draw CBC [completed blood count] monthly r/t [related to] clozaril use. This order was discontinued 3/6/26.A physician's order dated 3/6/26, stated, Draw CBC monthly r/t clozaril use. This order was still active during the dates the resident's medical record was reviewed. There were no monthly CBC laboratory results in the resident's medical record for the months of June 2025, July 2025, August 2025, February 2026, April 2026, and May 2026.On 6/3/26 at 10:47am, an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that laboratory results should be uploaded under the Documents tab or the Results tab in the electronic medical record. The RDCS stated that if laboratory results were not uploaded under either of these tabs, then it was likely that the facility did not have a record of the labs being completed.

Based on interview, the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. Specifically, the facility did not employ a full-time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of nutrition services. Findings included: On 5/27/25 at 8:55 AM, an initial walk-through of the kitchen was completed. An interview was conducted with the DM who stated he had not completed the training required to serve as the DM. The DM stated that he had been working as the DM for two months. The DM stated that the RD did not work at the facility full-time. The DM stated that he was in the process of obtaining his certifications. On 6/2/25 at 8:53 AM, a follow-up interview was conducted with the DM. The DM stated that he was taking his ServSafe test in two days and he would be taking the Certified Dietary Manager course in the next few weeks On 6/2/25 at 8:59 AM, an interview with the Administrator (ADM) was conducted. The ADM stated that he was aware that the DM was not certified as a dietary manager or with ServSafe. The ADM stated when their previous DM resigned, they moved the current DM to the position. The ADM stated that they have enrolled the DM for the certified dietary manager course, and he was taking his ServSafe test soon.

4. Resident 26 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, cognitive communication deficit, hemiplegia and hemiparesis of left side, dysphagia, aphasia, and hypertension. Resident 26's medical record was reviewed. On 12/26/24, resident 26 had a physician order initiated for a laboratory draw for a Prothrombin Time (PT) and International Normalized Ratio (INR). The laboratory results were not located in resident 26's medical record. On 5/29/25, the facility emailed a copy of the PT/INR laboratory results for the 12/26/24, order. On 5/29/25 at 2:47 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the 12/26/24, INR was printed from the laboratory website and was not located in resident 26's medical record. On 6/2/25 at 7:40 AM, a follow-up interview was conducted with the ADM. The ADM stated that the laboratory process was that the DON created a calendar for the labs with the dates of the draws. The DON would then follow-up on the results and notify the physician of the results. The ADM stated that the DON would then enter any new orders obtained from the physician after reviewing the lab results. The ADM stated that the DON would document in a progress note the lab results and then would upload the results into the medical record. The ADM stated that the results should be uploaded into the medical record within a week of receiving them back from the laboratory. Based on interview and record review, the facility did not file in the resident's clinical record the laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, for 4 out of 14 sampled residents, the residents did not have laboratory results filed in their medical record. Resident identifiers: 12, 15, 22, and 26. Findings included: 1. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included respiratory failure, unspecified dementia, muscle weakness, and bipolar disorder. Review of resident 12's record was completed on 5/27/25 through 6/2/25. On 12/6/24 at 11:50 AM, a health status note revealed the following. . Draw [Vitamin] B12, Folate and Iron panel for Anemia. On 12/6/24, a physician's order revealed to draw a Vitamin B12, Folate, and Iron blood panel one time only for Anemia for 1 Day was completed. On 12/7/24 at 9:58 AM, a health status note revealed the following. Received Vitamin B12, Folate, and Iron levels. MD [medical doctor] have been notified . It should be noted that no laboratory results could be located in the medical record. 2. Resident 15 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included type 1 diabetes mellitus, generalized anxiety disorder, chronic kidney disease stage 3, complete traumatic amputation of two or more left toes, bipolar disorder, and suicidal ideations. Review of resident 15's record was completed on 5/27/25 through 6/2/25. On 12/16/24 at 1:54 PM, a MD Progress Note revealed that resident 15 has been having muscle cramps. He wonders if his electrolytes were off. Muscle cramps - will order Basic Metabolic Panel (BMP). On 12/18/24, a physician's order revealed to draw a BMP and a magnesium level. One time, only for 1 day was completed. On 12/20/24 at 12:00 AM, an encounter progress note revealed that labs were reviewed. It should be noted that no laboratory results could be located in the medical record. 3. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included intracranial injury without loss of consciousness, type 2 diabetes mellitus, mixed receptive-expressive language disorder, dementia with mood disturbance and agitation, and major depressive disorder with psychotic symptoms. Review of resident 22's record was completed on 5/27/25 through 6/2/25. On 12/18/24, a physician's order revealed to draw a complete blood count with differential, comprehensive metabolic panel, and Valproic Acid one time only was completed. On 4/10/25, a physician's order revealed to draw a glycated hemoglobin, thyroid stimulating hormone, Lipid Panel, and Prolactin. One time, only for 1 day was completed. It should be noted that no laboratory results could be located in the medical record. On 5/29/25 at 2:47 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the lab results requested were uploaded to the resident's medical record today.

Based on interview and record review, it was determined, for 1 of 14 sampled residents, the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made to the administrator, the State Survey Agency (SSA), and Adult Protective Services (APS). Specifically, the facility investigations for a residents allegation of sexual abuse and an elopement did not have a documented date that APS was notified. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, unspecified convulsions, diabetes mellitus, asthma, hypothyroidism, restless leg syndrome, and dysphagia. Resident 1's facility abuse investigations were reviewed. On 5/2/24 at 2:47 PM, the facility Form 358 documented that the local Police Department (PD) notified the facility that they found resident 1 wandering one street north of the facility and he seemed confused. The local PD reported that they transported resident 1 to a local area hospital for evaluation. The form documented that APS was notified at 3:15 PM, but no date was documented for the notification. On 12/6/24 at 8:00 PM, the facility Form 358 documented that resident 1 reported to the floor nurse that he had rectal pain and that he had been raped. The form documented that resident 1 was unable to recall a timeline or sequence of events, was unable to provide details of the alleged perpetrator, and was unable to provide details of the event. The form documented that APS was notified at 9:15 PM, but no date was documented for the notification. On 5/28/25 at 12:08 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the previous ADM conducted the investigations and documented the APS notification. The ADM stated that he did not have any other documentation for the APS notification. The ADM stated that he reached out to the previous ADM to see if he had documentation of APS notification. The ADM also stated that he had submitted a Government Records Access and Management Act request to APS for copies of the notification verification.

Based on interview and record review, it was determined, for 1 out of 14 sampled residents, the facility did not make prompt efforts to resolve grievances the resident may have or maintain evidence demonstrating the results of all grievances. Specifically, a resident reported that his wallet and all personal documents were missing and requested assistance with obtaining new identification (ID) cards and the facility did not maintain evidence demonstrating the grievance investigation and decision. Resident identifier: 18. Findings included: Resident 18 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included schizophrenia, tremor, stimulant abuse, chronic obstructive pulmonary disease, peripheral vascular disease, and hypertension. On 5/27/25 at 8:54 AM, an interview was conducted with resident 18. Resident 18 stated that his wallet was missing with his identification and Medicaid card. Resident 18 stated that he informed the Resident Advocate (RA) and was told that she would assist him with obtaining new identification. Resident 18 stated that the RA never got back to him about how to get a new ID. Resident 18's medical record was reviewed. On 7/20/22, the personal inventory list documented one wallet in possession of the resident. The list did not document the contents of the wallet. On 9/13/23 at 6:58 AM, resident 18's progress note documented, It was brought to RA's attention that [Resident 18's] wallet was reported stolen in March. The investigation was done properly. [Resident 18] said that there had been some contacts and his ID in the wallet. RA found a caseworker's contact in his admission packet, and added that to his chart. RA asked [Resident 18] if there were any other contacts that he can think of, and he said no. RA is going to replace his wallet and get him a new ID. The grievance binder was reviewed from September 2023 through May 2025. No grievances were identified for resident 18 that pertained to the missing wallet and identification cards. Review of the facility Resident and Family Grievances policy documented that the facility would make prompt efforts to resolve grievances. Prompt efforts to resolve included facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. The policy documented under procedure that The Grievance Officer will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. The policy stated that Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. The policy was implemented on 4/11/25. On 5/28/25 at 7:51 AM, an interview was conducted with the RA. The RA stated that she had worked at the facility for two years and was in charge of the grievance investigations. The RA stated that she believed resident 18's wallet was replaced but she does not think she replaced his ID. The RA stated that sometimes she kept the ID in her office depending on if the resident requested it. The RA stated that she did not obtain new identification cards for the resident. The RA stated that this was something that she would typically start a grievance investigation for. The RA was observed to review the grievances to locate any investigation for resident 18's missing wallet and ID. The RA stated she did not have a grievance investigation for the missing property. The RA stated that she would assist the resident with obtaining a new ID. The RA stated she would contact the Social Security Administration to obtain a new card and then attempt to get a new state ID. The RA stated the timeframe for initiating a grievance investigation was within a week, and that this was something that should have been resolved. The RA stated that she would reach out to resident 18's case worker to obtain a new Medicaid card and would start the process of obtaining a new birth certificate and Social Security card.

Based on interview and record review, the facility did not allow the resident the right to formulate an advance directive. Specifically, for 1 out of 14 sampled residents, a resident that did not have a Physician Orders for Life-Sustaining Treatment (POLST) or Advance Directive was documented as full code in their medical record. Resident identifier: 32. Findings included: Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, acute respiratory failure with hypoxia, chest pain, pleural effusion, chronic obstructive pulmonary disease, asthma, atrial fibrillation, type 2 diabetes mellitus with complications, secondary hypertension, and shortness of breath. Resident 32's medical record was reviewed. A physician's order dated 10/8/24, documented that resident 32 was a full code, full treatment, and a trial period of artificial nutrition. On 10/8/24 at 5:16 PM, an admission Progress Note documented . POLST status: . was blank. An Advanced Directive or POLST form were unable to be located in the medical record. On 5/28/25 at 1:15 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the POLST form was completed on admission. The DON stated once the POLST form was completed the staff would turn them into her and she would give them to the Medical Director (MD) to be signed. The DON stated the Resident Advocate would audit the POLST form monthly. On 5/29/25 at 1:44 PM, an interview was conducted with the Administrator (ADM). The ADM confirmed that he was unable to locate resident 32's POLST form. The ADM stated that he had the MD signed a new POLST form for resident 32. The facility policy Residents' Rights Regarding Treatment and Advance Directives was reviewed. The policy was implemented on 4/11/25. Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. 4. The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. 5. The facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant health care decisions. 6. The facility will define and clarify medical issues and present them to the resident or legal representative as appropriate. 7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. 8. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.

Based on interview and record review, it was determined, for 1 of 14 sampled residents, the facility did not ensure that residents who use psychotropic drugs received a gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, a resident did not have an attempted GDR for Depakote and the Trazodone did not have a rationale for the clinical contraindication. Resident identifier: 26. Findings included: Resident 26 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, cognitive communication deficit, hemiplegia and hemiparesis of left side, dysphagia, aphasia, and hypertension. Resident 26's medical record was reviewed. Resident 26's physician orders revealed the following: a. On 2/6/24, an order was initiated for Trazodone Oral Tablet 50 milligram (mg), give 50 mg by mouth at bedtime related to insomnia. b. On 2/6/24, an order was initiated for Divalproex Sodium Oral Tablet Delayed Release 125 mg, give 250 mg by mouth two times a day for increased behaviors. On 5/19/25, a Clinical Contraindication GDR for Trazodone was completed. The form documented the target symptom(s) or distressed behavior was insomnia. The form had areas listed for the reason of the contraindication but none of the reasons were checked or indicated. No documentation could be found for an attempted GDR or clinical contraindication for the use of the Divalproex. On 5/29/25 at 2:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 26's behaviors were impatience, wanting assistance immediately, some yelling out at times, and a history of hitting and aggressive behaviors. LPN 2 stated resident 26 had been physically and verbally aggressive and had tried to hit the Certified Nursing Assistants in the past. LPN 2 stated that the Divalproex was for resident 26's behaviors. LPN 2 stated that they monitored resident 26's behaviors on the Treatment Administration Record for agitation every shift. On 5/29/25 at 2:47 PM, an interview was conducted with the Corporate Resource Nurse (CRN) and the Director of Nursing (DON). The CRN stated that she filled out resident 26's clinical contraindication form for the Trazodone, the provider then signed it, and the DON needed to fill in the form. The CRN stated that the GDR was discussed during the psychotropic meetings. The CRN stated that she filled out the GDR form for those resident's that needed a GDR and the physician brought those forms to the psychotropic meeting. The DON stated that the physician should document a rationale for the clinically contraindication to the GDR. The DON stated that the physician note dated 3/17/25, documented that resident 26 was prescribed Depakote for behaviors. The DON stated that they did not attempt a GDR for the Depakote and it was used for agitation.

Based on interview and record review, it was determined, for 1 of 14 sampled residents, the facility did not ensure that all residents received the treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, a resident had complaints of constipation that were not treated with the facility bowel protocol. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of schizophrenia, Parkinsonism, generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, congestive heart failure, peripheral vascular disease. On 5/27/25 at 9:35 AM, an interview was conducted with resident 4. Resident 4 stated that within the last two months he had experienced some constipation and went a long time without a bowel movement (BM). Resident 4 stated that he used to take Milk of Magnesia (MOM) for constipation. Resident 4 stated that his last BM was on Saturday. Resident 4's medical record was reviewed. Resident 4's physician orders revealed the following: a. On 3/29/24, an order was initiated for MOM Suspension 400 milligrams (mg)/5 milliliters (ml), give 30 ml by mouth as needed for Constipation. b. On 11/26/24, an order was initiated for MOM Oral Suspension 400 mg/5 ml, give 30 ml by mouth every 24 hours as needed for constipation use on day 3 of no BM. Resident 4's May 2025 Medication Administration Record (MAR) documented that the MOM was not administered during the month. Review of resident 4's bowel elimination pattern for the last 30 days revealed: a. On 5/8/25 through 5/13/25, the task documented no BM. The resident went six days without a BM. b. On 5/23/25 through 5/25/25, the task documented no BM. The resident went three days without a BM. On 10/1/18, resident 4 had a care plan initiated for Activities of Daily Living self-care performance deficit related to schizophrenia. The care plan documented under toileting that resident 4 used a urinal for bladder elimination. The care plan did not address resident 4's bowel elimination patter nor treatment for constipation. The care plan focus area for toileting was last updated on 7/27/23. The facility bowel protocol documented that any resident who had gone six full nursing shifts or three days without a bowel movement needed to have the bowel protocol initiated. The protocol documented that after six shifts without a BM staff were to administer Step 1 of the protocol, MOM 30 ml by mouth. The nurse on shift must document whether milk of magnesia was effective or not in producing a bowel movement before shift's end. The protocol Step 2 documented that if the MOM did not produce a BM within 12 hours or the resident refused the next nurse on shift needed to administer a Dulcolax suppository 10 mg rectally. The nurse on shift must document whether the suppository was effective or not in producing a bowel movement before shift's end. The protocol Step 3 documented that if the Dulcolax did not produce a BM within 12 hours of administration the next nurse on shift needed to administer a Fleets enema rectally. The nurse on shift must document whether the enema was effective or not in producing a bowel movement. If no bowel movement was produced, the nurse on shift needs to contact the medical director for further instructions prior to the shift's end. On 5/29/25 at 7:59 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated she did not know where the bowel protocol was located but she thought they had standing orders for the protocol. LPN 2 stated that after three days without a bowel movement they were to administer treatment per the bowel protocol. LPN 2 stated that the Director of Nursing (DON) assisted with tracking of resident bowel movements. On 5/29/25 at 8:07 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that she would monitor the resident's bathroom activity and would check the toilet if she did not assist the resident with toileting. CNA 3 stated that resident 4 was independent with toileting and she would just ask him if he had a bowel movement. CNA 3 stated that if the resident did not have a BM she would notify the nurse. CNA 3 stated that she documented the residents bowel movements in the electronic medical record. On 5/29/25 08:14 AM, an interview was conducted with he DON. The DON stated that they had a bowel protocol that should be implemented if a resident did not have a BM after three days. The DON stated that they had a standing order for MOM for constipation and the nurses and herself tracked resident bowel movements. The DON stated that she generated a report and conducted a daily audit of all resident bowel movements. The DON stated that if there were no documented bowel movements she would ask the staff to check with the resident if they were continent and ask if they had a BM. The DON stated if the resident was not able to inform the staff of their BM then they would implement the bowel protocol. The DON stated that the nurse would inform her if the resident did not have a BM and then they would document in the medical record what treatment was provided. The DON stated that resident 4 did not like to take the MOM. The DON stated that it should have been documented in the MAR if the MOM was administered or refused. The DON reviewed resident 4's MAR and stated that she did not see that the MOM was refused. The DON stated that she did not see any other documentation in the nurse progress notes about a refusal or that resident 4 had a BM. The DON stated that per the bowel protocol the nurse should have administered the MOM on day three of no BM, administered a Dulcolax suppository on day four of no BM, and administered a Fleets enema on day five of no BM. The DON stated that after all treatment had been administered and were not successful they should have notified the provider.

Based on interview and record review, it was determined, for 1 of 14 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframe's to meet the resident's medical, nursing, and psychosocial needs that were identified in the comprehensive assessment. Specifically, the resident's care plan did not address the resident's bowel elimination pattern. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of schizophrenia, Parkinsonism, generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, congestive heart failure, peripheral vascular disease. On 5/27/25 at 9:35 AM, an interview was conducted with resident 4. Resident 4 stated that within the last two months he had experienced some constipation and went a long time without a bowel movement (BM). Resident 4's medical record was reviewed. Resident 4's physician orders revealed orders for Milk of Magnesia suspension for the treatment of constipation. The May 2025 Medication Administration Record documented that the Milk of Magnesia was not administered during the month. Review of resident 4's bowel elimination pattern for the last 30 days revealed: a. On 5/8/25 through 5/13/25, the task documented no BM. The resident went six days without a BM. b. On 5/23/25 through 5/25/25, the task documented no BM. The resident went three days without a BM. On 10/1/18, resident 4 had a care plan initiated for Activities of Daily Living (ADLs) self-care performance deficit related to schizophrenia. The care plan documented under toileting that resident 4 used a urinal for bladder elimination. The care plan did not address resident 4's bowel elimination pattern nor treatment for constipation. The care plan focus area for toileting was last updated on 7/27/23. On 5/29/25 at 8:14 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the bowel and bladder elimination would be addressed in the care plan under ADLs for toileting. The DON stated that the care plan currently only addressed the resident's urinary elimination.

Based on interview and record review, it was determined, for 2 of 14 resident's sampled, the facility did not ensure that the resident's transfer or discharge was documented in the resident's medical record and the information was communicated to the receiving provider included contact information for the practitioner responsible for the care of the resident; resident representative contact information; Advanced Directive information; all special instructions or precautions for ongoing care; a comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, the resident's medical record did not contain documentation of what information was sent to the receiving provider for a transition of care. Resident identifiers: 7 and 15. 1. Resident 7 was admitted to the facility on [DATE] and was re-admitted to the facility on [DATE] with diagnoses which included Human Immunodeficiency Virus, generalized anxiety disorder, paranoid schizophrenia, and viral hepatitis C. Resident 7's medical record was reviewed. On 2/28/25 at 7:38 AM, a Health Status Note documented, Resident has been very anxious this AM, pacing around the facility and calling several people on the phone. He called 911 and requested to go to [local area hospital] complaining of brain pain. Resident showed no S/S [signs and symptoms] of Acute distress and did not mention any issues to staff before calling 911. Sent resident with EMS [emergency medical services] to [name of hospital]. Resident 7's medical record revealed no documentation of a transfer/discharge summary or what information was sent to the receiving provider. 2. Resident 15 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included type 1 diabetes mellitus, generalized anxiety disorder, chronic kidney disease stage 3, complete traumatic amputation of two or more left toes, bipolar disorder, and suicidal ideations. Review of resident 15's record was completed on 5/27/25 through 6/2/25. On 1/25/25 at 2:47 PM, a transfer to hospital summary note revealed that the patient reported feeling dizzy to the nurse, nurse went and assessed him, blood sugar 430, blood pressure (BP) 100/70, respiration rate (RR) 14, temperature (T) 97.0, heart rate (HR) 58, oxygen saturation 70 at room air (RA), patient quickly became pale and unresponsive, continue with HR, 911 was called to the facility, staff stayed with patient monitoring him, places oxygen via nasal cannula at 5 liter (L), saturations eventually went up to 90 at 5L, patient became somewhat more responsive, alert/oriented to self and situation, patient was able to follow simple commands of squeezing nurse's hand, no facial asymmetry noted. Paramedics transfer resident to hospital. Medical Doctor (MD) notified of the incident. On 2/18/25 at 5:11 PM, a health status note revealed the following. Patient reported to nurse the feeling of collapse and right side weakness, he stated he could not walk due to the weakness, he states not feeling those symptoms before. Nurse assessed patient for other symptoms to rule out possibility of stroke, no signs of facial drooping or asymmetry, equal strength of hands, no confusion, patient alert and oriented to person, place, time, and situation consistent with baseline, patient talkative, wheeling himself on manual wheelchair with both hands, BP 180/95, RR 18, T 97.0, HR 88, and oxygen 97% RA, per patient request he would like to go to the emergency department for further assessment, house MD has been notified. Resident 15's medical record revealed no documentation of a transfer/discharge summary or what information was sent to the receiving provider. On 5/29/25 at 9:29 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that she would notify the physician of the resident's change in condition and then she would contact EMS for a transfer to the hospital. LPN 2 stated that she would notify management and the family of the transfer. LPN 2 stated that she would give report to EMS and provide them with copies of a transfer/discharge sheet, order summary, recent physician note, recent labs, and a copy of the Physician Orders for Life Sustaining Treatment (POLST). LPN 2 stated that she would document in a progress note the resident's change in condition, who was contacted and what assessment and treatment that she provided. LPN 2 stated that she would also document what paperwork was sent with the resident to the receiving provider. LPN 2 stated that there was a progress note template that had a spot for what documentation was sent to the receiving provider. On 5/29/25 at 10:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the process for a transfer was to print the discharge/transfer report, the order summary, and a face sheet which contains the POLST information to send with EMS. The DON stated that the nurse should document in a progress note the event details and need for transfer, any orders received from the provider, notification of management and Power of Attorney if applicable. The DON stated that the progress note should also include the assessment and any recent vital signs. The DON stated that they did not always document what documentation was sent to the receiving provider. The DON stated that if it was not documented they would not know what was sent to the receiving provider, and if a transfer/discharge assessment was not in the chart then it was not completed at the time of the event.

Based on observation, interview, and record the review, it was determined, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 18 sampled residents, a resident that was observed and verbally expressed their pain was not provided pain medication. In addition, there was a delay in the facility Medical Doctor (MD) responding to the nurses message regarding resident 33's pain. Resident identifier: 33. Findings included: On 9/10/23 at 11:43 AM, an observation of resident 33 was conducted. Resident 33 was observed in a wheelchair at the nurses station and stated to the Licensed Practical Nurse (LPN) that something needed to happen with his pain because he could not stand it anymore and he was not getting any sleep. Resident 33 also stated that he had ascites. The LPN was observed to palpate resident 33's stomach. Resident 33's stomach was observed to be tight and distended. The LPN and resident 33 were observed to go to resident 33's room. [Note: There were no progress notes regarding the event. Resident 33 did not receive any pain medication. Resident 33 was transported to the hospital on 9/10/23 at 9:45 PM, related to pain.] Resident 33 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cirrhosis of liver, hepatic encephalopathy, schizotypal disorder, polyneuropathy, secondary hypertension, post-traumatic stress disorder, and major depressive disorder. Resident 33's medical record was reviewed on 9/11/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 33 had a Brief Interview for Mental Status (BIMS) score of 9. A BIMS score of 8 to 12 indicated moderately impaired cognition. In addition, the MDS assessment documented that resident 33 had received scheduled, as need (PRN) pain medications, and non-medication interventions. A pain assessment interview was conducted. The Pain Assessment Interview documented that resident 33 had pain and the frequency was almost constantly. The pain made it hard for resident 33 to sleep at night and resident 33's day to day activities were limited due to pain. Resident 33's pain intensity on a numeric rating scale of 00 to 10 was documented as a 6. A care plan Focus initiated on 7/25/23, documented [Resident 33] has acute pain r/t [related to] polyneuropathy, cirrhosis of the liver, generalized weakness, limited mobility. A care plan Goal documented The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The Interventions included: a. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. b. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. c. Notify physician if interventions were unsuccessful or if current complaint was a significant change from residents past experience of pain. The July 2023 Medication Administration Record (MAR) was reviewed. A physician's order dated 7/13/23, documented Tylenol Extra Strength Oral Tablet 500 MG [milligrams] (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. a. On 7/16/23, Tylenol was administered, pain score was 5. b. On 7/20/23, Tylenol was administered, pain score was 5. The August 2023 MAR was reviewed. a. A physician's order dated 8/16/23, documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 4 hours as needed for pain. Discontinued on 8/16/23. On 8/16/23, oxycodone was administered, pain score was 9. b. A physician's order dated 8/19/23, documented oxyCODONE HCl [hydrochloride] Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 8 hours as needed for Pain for 5 Days. Discontinued on 8/24/23. i. On 8/19/23 at 4:15 PM, oxycodone was administered, pain score was 8. ii. On 8/20/23 at 12:21 AM, oxycodone was administered, pain score was 8. iii. On 8/20/23 at 8:48 AM, oxycodone was administered, pain score was 2. iv. On 8/20/23 at 5:40 PM, oxycodone was administered, pain score was 4. v. On 8/21/23 at 1:51 AM, oxycodone was administered, pain score was 8. vi. On 8/21/23 at 10:42 AM, oxycodone was administered, pain score was 7. vii. On 8/21/23 at 9:17 PM, oxycodone was administered, pain score was 5. viii. On 8/22/23 at 5:42 AM, oxycodone was administered, pain score was 5. ix. On 8/22/23 at 3:38 PM, oxycodone was administered, pain score was 7. x. On 8/23/23 at 4:30 AM, oxycodone was administered, pain score was 3. [NAME]. On 8/24/23 at 7:08 AM,oxycodone was administered, pain score was 7. c. A physician's order dated 8/29/23, documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 6 hours as needed for Pain for 1 Day. Discontinued on 8/30/23. i. On 8/29/23 at 11:45 AM, oxycodone was administered, pain score was 8. ii. On 8/29/23 at 7:13 PM, oxycodone was administered, pain score was 8. iii. On 8/30/23 at 7:09 AM, oxycodone was administered, pain score was 6. iv. On 8/30/23 at 3:18 PM, oxycodone was administered, pain score was 8. The September 2023 MAR was reviewed. a. A physician's order dated 7/13/23, documented Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. [Note: There were no administrations documented in September 2023.] b. A physician's order dated 7/13/23, documented Monitor pain level q [every] shift using (0-10 or FLACC [Face, Legs, Activity, Cry, Consolability] scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t [due to] no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. i. On 9/1/23 between 6:00 PM to 6:00 AM, pain score 8. ii. On 9/3/23 between 6:00 PM to 6:00 AM, pain score 8. iii. On 9/4/23 between 6:00 AM to 6:00 PM, pain score 7. iv. On 9/6/23 between 6:00 PM to 6:00 AM, pain score 10. v. On 9/9/23 between 6:00 AM to 6:00 PM, pain score 7. vi. On 9/10/23 between 6:00 AM to 6:00 PM, pain score 6. Interventions provided to resident 33 included scheduled pain medication, repositioning, and rest. vii. On 9/10/23 between 6:00 PM to 6:00 AM, pain score 8. Interventions provided to resident 33 included scheduled pain medication, repositioning, and rest. On 7/13/23, a Pain Assessment documented that resident 33 complains of severe constant pain. Resident 33's acceptable level of pain using the 0-10 pain scale was a 5. On 7/20/23 at 9:39 PM, an Orders - Administration Note documented Note Text: Tylenol Extra Strength Oral Tablet 500 MG Give 1 tablet by mouth every 6 hours as needed for pain pain to mid-right abdominal area. On 7/27/23 at 9:30 PM, an Orders - Administration Note documented Note Text: Monitor pain level q shift using (0-10 or FLACC scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. The notes section documented right side of abdomen. On 8/5/23 at 9:01 PM, an Orders - Administration Note documented Note Text: Monitor pain level q shift using (0-10 or FLACC scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. The notes section documented resident complains of chronic low abdominal pain. On 8/16/23, a physician's order documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 4 hours as needed for pain. The order had a discontinue date of 8/16/23 at 7:22 PM. The facility MD documented a reason for discontinue was Not needed at this time. On 8/17/23 at 3:21 PM, a Health Status Note documented Note Text: DON [Director of Nursing] spoke to [name removed] NP [Nurse Practitioner] with [name of clinic removed] to clarify abx [antibiotic] orders. DON also asked if [name removed] NP would escribe resident's pain medication (Oxycodone 5mg po [by mouth] Q4h [hours] PRN) to [name of pharmacy removed] so they could deliver medication to facility. DON spoke to [name of pharmacy removed] to confirm receipt of escribed order, pharmacy confirmed. Both medications should be sent out with the medication delivery tonight. Provider is aware. On 8/17/23, a physician's order from the local clinic documented oxycodone 5 mg tablet every four hours PRN for pain. [Note: The physician's order was not initiated.] On 8/17/23 at 9:13 PM, an Orders - Administration Note documented Note Text: Monitor pain level q shift using (0-10 or FLACC scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. The notes section documented complains of achy chronic pain with right leg. On 8/19/23 at 4:09 PM, a Health Status Note documented Note Text: Resident reported pain 9/10 related to his TheraSphere treatment, MD have been notified and received order to start Oxycodone 5 mg TID [three times a day] PRN x 5 days, resident has been notified and first dose have been administered. On 8/19/23 at 4:11 PM, a physician's order documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 8 hours as needed for Pain for 5 Days. On 8/21/23 at 2:20 AM, a Health Status Note documented Note Text: Patient compliant with oral ABX, and pain medication q 8 hrs [hours]. Understanding that it is PRN and only available every 8 hrs when requested . No evidence of infection. Patient states a lot of pain, No evidence FLACC to back it up. Teach patient that the pain medication is only available for 5 days. He understands. Kept waking up and asking for the pain med [medication]. Kept reminding him when it was available. On 8/26/23 at 10:51 PM, an Alert Note documented Note Text: Resident states he is still having extreme pain to abdomen (rubbing his upper abdomen from sided to side) d/t his recent theraspere procedure. No S/S [signs or symptoms] of facial grimacing, guarding, difficulty repositioning or ambulating. Notified management and [name of facility MD removed]. On 8/29/23 at 11:25 AM, a Health Status Note documented Note Text: Patient reported still having pain rated 8/10 from the TheraSphere treatment, [name of facility MD removed] was notified, received order from her to contact Radiology at [name of clinic removed] to follow-up with patient's pain concern. Nurse talked to [name removed], NP who believes patient's pain should be improving by now and believes his pain might be due to something else other than theraspere, she ordered one day of oxycodone 5 mg PO x q6h PRN and recommends for patient to discuss his pain with the hepatic team on tomorrow's appointment, House MD and resident have been notified and nurse also discuss with patient NP's recommendation of discussing this concern with the hepatic team, patient stated understanding and is aware of tomorrow's appointment. On 8/29/23 at 11:33 AM, a physician's order documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 6 hours as needed for Pain for 1 Day. On 8/30/23 at 4:24 PM, a Health Status Note documented Note Text: Pt [Patient] had appointment w/ [with] [name of doctor removed] for a liver follow-up. Ultrasound ordered and scheduled d/t resident's abd [abdomen] pain. New prescription sent to pharmacy for Rifaximin. Provider recommends protein shakes TID in addition to small, frequent meals. Resident referred to pain specialist d/t frequent pain. Orders entered for endoscopy/colonoscopy pre-procedure protocol and ultrasound. Protocol discussed with staff and resident to ensure compliance. [Name of facility MD removed] notified. On 8/30/23 at 8:39 PM, an Orders - Administration Note documented Note Text: Monitor pain level q shift using (0-10 or FLACC scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. The notes section documented Unable to get a response on pain at this time. Resident is asked to be left alone and responded with vulgar language. On 9/3/23 at 8:09 PM, an Orders - Administration Note documented Note Text: Monitor pain level q shift using (0-10 or FLACC scale). Acceptable pain level: 4. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions every shift. The notes section documented pt refused Tylenol that was offered. suggested sleep and move positions. On 9/6/23 at 9:40 PM, an Alert Note documented Note Text: 2140 [9:40 PM] Patient complains of pain 10/10 to right abdominal area as he points to several areas on the right side of his abdomen. Patient states he can not handle the pain anymore and does not want to spend another night at [name of facility removed] without getting something for his pain. Vitals- 117/78 BP [blood pressure], 99 P [pulse], 16 R [respirations], O2 [oxygen] Sats [saturations] 99% RA [room air] Patient said he would go to [name of hospital removed] or [name of hospital removed]. Notified [name of facility MD] and DON. On 9/7/23, a Referral To Physicians And Clinics Form documented, Resident returned from ER [emergency room ] on 9/7/2023 @ 0650 [6:50 AM]. No paperwork was sent back to our facility from Hospital ER. Resident reports to nurse that 'they drained fluid from my stomach' but is unsure of how much. Provider was notified. On 9/10/23 at 9:30 PM, a Health Status Note documented Note Text: Resident reported to day shift nurse that he was having severe abdominal pain that could not be relieved. Day shift nurse reported resident's concern to provider. Night shift reported to provider that resident wanted to go to the ER. Provider approved this request. On 9/10/23 at 9:45 PM, a Transfer/Discharge Report documented Pt is showing increased s/s of Jaundice. Resident has increased abdominal pain. Bowel sounds WNL [within normal limits]. Abdomen more rigid, tender. Pain 9/10 reported by resident. On 9/12/23 at 10:38 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 33 went to the hospital Sunday evening, 9/10/23, mostly for pain. RN 1 stated she spoke with the hospital yesterday and the hospital stated that resident 33 was admitted for observation. RN 1 stated the hospital did a paracentesis on resident 33 and RN 1 thought they had removed a half liter of fluid and resident 33's pain did not improve. RN 1 stated that she spoke to the hospital today and they were going to do another paracentesis and resident 33 would be coming back to the facility. On 9/13/23 at 12:27 PM, an interview was conducted with RN 2. RN 2 stated that communication with the facility MD was done through an app called WhatsApp. RN 2 referred to the WhatsApp messages and stated on 9/10/23 at 12:23 AM, the LPN had messaged the facility MD regarding resident 33 complaining of abdomen pain, tenderness right lower quadrant, active bowel sounds times four, complains of stabbing pain, nausea vomiting, and loss of appetite. On 9/10/23 at 3:04 PM, the facility MD responded was [resident 33] okay. [Note: The response from the facility MD was two hours and 41 minutes after the LPN sent the initial message.] On 9/10/23 at 6:43 PM, the LPN responded that no resident 33 was still feeling awful consistent complaints. [Note: The LPN responded three hours and 22 minutes after the facility MD responded.] On 9/10/23 at 7:18 PM, the facility MD responded did resident 33 feel bad enough to need to go to the ER again. [Note: Resident 33 was sent to the ER at 9:45 PM, nine hours and 36 minutes after the initial message to the facility MD.] RN 2 stated that he had sent resident 33 to the ER at that time. RN 2 stated that resident 33 had Tylenol and gababentin available for pain. RN 2 stated resident 33 had oxycodone after a procedure and the oxycodone was discontinued per the order. RN 2 stated there was another order that was given for the oxycodone by resident 33's doctor but the order was only for a certain amount of days. RN 2 stated that the oxycodone did help resident 33's pain per the resident. RN 2 stated that resident 33 had complained about pain but not in the areas that he did on Sunday, 9/10/23. RN 2 stated that resident 33 was given Tylenol and nonpharmalogical interventions for pain. RN 2 stated on Sunday, 9/10/23, resident 33 was very verbal and grimacing and RN 2 knew something was bad. RN 2 stated that an initial order for oxycodone was created but it was post procedure and the facility MD reached out wanting to know if resident 33 still needed the oxycodone. RN 2 referred to the WhatsApp message and stated on 8/18/23, the facility MD responded Don't put on order unless he needs that. RN 2 further stated that around 8/18/23, resident 22 was definitely not in the pain he was in on Sunday. On 9/13/23 at 12:52 PM, an interview was conducted with the DON. The DON stated the oxycodone order was for the therasphere procedure that resident 33 had due to post procedure pain. The DON stated a short term order for the oxycodone was for four days and the oxycodone was not scheduled. The DON stated that the Hepatology clinic sent the referral out for the pain specialist. The DON stated that she was not sure where the paperwork was sent for the pain specialist referral and she had not heard anything. The DON stated that she had spoke to the therasphere provider and they stated it would be unusual to have pain past the four days for the therasphere. On 9/13/23 at 1:03 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated if a resident had pain and there were not orders or sufficient orders to address pain the staff were to contact the provider. The RNC stated the WhatsApp was for nonurgent issues. The RNC stated if the provider did not respond the staff should reach out again or call the provider in order to get a response. The facility Pain Assessment and Management policy was reviewed. Purpose The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident ' s goals and needs and that address the underlying causes of pain. Steps in the Procedure Recognizing Pain 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. 2. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc.; c. Changes in gait, skin color and vital signs; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitations in his or her level of activity due to the presence of pain; f. Guarding, rubbing or favoring a particular part of the body; g. Difficulty eating or loss of appetite; h. Insomnia; and i. Evidence of depression, anxiety, fear or hopelessness. 3. Possible Physiological Signs of Pain: a. Increased blood pressure; b. Tachycardia; c. Increased respirations; and d. Diaphoresis. 4. Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the term pain and use other descriptors such as throbbing, aching, hurting, cramping, numbness or tingling. 5. Review the medication administration record to determine how often the individual requests and receives pain medication, and to what extent the administered medications relieve the resident ' s pain. Assessing Pain: 1. During the comprehensive pain assessment gather the following information as indicated from the resident (or legal representative): a. History of pain and its treatment, including pharmacological and non-pharmacological interventions; b. Characteristics of pain: (1) Intensity of pain (as measured on a standardized pain scale); (2) Descriptors of pain; (3) Pattern of pain (e.g., constant or intermittent); (4) Location and radiation of pain; and (5) Frequency, timing and duration of pain. c. Impact of pain on quality of life; d. Factors that precipitate or exacerbate pain; e. Factors and strategies that reduce pain; and 2. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident ' s cognitive level. 3. Discuss with the resident (or legal representative) his or her goals for pain management and satisfaction with the current level of pain control. Implementing Pain Management Strategies: 1. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: a. Environmental - adjusting the room temperature, smoothing the linens, providing a pressure-reducing mattress, repositioning, etc.; b. Physical - ice packs, cool or warm compresses, baths, transcutaneous electrical nerve stimulation (TENS [transcutaneous electrical nerve stimulation]), massage, acupuncture, etc.; c. Exercise - range of motion exercises to prevent muscle stiffness and contractures; and d. Cognitive or Behavioral - relaxation, music, diversions, activities, etc. 2. Pharmacological interventions (i.e., analgesics) may be prescribed to manage pain, however they do not usually address the cause of pain and can have adverse effects on the resident (e.g., drowsiness, increased risk of falling; loss of appetite). 3. Addiction to narcotic analgesics is not likely if used appropriately for moderate to severe pain. 4. The physician and staff will establish a treatment regimen based on consideration of the following: a. The resident's medical condition; b. Current medication regimen; c. Nature, severity and cause of the pain; d. Course of the illness; and e. Treatment goals. 5. Strategies that may be employed when establishing the medication regimen include: a. Starting with lower doses and titrating upward as necessary; b. Administering medications around the clock rather than PRN; c. Combining long-acting medications with PRNs for breakthrough pain; d. Combining several analgesics or analgesics with other drug classes; and e. Reducing or preventing anticipated adverse consequences of medications (e.g., bowel regimen to preventing constipation related to opioid analgesics). 6. Implement the medication regimen as ordered, carefully documenting the results of the interventions. Reporting Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident ' s pain; 2. Adverse effects from pain medications, such as gastrointestinal bleeding from nonsteroidal antiinflammatory drugs (NSAIDs [Non-steroidal anti-inflammatory drugs]), anorexia, confusion, lethargy, severe constipation, or ileus related to opioids; and/or 3. Prolonged, unrelieved pain despite care plan interventions.

Based on observation, interview and record review it was determined, for 2 out of 28 sampled residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically, a resident sustained multiple falls which resulted in facial lacerations. The incident will be cited at a harm level. The same resident had a successful elopement from the facility and sustained a fall. In addition, an another resident sustained a fall after a [CONDITION(S)] which resulted in a fracture. Resident identifiers 4 and 15. Findings included: 1. Resident 15 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included [CONDITION(S)], contracture, brachial [MEDICATION(S)] disorder, mood disorder, neuralgic amyotrophy, and dementia. On 11/8/21 at 9:30 AM, resident 15 was observed sleeping in bed with the blankets pulled up over the head. On 11/8/21 at 10:00 AM, resident 15 was observed sleeping in bed with the blankets pulled up over the head. On 11/8/21 at approximately 12:30 PM, resident 15 was observed seated in their room on the bed eating lunch. On 11/08/21 at 12:53 PM, resident 15 was observed ambulating independently in the main dining area while returning from the smoking patio. A strong odor of cigarette smoke was noted on the resident. Resident 15 was greeted and replied with hello. Resident 15 did not answer any questions asked by this surveyor. Resident 15 was observed wearing a brace on the right wrist. The resident demonstrated that he could open and close both hands. Resident 15's hands were observed without any [CONDITION(S)], cigarette ash or stains. No cigarette stains or [CONDITION(S)] were observed on the resident 15's clothing. Resident 15 ambulated back to his bedroom. A. Falls Resident 15's medical records were reviewed. Resident 15's physician orders revealed the following: a. [MEDICATION(S)] Solution 250 milligram (mg)/5 milliliter (ml), Give 500 mg by mouth at bedtime related to UNSPECIFIED CONVULSIONS. The order was initiated on 11/11/21. b. [MEDICATION(S)] Tablet, Give 5 mg by mouth at bedtime related to UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE. The order was initiated on 11/11/21. c. WANDERGUARD: To be used at all times due to elopement risk. Device located on left ankle. Verify placement of wanderguard every shift. The order was initiated on 9/1/21. d. WANDERGUARD: Check function of device daily every day shift for elopement risk. The order was initiated on 9/2/21. e. [MEDICATION(S)] Tablet 1000 mg, Give 2 tablet by mouth one time a day for Seizures. The order was initiated on 9/2/21. f. [MEDICATION(S)] Solution 250 mg/5 ml, Give 750 mg by mouth two times a day related to UNSPECIFIED CONVULSIONS. The order was initiated on 9/2/21. g. [MEDICATION(S)] Tablet ([MEDICATION(S)]), Give 50 mg by mouth two times a day for Seizures. The order was initiated on 9/2/21. h. [MEDICATION(S)] Tablet ([MEDICATION(S)]), Give 50 mg by mouth two times a day related to UNSPECIFIED CONVULSIONS. The order was initiated on 9/2/21. i. [MEDICATION(S)] Tablet 1000 MG ([MEDICATION(S)]), Give 1 tablet by mouth one time a day for Seizures. The order was initiated on 9/2/21. j. [MEDICATION(S)] Tablet, Give 20 mg by mouth one time a day related to MOOD DISORDER. The order was initiated on 9/2/21. Review of the facility incident reports for resident 15 revealed the following: a. On 1/31/21 at 1:30 PM, the resident stood up from a chair after smoking and lost balance falling backwards and hit the back of head. No injuries were noted. The resident was educated on standing up slowly and the aide was educated on assisting the resident with standing. b. On 2/26/21 at 9:00 AM, the aide in a nearby room heard a thud, exited and found resident 15 face down with the right cheek on the ground. Injuries noted were an abrasion below the left eye, sheering with swelling to the right posterior wrist and ring finger, and a small laceration to the tongue with minor bleeding. Resident 15 was re-educated on calling for assistance when preparing to ambulate, and to make sure proper footwear/attire was worn. c. On 3/7/21 at 4:10 PM, the nurse heard a loud crashing sound. Resident 15 was found on the bathtub casing with his face against wall. Resident 15 had excessive blood dripping from the head due to a shattered window. Resident 15 stated he fell and hit his face on the glass. The resident was transferred to the emergency room for treatment. No new interventions were documented. d. On 4/3/21 at 6:00 AM, resident 15 attempted to stand from the wheelchair and fell over the wheelchair. No injuries were noted. No new interventions were documented. e. On 4/4/21 at 12:15 PM, resident 15 was using the toilet, stood, turned to flush and fell against the door and slid to ground. No injuries documented. Resident 15 was reminded to use staff to assist with standing and using the restroom. f. On 4/15/21 at 11:00 PM, resident 15 fell out of bed. Resident 15 was educated to keep alarm tab on at all times, and to call for assistance. Staff were educated to make sure tab alarm was on resident. Review of resident 15's hospital History and Physical on 3/7/21 documented that the resident presented after an unwitnessed fall through a pane of glass. It was possible that it was a [CONDITION(S)] or syncopal event. Procedures performed were laceration repair of 3 separate lacerations on the face. The first measured 3 centimeters (cm) on the right cheek. The second measured 2 cm on the right upper eyelid. The third measured 2 cm on the left upper eyelid. The wounds were anesthetized with 1% [MEDICATION(S)]. The wounds were explored to the base and no evidence of neurovascular injury, no evidence of retained glass or foreign body, and no evidence of tarsal plate involvement was noted. The wounds were irrigated with saline and repaired using 5-0 Ethilon with simple interrupted sutures. Review of resident 15's progress notes revealed the following: a. On 2/20/21 at 6 AM to 6 PM, weekly note documented that the resident was alert and oriented times 2, expressed basic needs and wants. Ambulated with a slow gait. Would ask for extra cigarettes during the day and could be anxious about smoking between scheduled times. b. On 2/26/21 at 9:30 AM, the aide heard a sound outside the resident room, opened door to find the resident face down on the ground. The resident stated he tripped and fell over his own foot. Abrasion to left cheekbone and right wrist with swelling. X-ray to right wrist ordered. c. On 2/26/21 at 10:45 AM, x-ray results to right writs received, no fracture noted. d. On 3/1/21 at 6 PM to 6 AM, the weekly note documented that the resident ambulated independently. e. On 3/7/21 at 4:40 PM, at 4:10 the nurse heard a loud crashing noise and found resident 15 laying awkwardly on tub surround enclosure with head against east wall with a large amount of blood dripping down wall and off head. The window above was broken. The nurse called for the aide to assist with positioning resident 15 to a sitting position. Resident 15 stated that he tripped and fell , no other explanation was offered. Injuries observed were small laceration to posterior ringer finger below 2nd knuckle with scant blood. A 2-3 inch laceration to the right temple above the cheekbone, a laceration to the bridge of the nose, one right brow, and a 3-4 inch laceration to left eyelid. The resident was sent to the emergency department for treatment. f. On 3/9/21 the note documented a bed alarm in place. g. On 3/15/21 the note documented that resident 15 was alert and oriented (A & O) times 3. He ambulated with assistance from staff and used a tab alarm for fall prevention. h. On 3/22/21 the note documented A & O times 2-3. Able to communicate wants and needs. Usually ambulated ad lib. This week resident 15 was instructed to use the wheelchair for ambulation with a personal alarm to keep him safe. The resident wanted to walk, but was still a little weak. i. On 4/3/21 the note documented that the patient was unsteady on feet, stood up and fell out of wheelchair. Resident 15 keeps removing his personal alarm, kept trying to get to wheelchair independently, sometimes not able to make it, sits on floor. Resident 15 was a one person assist to stand and back to bed with alarm attached. j. On 4/4/21 at 12:15 PM, the note documented that resident 15 was using the toilet, stood and turned to flush the toilet, fell against the door and slid to the floor. The aide and nurse assisted him to stand. Slight redness to left cheekbone with minimal swelling noted. Reminded resident to let staff assist with standing and using restroom. k. On 4/4/21 at 6 PM to 6 AM, the note documented that resident 15 continued to remove the personal alarm and tried to walk independently. Resident 15 was not steady. l. On 4/8/21 at 6 PM to 6 AM, the note documented that resident 15 had some weakness, and had difficulty going to the toilet. m. On 4/15/21 the note documented that the resident fell out of bed and was pulling at alarms. No injuries were noted. n. On 4/26/21 the weekly 6 PM to 6 AM note documented that the resident wore a personal alarm to notify staff if he tried to stand up. Resident 15 was resistant to the alarm and was able to turn it off and put it in his pocket. Resident 15 stumbles, slipped out of wheelchair, and jumped up and walked to restroom, removed alarm to do this. o. On 5/21/21 the note documented that the tab alarm was discontinued due to steady gait. p. On 6/7/21 the note documented that the resident ambulated independently. Review of resident 15's Minimum Data Set (MDS) Assessments revealed the following: a. On 11/22/20 the Annual MDS assessed resident 15's Functional Status under Section G for bed mobility as Supervision with set up help; Limited 1 person assist for transfer, walk in room, walk in corridor, and off the unit; Total dependence 1 person assist for dressing and toilet use; and Limited 1 person assist for eating. The assessment did not conduct a Brief Interview for Mental Status (BIMS) under Section C due to resident was rarely/never understood. The Care Area Assessment (CAA) Summary triggered a care plan for falls and identified it was existing. b. On 2/22/21 the Quarterly MDS assessed resident 15's Functional Status under Section G for bed mobility as Supervision with set up help; Limited 1 person assist for transfer, walk in room, walk in corridor, and off the unit; Total dependence 1 person assist for dressing and toilet use; and Limited 1 person assist for eating. The assessment did not conduct a BIMS under Section C due to resident was rarely/never understood. The CAA was not applicable for a quarterly assessment. c. On 9/15/21 the Admission MDS assessed resident 15's Functional Status for bed mobility as Supervision with set up help; Supervision with set up help for transfer, walk in room, and walk in corridor; Independent with no help from staff on locomotion on unit and off unit; Extensive 1 person assist for dressing; and Supervision set up help only for eating and toileting. The assessment did not conduct a BIMS score under Section C and was documented as Not assessed. The CAA Summary triggered a care plan for falls and identified it was modified. Review of resident 15's Care Plan revealed the following: a. A RESOLVED care plan: The resident has had an actual fall with minor injury above right and left eye brow due to unsteady gait. The care plan was initiated on 10/22/21. A RESOLVED goal was: The resident's left eyebrow laceration will resolve without complication by review date and the Left eye abrasion will resolve without complication by review date. The goal was initiated on 10/22/21. The RESOLVED interventions were: Bed will be in lowest position for patient's safety and fall precaution; For no apparent acute injury, determine and address causative factors of the fall. Resident would sit for a few minutes before standing; Monitor/document /report as needed for 72 hrs (hours) to physician for signs and symptoms of: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. It should be noted that the care plan was initiated nearly 7 months after the incident occurred. b. A RESOLVED care plan: The resident has had an actual fall with minor injury above right and left eye brow due to unsteady gait. The care plan was initiated on 10/22/21. A RESOLVED goal was: The resident will resume usual activities without further incident through the review date. The RESOLVED interventions were: Neuro (neurological)-checks [times] 72 hrs; Provide activities that promote exercise and strength building where possible; and Provide 1:1 activities if bedbound. It should be noted that the care plan was initiated nearly 7 months after the incident occurred. c. The resident had a [CONDITION(S)] disorder. The care plan was initiated on 10/22/21. A goal of the resident was to be/remain free of [CONDITION(S)] activity through review date and was initiated. The interventions identified were: Ask resident about presence/absence of aura prior to [CONDITION(S)]; Give medications as ordered; Monitor/document for effectiveness and side effects; Obtain and monitor lab (laboratory)/diagnostic work as ordered; Report results to the physician and follow up as indicated; and [CONDITION(S)] PRECAUTIONS: Do not leave resident alone during a [CONDITION(S)], Protect from injury, If resident was out of bed, help to the floor to prevent injury, Remove or loosen tight clothing, do not attempt to restrain resident during a [CONDITION(S)] as this could make the convulsions more severe, Protect from onlookers, draw curtain etc. It should be noted that there was no current care plan for at risk for falls for resident 15. On 11/15/21 at 9:20 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 15 was able to ambulate independently and right now he was safe. RN 1 stated that in the past he had periods of unsteadiness, but that he had no recent falls. RN 1 stated that resident 15 was discharged and readmitted and had no falls since readmission. RN 1 stated that she was not sure what had changed with resident 15's functional mobility to improve it. RN 1 stated that resident 15 had no recent medication changes and it was hard to tell what contributed to the improvement. RN 1 stated that resident 15 was moved to the front of the building to keep a closer eye on him. RN 1 stated resident 15 previously had a tab alarm, but at some point he refused it. RN 1 stated resident 15 kept taking it off and saying no to it. RN 1 stated that during resident 15's periods of unsteadiness they assisted with ambulation and transfers. RN 1 stated that currently resident 15 was steady on his feet. RN 1 stated that resident 15 required no assistance with toileting, and he was continent of bowel and bladder. RN 1 stated that she was not present during resident 15's elopement. RN 1 stated that she only knew that he went outside and jumped the fence. RN 1 stated that resident 15 had no previous attempts at elopement that she recalled. RN 1 stated that when resident 15 started declining and was unsteady on his feet the physician referred him to a neurologist. RN 1 stated that she made an appointment for resident 15 with the neurologist and the soonest appointment she could get was on November 2, 2021. RN 1 stated that documentation of all her attempts at earlier appointments were in the progress notes. On 11/09/21 at 9:57 AM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that she had worked at the facility for 4 years. CNA 3 stated that anything new that happened with a resident was reported to her by the supervisor. CNA 3 stated that if a resident had a behavior or change in condition it would be passed off to her in report. On 11/15/21 at 10:10 AM, an interview was conducted with CNA 4 and CNA 5 utilizing the English/Spanish Translator application. CNA 4 stated that resident 15 ambulated independently, was sometimes unsteady, and came out of his room for cigarettes and coffee. CNA 5 stated that resident 15 did not utilize a walker or wheelchair for ambulation. CNA 4 stated that resident 15 did not need assistance with toileting. CNA 5 stated that resident 15 had not had any falls since she had worked at the facility for the last month. CNA 4 stated that to her knowledge resident 15 had never left the building, and had not eloped prior to the placement of the wander guard. CNA 5 stated that resident 15 currently had a wander guard in place. On 11/09/21 at 10:25 AM, an interview was conducted with CNA 2. CNA 2 stated that she utilized a communication application to communicate information to the CNAs for each resident behavior or change in condition and changed the written report to pass off information to the next shift to read. CNA 2 stated the written report was for information on incidents that had occurred that day. CNA 2 stated that for new CNAs she explained each resident's care needs, and then they could look in the computer on what the resident history was and what their needs were. On 11/15/21 at 1:47 PM, an interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC). The RNC stated that the previous Administrator prior to the acquisition by the new company was doing the care plans. The RNC stated that they were not updating the care plans with new interventions. The RNC stated that the process now was that the IDT reviewed the incident, tried to determine the root cause, the care plans were updated, the comprehensive care plans were updated, and the new MDS Coordinator did that process Annually and Quarterly also. The RNC stated that with resident 15's history they typically have an at risk for falls care plan initiated. B. Elopement Review of the facility initial entity report documented, On 7/10/2021 at 10:44 AM, the facility reported that, on 7/10/2021 at 8:45 AM, the resident was found to have eloped from the facility. The resident was last seen at 8 AM during a scheduled smoking time. Other facility residents notified the staff that there was 'a guy that had fallen down near the road in front of the building'. The nurse went outside to assess the situation and see if she could give any medical assistance. At that time, the nurse noticed that the 'guy' was the resident of the facility who had eloped. The nursing staff did a head to toe assessment and assisted the resident back to the building. APS (Adult Protective Services) was notified. The family and physician were notified. The facility will contact the resident's guardian and seek receive approval to temporarily transfer the resident to a sister facility with a wander guard system while [name of facility] can assess and install a wander guard system of their own. Review of resident 15's progress notes revealed the following: a. On 7/10/21 at 8:45 AM, the note documented, Nurse at med (medication) cart; residents sitting at window in dayroom notified nurse of a man laying in middle of road; nurse looked and saw man laying on side with 3 men around him; nurse notified staff they'd be stepping out to see if they needed help; nurse approached scene asking men if EMS (emergency medical services) had been notified, they said EMS not notified; nurse looked a man to assess, recognized res. (resident); nurse then asked if incident had been witnessed; one of the men states it appeared that he had tripped and they went to him to ensure his safety, nurse asked if res. hit head, bystander stated he didn't hit head; witnesses and nurse slowly assisted res. to sitting position, res. denied light headed/dizziness; assisted to standing, again res. denied being light headed or dizzy; assisted res. back to facility; assessment performed; PERRLA (pupils, equal, round, reactive to light and accommodation), grips at baseline, skin tear to R (right) lateral wrist (2.5 cm), abrasions to L (left) pinky (1 x 3 cm) and abrasion to R shin (2 x 7 cm); cleansed areas with wound cleanser, applied [MEDICATION(S)], wrapped with [MEDICATION(S)] and secured with coban; VS (vital signs) signs (sic) BP (blood pressure): 105/69 HR (heart rate): 75 RR (respiratory rate): 16 O2 (oxygen): 96% RA (room air) T (temperature): 98.0 denies pain with exception of abrasions, reports pain 'better' after tx (treatment); staff checked exterior doors/exits for point of egress, step ladder found next to fence in front courtyard, ladder secured b. On 7/10/2021 at 4:00 PM, the note documented, resident 15 required immediate transfer to due to resident's imminent risk for elopement as evidenced by successful elopement today. Resident has cognitive deficits associated with mental illness, such as impaired safety awareness, impulsivity, and impaired judgment. Less restrictive measures such as indirect supervision, distraction, redirection, orientation and re-orientation to facility routines and practices were not effective in mitigating elopement risk. [Name of facility] can no longer manage resident s elopement risk as no wander guard system is in place and staffing at a 1:1 is not feasible. [Name of sister facility] has a wander guard system as well as a door monitor and the IDT (Interdisciplinary team) believes that resident's elopement risk can more safely and effectively be managed at this receiving facility. c. On 9/7/2021 at 11:43, the physician note documented that resident 15 was readmitted for care. He had been transferred to another facility because he needed a more secure environment due to wander risk. The current facility had a wander guard system so he had been readmitted per the guardian's request. Review of resident 15's Care Plan revealed the following: a. The resident was an elopement risk related to impaired safety awareness. The care plan was initiated on 10/22/21. Interventions identified were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; Monitor for fatigue and weight loss; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; and Resident will smoke with supervision. It should be noted that the care plan was developed 104 days after the incident occurred and 52 days after resident 15's re-admission to the facility. On 11/15/21 at 1:47 PM, an interview was conducted with the DON and the RNC. The DON stated that she was notified by RN 3 that resident 15 had eloped and fallen outside the facility. The DON stated that resident 15 did not have any injuries from the elopement fall. The DON stated that a ladder was found against the fence and that was the resident's method for elopement. The RNC stated that the previous maintenance director had been working on the roof and had not secured the ladder. The RNC stated that resident 15 would not have been able to hop the fence had the ladder not been left out. The RNC stated that the current wander guard system prevents resident 15 from going out to the courtyard area unsupervised. 2. Resident 4 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)], drug induced subacute dyskinesia, [CONDITION(S)], and unspecified [CONDITION(S)] not due to a substance or known physiological condition. On 11/8/21 at 12:18 PM, resident 4 was observed outside smoking independently. Resident 4 stated that he did not want to be around anyone. On 11/8/21 at 1:11 PM, resident 4 was observed resting in bed in one of the two upstairs rooms in the facility. On 11/10/21, resident 4's electronic medical record review was completed. Nursing notes revealed the following: a. On 8/24/21 at 3:07 AM, revealed that at 2:18 AM, resident 4 was coming down the stairs then crash. He is collapsed on the stairs, not responsive or aware, half way up. Protect head, assist him to the floor pillow for head. He's breathing fast and steady and loud, not responsive . [CONDITION(S)] He's awake now, sits, up, states no pain when asked, responding normal . walks up the stairs, closely followed by aide in case he collapses again. Aide assists him to bed . opens the top door again stop him, have him sit on top step, he does Ask [resident 4] to go back to bed for a little while to recover. He does 245 [AM]. [resident 4] insists on a smoke, assist him down the stairs and aide assists him, also watches him, no further [CONDITION(S)] activity. Monitor him walking up the stairs to bed. Encourage him to sleep for a while. vitals normalize. Acting like usual. Upstairs sleeping now. b. On 8/24/21 at 9:46 AM, resident 4 complained of pain to left shoulder and left ankle. The nurse noted new discoloration and some swelling on his left ankle, no deformities noted. c. On 8/24/21 at 4:04 PM, resident 4 returned from the Emergency Department. d. On 8/24/21 at 10:50 PM, resident 4 had a diagnosis of a fracture of the left humeral head. Resident 4 remained downstairs while recovering. e. On 8/26/21 at 7:33 PM, resident 4 was walking safely alone, and up the stairs, shadowed . The Emergency Department discharge paperwork from 8/24/21, page 3, revealed that Follow-up care consisted of Follow up with your healthcare provider, or as advised. A shoulder joint will become stiff if left in a sling for too long. Ask your doctor when it is safe to start range-of-motion exercises. Resident 4's care plan was reviewed and revealed the following: a. On 6/15/2020, resident 4 had a fall due to an unsteady gate. The interventions were to monitor and provide activities that promoted exercise and strength building. These were resolved on 11/7/21. b. On 11/6/21, a risk for falls focus was initiated for resident 4. c. On 11/6/21, a focus was added for behavior problem (verbal/physical aggression/resisting cares) r/t (related to) delusions, hallucinations, mental health problems associated with behavioral disturbances, fatigue, [CONDITION(S)], dementia. The goal was The resident will have fewer episodes of verbal and physical aggression weekly by review date. Resident 4's care plan was not updated after his [CONDITION(S)], though resident 4 had no previous [CONDITION(S)] activity. No interventions were initiated to provide goals or interventions related to seizures. Resident 4's care plan was not updated after his fall on 8/24/21 with new interventions. Resident 4 had no assessments after the fall to determine his safety with climbing and descending stairs. Minimum Data Set (MDS) Assessments for resident 4 revealed the following: a. On 4/15/21, a quarterly MDS revealed that resident 4 required limited assistance with transfers, walking, dressing, eating, toilet use, personal hygiene, and bathing. b. On 9/27/21, a quarterly MDS revealed that resident 4 did not self-transfer, required supervision for walking, that resident 4 did not move off the unit location, required assistance with eating, physical assistance with personal hygiene, and was dependent for bathing. For walking, turning and transferring, resident 4 was not steady, but able to stabilize without staff assistance. c. On 11/2/21, a quarterly MDS revealed that resident 4 required supervision for bed mobility, was unable to transfer, required supervision when walking, had only left the unit once or twice with physical assistance, required set up help with dressing that only occurred once or twice, required two person physical assistance with eating that only occurred once or twice, supervision with toilet use, and set up for personal hygiene. Bathing did not occur. For walking, turning and transferring, resident 4 was not steady, but able to stabilize without staff assistance. A physical therapy progress note dated 6/29/21 revealed that resident 4 required assistance with standing, was able to walk sixty feet with support, and resident 4's lower extremities were weak with decreased gait and balance. Resident 4 had reached max rehab. A physician's order on 9/15/21 revealed that resident 4 required physical therapy after his injury. On 11/9/21 at 10:23 AM, CNA 3 was interviewed. CNA 3 stated that resident 4 seemed to walk fine and did not require supervision or assistance. CNA 3 stated that she did not know resident 4 had a [CONDITION(S)] diagnosis. On 11/9/21 at 10:55 AM, CNA 4 was interviewed. CNA 4 stated that she received information about the residents' needs from the other CNAs. CNA 4 stated that she did not know of any special requirements for resident 4. On 11/9/21 at 10:31 AM, CNA 5 was interviewed with a translator application. CNA 5 stated that she did not know resident 4 had a [CONDITION(S)]. CNA 5 stated that resident 4 had a room upstairs because he can walk. CNA 5 stated that resident 4 was not provided supervision or assistance with ambulating. On 11/10/21 at 8:07 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that the orthopedic physician's report revealed that resident 4 would not return to full range of motion in his left arm. RN 2 stated that resident 4 had weakness when walking at times and had emotional and behavioral issues. RN 2 stated that resident 4 often came downstairs at night and asked for items, because he did not sleep well. On 11/10/21 at 3:45 PM, an interview was conducted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC). The RNC stated that resident 4 had no [CONDITION(S)] history before 8/24/21, but resident 4 had been taking [MEDICATION(S)] for mood stabilization. The RNC stated that resident 4 remained on the ground level of the facility until he was on [MEDICATION(S)] for one month. The RNC stated that the physician was informed after resident 4 moved back upstairs, and stated that the physician was not consulted about room changes. The RNC stated that she did not know if resident 4 had full range of motion. The CRN stated that the care plan was not updated to ensure the safety of resident 4 sleeping upstairs. The Director of Nursing (DON) stated that resident 4 wanted to return to sleeping upstairs, because he really wanted to be upstairs and liked his roommate. The DON stated that there was no assessment to determine if resident 4 was safe to sleep upstairs. The DON stated that resident 4's insurance would not pay for additional therapy.

Based on observation, interview and record review it was determined, for 4 of 28 sample resident, that the facility did not ensure each resident had the right to be free from abuse. Specifically, there were two residents involved in four altercations that resulted in one resident sustaining a dislocated finger. In addition, another resident was found with his pants down with another resident touching him. The facility determined the residents with cognitive impairment and mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not evaluate if other residents were at risk for being sexually abused by the perpetrator. Both of the above incidents were cited at a harm level. Resident identifiers: 1, 11, 15, 20, 27 and 133. Findings include: A. Resident to Resident physical altercations: 1. On 11/8/21 at 1:50 PM, an observation was made of the resident 1 and resident 15. Resident 1 was seated in a wheelchair in the dining area eating popcorn. Resident 15 was observed to walk by resident 1 and pushed against resident 1. Resident 15 was observed to sit across from resident 1 in the dining room after he pushed against resident 1. Resident 1 was observed to stand up out of his wheelchair and walk to resident 15. Resident 1 was observed to hit resident 15 with closed fists in the head. The Activities Director (AD) was observed to step between the residents. Resident 10 was observed to be sitting next to resident 1. Resident 10 stated to the AD that resident 15 hit resident 1 in the head when he walked past. Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 and resident 15's incident reports were reviewed and revealed the following: a. Resident 1's incident report on 10/8/21 at 2:00 PM revealed, At 1250 (12:50 PM) resident was walking past another resident pushing his wheelchair. Pt (patient) moved aggressively towards that resident, appearing to attempt to scratch him, with no warning or verbal words exchanged prior. No trigger to this episode is known by staff. The immediate action taken was PT removed from the area to separate him from the other resident. Staff attempted to talk to him about the incident. He is hard of hearing and refused to utilize the communication board to talk with staff. Resident had no injuries r/t (related to) the incident. Admin (Administrator)/abuse coordinator notified and reported incident to [State Survey Agency] and APS (Adult Protective Services). NP (Nurse Practitioner) notified as well. Resident 15's incident report on 10/8/21 at 1:49 PM revealed, At 1250 (12:50 PM) [resident 1] was walking past this resident, pushing his wheelchair. [Resident 1] moved aggressively towards this resident, appearing to attempt to scratch him. With no warning or verbal words exchanged prior. No trigger to this episode is known by staff. The immediate action taken was [Resident 1] was removed from the area to separate him from this resident. Nurse assessed and resident had no injuries r/t the incident.Admin/abuse coordinator notified. b. Resident 1's incident report dated 10/9/21 at 8:30 AM revealed, Patient was walking down the hallway pushing his wheelchair and started running towards another resident, who was walking in the hallway as well. He made contact with him using his wheelchair, causing the other resident to fall. This happened too quickly for staff to intervene. The immediate action taken was Upon becoming aware of the incident, staff separated the residents from each other. They were redirected to different areas. Notified MD (Medical Doctor) and admin/abuse coordinator. Admin report to [State Survey Agency] and APS. Resident has been provided 1:1 (one on one) staff member for supervision to ensure he remains separated from the other resident while staff work on developing a behavioral plan of care with resident. He has been clearly educated that his behavior is not acceptable. Resident has not been willing to discuss resident incidents with staff members. Resident 15's incident report dated 10/9/21 at 8:30 AM revealed, RN (Registered Nurse) observed this resident walking down the hallway. [Resident 1] was also walking down the hallway with his wheelchair and suddenly attempted to run into [resident 15], causing [resident 15] to fall. [Resident 15] got up and tried to hit other resident but the RN intervened and redirected both residents to separate areas. The immediate action taken was Nurse assessed resident.Alert charting initiated. c. Resident 1's incident report on 11/8/21 at 2:04 PM revealed, The patient was sitting in front room during an activity when resident [15] stood up and slapped him on the forehead, as reported by [another resident]. This was not witnessed by staff. Activities director responded upon being notified of what happened to separate the residents and notify the nurse. Patient stating other resident slapped him on the forehead. No known reason was given. The immediate action taken was Nurse assessed patient. No apparent injuries noted.No change in behavior from baseline to indicate distress. Patient redirected to a separate area. Admin notified. Resident 15's incident report dated 11/8/21 at 2:21 PM revealed, [Resident 1] was sitting on the front TV room during an activity. Resident stood up, approached [resident 1] and slapped him on the forehead then returned to his chair. Activity Director separated both residents and redirected to different areas. The incident report further revealed Resident was unable to provide a reason that he slapped the other resident on the forehead. The immediate action taken was Nurse assessed patient. No apparent injuries.Nurse educated patient on the inappropriateness of his behavior. Patient smiled and stated 'I know.' Staff continued to monitor the patients when they are in the same location as each other. d. Resident 1's incident report dated 11/8/21 at 4:10 PM revealed, Certified Nursing Assistant (CNA) reported to nurse that she witnessed [resident 15] push [resident 1] and [resident 1] fell to the ground without hitting his head. CNA went and assisted resident, ensuring he was separated from the other resident. Residents were being supervised, but the incident happened too quickly for staff to intervene. CNA called nurse to have resident assessed and called for assistance from other staff members to have [resident 15] move to a different area. Resident 15's incident report dated 11/8/21 at 4:10 PM revealed, CNA reported to nurse that she witnessed [resident 15] push [resident 1] and [resident 1] fell to the ground without hitting his head. CNA was unable to reach the residents in time to intervene as it happened too quickly. CNA called nurse to have resident assessed and called for assistance for other staff member to have [resident 15] move to a different area. The report further revealed [Resident 15] states that [resident 1] tried to run him over with his wheelchair and then [resident 15] pushed him. This was not accurate as CNA witnessed the incident in its entirety and resident has not tried to run into him with his wheelchair. This happened previously, but not today. The immediate action taken was Staff separated residents to different areas and then notified Administrator. Administrator assigned one aide to stay with [resident 1] 1:1 at all times until IDT (Interdisciplinary Team) could determine what next actions to take regarding these residents. Resident 1's medical record was reviewed on 11/10/21. A annual Minimum Data Set (MDS) dated [DATE] revealed resident 1's Brief Interview of Mental Status (BIMS), long term and short term memory were not assessed. The MDS further revealed that resident 1 required setup help with supervision for walking in corridor and locomotion on the unit. A care plan dated 10/25/21 revealed [Resident 1] has a behavior problem verbal or physically aggressive and at times refuses cares r/t physical behavioral symptoms directed towards others, verbal behavior directed towards others, sensory impairments, [CONDITION(S)] and dementia. The goal developed was [Resident 1] will have fewer episodes of by review date. The following interventions developed and initiated on 11/08/21 were: a. Administer medications as ordered. Monitor/document for side effects and effectiveness, b. Anticipate and meet the resident's needs. c. Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. d. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. e. Explain all procedures to the resident before starting and allow the resident (10 minutes) to adjust to changes. f. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. g. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Evaluated residents triggers, resident has a trigger due to a specific resident. Resident requested to transfer to different facility has been approved. Resident 1's progress notes revealed the following entries: a. On 7/14/21 at 5:08 PM, Behavior Note: Resident walking into dining room for dinner and flipped another resident off. b. On 7/18/21 at 3:05 PM, Pt flipped off another resident as he walked by him, nurse educated pt on inappropriate behavior, pt did not responded and walked away to his room. c. On 7/22/21 at 10:17 AM, Res. entered day room, walked passed another res., began yelling [and] swearing at other res; nurse waited until res calm, attempted to give res meds (medications); res threw meds at nurse; res attempted to hit nurse with W/C (wheelchair); res. redirected [and] taken back to room; MD [and] DON (Director of Nursing) notified. d. On 7/27/21 at 1:47 PM, Patient flipped off another resident as he was walking by him, making other resident agitated and upset. Educated patient on inappropriate behavior, patient did not responded or look at nurse. e. On 7/30/21 at 7:38 AM, Res. in dining area having physically aggressive behavior; res. removed from area; situation resolved. f. On 8/13/2021 at 1:22 PM, Nurse Practitioner note Recertification visit: I am here to see [resident 1] for a routine visit. A/P (assessment and plan):. 2.Dementia with behavioral disturbances- behaviors fairly stable. Continue [MEDICATION(S)] and continue to monitor. Adjust POC (plan of care) as needed. Complete POC reviewed and no changes made at this time. g. On 8/16/21 at 2:57 PM, Patient combative during cares, refused to wear shoes, refused to use walker or wheelchair, several times during the shift came out of his room with no pants, difficult to redirect, kicked aide when she help him put pants on. Will continue to monitor. h. On 8/23/21 at 10:47 AM, Patient needing continuing redirection, constantly coming out of his room without any pants, combative when attempting to redirect back to his room or when explaining that he needs to wear some pants on. DON notified. i. On 9/13/21 at 2:24 PM, Patient verbally abusive towards staff during cares. Continuously flipping other residents off during the shift, other residents becoming very agitated for his behaviors. Educated patient on inappropriate behavior, patient flipped nurse off went to his room and slammed the door several times. j. On 9/14/21 at 4:30 PM, Patient continuously flipping other residents off. Educated patient on inappropriate behavior, patient ignores nurse and stated 'I can't hear you', nurse attempt writing education but patient just walk away angry. k. On 10/8/21 at 8:10 AM, Spoke to resident regarding aggressive behavior, resident stated that he was just upset and that he will be better. I let resident know that I will put together a behavior plan and have him sign it. Resident agreed. l. On 10/8/21 at 4:50 PM, Alert Note: pt was involved a physical altercation. No injuries were noted. Director talked with pt about his behavior and if it continues pt may not be able to stay here. pt has been asking for more pain over the past few days. no other concerns at this time. j. On 10/9/21 at 8:40 AM, Patient was walking down the hallway pushing his wheelchair, patient started running towards another resident who was walking on the hallway as well and made him fall. Redirected patient to a different area to avoid further confrontation. Educated patient on inappropriate behavior, pt ignores nurse, no response from patient. k. On 10/11/21 at 1:05 PM, Patient flipping off another resident when walking by him. Other patient redirected to another area. No further altercation. l. On 10/11/21 at 2:28 PM, MD Progress Note: Recertification visit: [Resident 1] has had some agitation recently per nurse. 1. Dementia with behavioral disturbance - has tolerated a dose reduction of [MEDICATION(S)]. will continue to try to wean off. He also takes [MEDICATION(S)] and [MEDICATION(S)] but [MEDICATION(S)] might be for seizures. m. On 11/8/21 at 2:18 PM, Resident [15] was sitting on his wheelchair at the front TV room during an activity, when resident [1] stood up and slapped him on the forehead, resident [15] stood up but activity director separated resident to different areas. MD, DON and administrator have been notified of incident. n. On 11/8/21 at 4:20 PM, CNA reported to nurse that resident [1] was pushed by resident [15] and fell to the ground. Nurse assess patient. Patient [1] reports pain on the left first finger. Finger appears to be deformed and patient complains of pain to touch. Notified DON, administrator and MD, received order to transfer patient to the ER (emergency room ) at [local hospital], applied ice pack to affected area and administered PRN (as needed) pain medication. o. On 11/8/21 at 6:30 PM, Discharge. :Resident is initially being sent to [local hospital] for evaluation and treatment.Resident requested to be transferred to another facility . Resident 1's CNA documentation regarding Behavior symptoms was reviewed from 10/12/21 through 11/8/21. The documentation on 11/8/21 revealed abusive language. Resident 1 had abusive language documented 5 times during that time period. Resident 1 had pinching/scratching/spitting behaviors documented on 10/14/21 and 10/21/21. Resident 1 had yelling/screaming behaviors on 10/14/21, 10/15/21, 10/22/21, 10/31/21 and 11/3/21. Resident 1 had threatening behavior on 10/14/21 and 10/21/21. There was no documentation regarding what the behaviors were. A behavioral plan was signed by resident 1 on 10/11/21 which revealed that the facility was concerned about resident 1 physically assaulting and making inappropriate physical gestures towards residents and staff members, verbally aggressive towards other residents and staff members, and slamming doors and disruptive in the environment. The plan further revealed if the behaviors did not cease then the facility would take further action which might include a 30 day notice. Resident 15's medical record was reviewed on 11/15/21. An admission MDS dated [DATE] revealed resident 15's BIMS was not assessed. Resident 15's long and short term memory were not assessed. Resident 15 was assessed as requiring supervision with setup help for transfers, walking in room, walking in corridor and locomotion off unit. The MDS further revealed resident 15 was independent with no set up or physical help for locomotion on unit. A care plan dated 10/22/21 revealed The resident is/has potential to be verbally aggressive r/t dementia, Poor impulse control. The goal was The resident will have fewer than 3 episodes per week of verbal behavior through the review date. The following interventions were developed: a. On 10/22/21, Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. It should be noted that there was no documentation that this intervention was implemented. b. On 10/22/21 Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. c. On 10/9/21 Assess resident's coping skills and support system. It should be noted that there was no documentation that this intervention was implemented. d. On 10/22/21, Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. It should be noted that there was no documentation that this intervention was implemented. e. On 10/22/21, Monitor behaviors. Document observed behavior and attempted interventions. It should be noted there were no attempted interventions documented when the above behaviors were documented by CNAs. f. On 10/22/21, 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. g. On 11/8/21, The resident was evaluated for triggers causing aggression, the trigger is isolated with a specific resident. That Resident request for a transfer from the facility was granted therefor the trigger has been resolved. Resident 15's progress notes revealed the following: a. On 9/2/21 at 8:09 AM, Resident adapting well to the facility, Communicates needs, . will continue to monitor and keep safe. b. On 9/18/21 at 8:44 PM, Patient . was sitting in chair watching a movie in day room for over 1 hour. He Left for personal reason, then came back a few minutes later and another patient was in the chair he had just vacated. [Resident 15] yelled at patient to get out of chair and shook his arm. Patient in the chair yelled back, not willing to move. RN stepped in between them and calmed them, redirected [resident 15] to another location and chair. [Resident 15] quiet now and calmly sat in the new chair. Easy to redirect. c. On 10/8/21 at 4:06 PM, Nurse Practioner (sic).I am here to see [resident 15] for a routine visit. No new illness or injury. Has been involved with some alterations the past few days, but they have not been initiated by him.A/P: 1. Dementia with behavioral disturbance - He has a wander guard due to elopement risk. He remains on [MEDICATION(S)] and Lorazepam. will track behaviors and review at [CONDITION(S)] meetings. Complete POC reviewed and no issues noted at this time. d. On 10/8/21 at 4:49 PM, Alert Note: pt was involved in a physical altercation with a mother (sic) resident, no scratches were noted from incident. will continue to monitor. e. On 10/9/21 at 8:40 AM, Resident was walking down the hallway when another resident ran over him with his wheelchair causing patient to fall and hit his head. Patient got up and tried to hit resident. Redirected both residents to separate areas. Assess patient, no noted injuries. f. On 10/12/21 at 1:34 AM, Pt had no injury or altercation this shift. Compliant with reminder of No Fighting. g. On 11/8/21 at 2:34 PM, Resident [15] was sitting on the TV room during activity, resident stood up and went to slapped resident [1] on the forehead. Activity director separated both residents, staff redirected residents to a different area. No apparent injuries noted. Educated resident on inappropriate behavior and patient stated 'I know'. h. On 11/8/21 at 5:21 PM, CNA reported to nurse that resident [15] pushed resident [1] and resident [1] fell to the ground. No injuries on resident [15]. Staff separated residents to different area, nurse assigned one aide to stay with resident [1] one on one at all times. i. On 11/8/21 at 11:10 PM, Pt had no further aggression this shift . j. On 11/9/21 at 11:44 PM, Pt had no aggression this shift. k. On 11 /11/21 at 1:55 AM, Pt had no physical aggression but did yell at other patients twice when he wanted to sit where they were sitting. Redirected well both times, removed him to his room second time. Compliant. He took a break, then came out nice. Resident 15 had CNAs documentation regarding Behavior Symptoms. The documentation from 10/12/21 through 11/9/21 was reviewed. Resident 15's behaviors documented were Repeats Movement. There was no documented pushing, abusive language, or threatening behavior documented. On 11/15/21 at 11:17 AM, an interview was conducted with Social Service Worker (SSW) 1. SSW 1 stated that she had been to the facility a couple times and was at the facility every 2 weeks. SSW 1 stated she did not work with resident 1 and had not been provided any referrals. On 11/9/21 at 1:57 PM, an interview was conducted with CNA 3. CNA 3 stated she had worked at the facility for 4 years. CNA 3 stated when she saw any patient with a behavior, she reported it to her supervisor. CNA 3 sated she was not sure what happened earlier on 11/8/21 with resident 1 and resident 15. CNA 3 stated that resident 1 was in a bad mood and yelled bad words at no specific residents. CNA 3 stated she was not sure if something happened between them before lunch. CNA 3 stated that resident 1 was laying down in his room and got up and was walking to the dining room. CNA 3 stated that resident 15 was sitting by the nurses station. CNA 3 stated everything was good. CNA 3 stated she went to get a cup of water on the other side of the dining room when resident 1 started yelling. CNA 3 stated resident 1 was walking but not steady and resident 1 hit resident 15. CNA 3 stated that happened between 2:00 PM and 2:30 PM. On 11/9/21 at 2:11 PM, an interview was conducted with the Activities Director (AD). The AD stated there were certain things in care plans and he had been instructed what to do with residents. The AD stated that in the past resident 1 had aggressive behaviors. The AD stated he had not seen resident 1 be aggressive but other staff had reported resident 1 had aggressive behaviors. The AD stated he was making popcorn for the movie and was cleaning the machine when resident 10 said there was a fight. The AD stated he looked and resident 1 was out of his wheelchair. The AD stated that resident 1 was by resident 15 and he jumped between them. The AD stated that resident 1 sat back down in his wheelchair. The AD stated RN 1 came into the dining room and he told RN 1 what he saw. The AD stated he did not see if resident 1 or 15 had hit each other. The AD stated that resident 1 picked different people to fight with but had not had an encounter with the resident for 2 to 3 months. On 11/9/21 at 10:53 AM, a interview was conducted with CNA 4 and RN 1. RN 1 translated for CNA 4. CNA 4 stated stated that she and CNA 2 communicated with each other and gave a verbal report to the aides they worked with each day. CNA 4 stated CNAs documented resident behaviors electronically. CNA 4 stated if she did not witness a behavior she did not document the behavior. CNA 4 stated she tried to separate residents into different areas when there was a resident to resident altercation. RN 1 stated that CNAs reported resident to resident altercations to the nurse. RN 1 stated that nurses then obtained statements from the CNA's. RN 1 stated the reports were in the electronic medical record. RN 1 stated that the DON reviewed the reports and updated the care plans. RN 1 stated she notified the doctor, DON, Administrator, guardian and implemented any new orders from the doctor. RN 1 stated that nurses and CNAs have access to the care plan. CNA 4 stated on 11/8/21 she heard yelling and ran to the hallway by the nurse's station. CNA 4 stated when she arrived resident 1 and resident 15 were not together and had been separated. CNA 4 stated she was listening to what everyone else was saying. CNA 4 stated that the AD separated the residents. CNA 4 stated that she tried to avoid having resident 1 and resident 15 in the same room. CNA 4 stated that she made sure that resident 15 was walked to the patio to smoke by a staff member so resident 15 did not run into resident 1. CNA 4 stated resident 1 had behavior issues and she keeps a closer eye on him. RN 1 stated that resident 1 sought out several residents including resident 17. RN 1 stated that resident 1 flipped other residents off and it upset the other residents. RN 1 stated that resident 1 and 15 had 2 altercations on 11/8/21. RN 1 stated the first one was about 1:30 PM during an activity. RN 1 stated that resident 15 slapped resident 1 on the head, then resident 1 stood up and headed to resident 15. RN 1 stated that resident 1 slapped resident 15 on the head once and there were no words exchanged. RN 1 stated that during the second altercation resident 15 pushed resident 1 and resident 1 fell . RN 1 stated that CNA 3 observed the altercation. RN 1 stated that resident 15 reported that resident 1 tried to run him over and so he pushed resident 1. RN 1 stated resident 1's first digit was dislocated from the fall and he was sent to the hospital. CNA 4 stated that she had been told many times to keep an eye on both resident 1 and resident 15. CNA 4 stated keeping an eye on them meant to make sure each CNAs section was being watched. CNA 4 stated if there was an activity going on so they were able to be in the same area. CNA 4 stated that the AD observed the first altercation. CNA 4 stated she was in a meeting during the second altercation. The facility Abuse Policy and Procedure revealed the following: Policy Statement: Every resident has the right to be free from all forms of abuse: verbal, sexual, physical, mental, neglect, corporal punishment and involuntary seclusion. The Definitions revealed 1. Resident abuse: the willful infliction of injury, . 4. Physical abuse: Abuse that results in bodily harm with intent. This includes hitting, slapping, pinching, kicking. The Abuse Interventions revealed 21. If abuse happens: separate the assailants from the victim immediately and keep assailant separated from other residents until the risk for further abuse subsides. 22. Residents with aggressive or abusive behaviors shall have their care plans written and revised as needed to include approaches to reduce or eliminate the risk for abuse. 23. If one resident jeopardizes the safety of another, alternative placement may be considered for the resident. On 11/9/21 at 10:40 AM, an interview was conducted with the CNA 2. CNA 2 stated before she cared for a resident, she asked the previous CNA what to look for. CNA 2 stated she asked what type of brief and what type of help the resident needed. CNA 2 stated she asked the previous CNA to explain what behaviors and what the resident needed. CNA 2 stated there was also an application used to share resident information and explain how to care for residents. CNA 2 stated that resident 1 was rude to people because he was verbally and physically by trying to hit people. CNA 2 stated resident 1 put his middle finger up to other residents and knocked his roommates items on the floor. CNA 2 stated that resident 1 tried to hit her one day with his fist closed. CNA 2 stated if resident 1 was upset, she asked him to calm down and then told the nurse. CNA 2 stated if another resident was in resident 1's way he yelled at the other resident. CNA 2 stated she did not know of any other resident to resident altercations but resident 1 was mean and agitated. On 11/09/21 11:19 AM, an interview was conducted with CNA 5. CNA 5 used a translator application on her phone for the interview. CNA 5 stated she tried to be as nice as possible to each resident. CNA 5 stated if there was a problem she called her supervisor nurse. CNA 5 stated she did not work on 11/8/21 when resident 1 and 15 had the altercations. CNA 5 stated resident 1 had a bad side but she knew he had a good side too. CNA 5 stated that he fought with resident 15 and another resident in the past. CNA 5 stated that resident 1 put his middle finger up at other residents. CNA 5 stated no one had told her about a resident to resident altercation on 11/8/21. On 11/10/21 11:40 AM, an interview was conducted with RN 2. RN 2 stated when there was a resident to resident altercation she broke it up and tried to keep those resident separated. RN 2 stated she kept them separated by having different rooms, different schedules and behavior contracts. RN 2 stated she was not sure what behavior contracts were and was not aware of any resident that had a behavior contract. RN 2 stated that resident 15 and resident 1 had a resident to resident altercation about a month ago and maybe more altercations. RN 2 stated both residents did not like each other and they sought physical aggression. RN 2 stated the residents would go after each other. RN 2 stated that resident 1 started it but once resident 15 was attacked then they went after each other. RN 2 stated she talked with the CNAs and educated the staff. RN 2 stated she talked to residents and redirect the residents. RN 2 stated that resident 15 did not participate in activities. RN 2 stated when they were not short staffed there were enough CNAs to keep the residents apart. RN 2 stated she had been educated through nursing school on how to deal with resident to resident altercations, but had not been educated through the facility. On 11/10/21 at 11:53 AM, a follow up interview was conducted with CNA 2. CNA 2 stated that she was in a meeting when the first incident happened with resident 1 and resident 15 on 11/8/21. CNA 2 stated that CNA 3 should have documented any behaviors in the CNA system. CNA 2 stated that CNA 3 was resident 1's CNA on 11/8/21. CNA 2 stated that she documented because when her shift was over she checked to see if all the CNA documentation was completed. CNA 2 stated that CNA 3 did not complete documentation for resident 1 so she completed it. CNA 2 stated that she told the CNAs to watch for resident 1 and resident 15 because they had been fighting. CNA 2 stated she told the evening CNAs about the altercation. On 11/15/21 at 10:14 AM, a follow up interview was conducted with RN 1. RN 1 stated that resident 1 had resident to resident altercations in the past. RN 1 stated that she separated the residents and took them to different areas. RN 1 stated that there was a smoking aide that made sure resident 15 went to the smoking area and did not interact with resident 1. RN 1 stated usually resident 1 initiated the resident to resident altercations. On 11/15/21 at 2:22 PM, an interview was conducted with the Administrator (Admin), DON, and the Regional Nurse Consultant (RNC). The RNC stated the first 2 altercations in October 2021 between resident 1 and resident 15 were back to back. The RNC stated that resident 1 was going after resident 15. The RNC stated that the second 2 altercations resident 15 was going after resident 1. The RNC stated resident 1 was hard of hearing and did not want to talk about why resident 15 and him did not get along. The RNC stated he did not have the same issues with the other residents. The RNC stated staff were unable to determine what the issue was. The RNC stated resident 1 was impulsive related to his traumatic brain injury. The RNC stated that resident 1 flipped people off going down the hall for no reason. The RNC stated that the only thing that we could come up with was resident 1 had cognitive deficit but he was able to u [TRUNCATED]

Based on observation, interview and record review, it was determined the facility did not ensure that the resident's environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, hot water temperatures between 6 resident rooms were observed to range in temperatures from 128 to 150 degrees Fahrenheit (F). The deficient practice identified, in regards to the hot water, was found to have occurred at an Immediate Jeopardy level due to the potential risk of scalding and 3rd [MEDICAL CONDITION] the residents residing within the facility. Additionally, a resident who attempted to wander outside the facility was not investigated and incidents of falls were not documented on the care plan or new interventions put in place. These were additional findings were found to have occurred at a potential for harm and will not be included in the Immediate Jeopardy. Resident identifiers: 12, 17, 18, 22, 23, 29 and 186. NOTICE: Notice of the Immediate Jeopardy was given to the Administrator on 5/23/18 at 2:00 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to hot water temperatures. PLAN: On 5/24/18 at 10:20 AM, the Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan stated the following: Fairview Care Center-East 455 South 900 East Salt Lake City, UT Phone: [PHONE NUMBER] Fax: [PHONE NUMBER] DATE: 5-24-18 at 1020 hours at this time we feel that the immediate jeopardy has been removed. FROM: Jake(NAME)Administrator of Fairview Care Center-East and Rob(NAME)Owner of Fairview Care Center-East TO:(NAME)Bateman Long Term Care Survey Manager Utah Department of Health The purpose of this letter of abatement is to allege removal of the conditions that constitute the condition of immediate jeopardy on 5-23-18 at 1613 (4:13 PM) hours. The following is the plan to abate shown in bold and all action taken to allege removal of the conditions that constitute the condition of immediate jeopardy on 5-23-18. Water heaters have been drained of all excessive hot water. -Water heaters were immediately started to be drained at 1300 hours (1:00 PM) on 5-23-18 by the maintenance staff of all excessive hot and was completed at 1355 hours (1:55 PM) on 5-23-18. -Maintenance started check every room and shower room that has access to water at 1355 hours (1:55 PM) on 5-23-18 to make sure water was shut off. Every room and shower room that has access of water was checked and void of water of 1405 hours (2:05 PM) on 5-23-18. A Thermometer will immediately be installed on the mixing valve. -Owner called (local plumbing company) at 1400 hours (2:00 PM) on 5-23-18 and scheduled them to come in to install a thermometer on the mixing valve. -(Local plumbing company) arrived at the facility at 1430 hours (2:30 PM) on 5-23-18 and inspected mixing valve and stated that they would leave to get supply and return to change mixing valve -(Local plumbing company) returned to the facility at 1510 hours (3:10 PM) on 5-23-18 and started installing thermometer on the mixing valve. -(Local plumbing company) finnished installing thermometer on the mixing valve at 1635 hours (4:35 PM) on 5-23-18 -(Local plumbing company) walked Maintenance and Administration through increase and decrease of temperature on mixing valve at 1640 hours (4:40 PM) on 5-23-18. Three new Thermometers will be purchased immediately for the facility. -Administrator sent facility staff member to purchase three new thermometers from the store at 1415 hours (2:15 PM) on 5-23-18. Maintenance will be trained immediately on how to calibrate prior to continuing shift or starting next. -Owner and Administrator in-serviced Maintenance staff at 1420 hours (2:20 PM) on 5-23-18 on how to calibrate thermometers. Training will immediately be performed and given to all staff prior to continuing shift or starting next shift on recognizing water temperatures. -Owner and Administrator in-serviced department heads and all present day and evening staff on recognizing water temperatures at 1445 hours (2:45 PM) on 5-23-18. -Administrator and D.O.N. in-served on coming nurse prior to starting their shift on recognizing water temperatures at 1740 hours (5:40 PM) on 5-23-18. -Administrator and D.O.N. (Director of Nursing) in-serviced on coming N[NAME] (night) staff prior to starting their shift on recognizing water temperatures at 2010 hours (8:10 PM) on 5-23-18. -Administrator and D.O.N. in-serviced on coming day staff who have not yet received in-service prior to starting their shift on recognizing water temperatures at 0540 hours (5:40 AM) on 5-23-18. -Additional staffs were identified at 0800 hours (8:00 AM) on 5-24-18 that have not yet received in-service training and were notified from 0810-0900 hours (8:10 to 9:00 AM) on 5-24-18 that they will not be able to work until in-service on recognizing water temperature is completed. Training will immediately be performed and given to all staff prior to continuing shift or starting next shift on reporting hot temperatures to Nursing Maintenance and Administrator. -Owner and Administrator in-serviced department heads and all present day and evening staff on reporting hot temperatures to Nursing, Maintenance and Administrator at 1455 hours (2:55 PM) on 5-23-18. -Administrator and D.O.N. in-serviced on coming staff nurse to starting their shift on reporting hot temperatures to Nursing, Maintenance and Administrator at 1750 hours (5:50 PM) on 5-23-18. -Administrator and D.O.N. in-serviced on coming N[NAME] staff prior to starting their shift on reporting hot temperatures to Nursing, Maintenance and Administrator at 2020 hours (8:20 PM) on 5-23-18. -Administrator and D.O.N. in-serviced on coming day staff who have not yet received in-service prior to starting their shift on reporting hot temperatures to Nursing, Maintenance and Administrator at 0550 hours (5:50 AM) on 5-24-18. -Additional staffs were identified at 0800 hours on 5-24-18 that have not yet received in-service training and were notified from 0810-0900 hours on 5-24-18 that they will not be able to work until in-service on reporting hot temperatures to Nursing, Maintenance and Administrator is completed. Staff will recognize Temperatures and know that the temperatures will be in the range of 105-115 Fahrenheit. -Owner and Administrator in-serviced department heads and all present day and evening staff on proper temperature range at 1505 hours (3:05 PM) on 5-23-18. -Administrator and D.O.N. in-serviced on coming nurse prior to starting their shift on proper temperature range at 1600 hours (4:00 PM) on 5-23-18. -Administrator and D.O.N. in-serviced on coming NC staff prior to starting their shift on proper temperature range at 2030 hours (8:30 PM) on 5-23-18. -Administrator and D.O.N. in-serviced on coming day staff who have not yet received in-service prior to starting their shift on proper temperature range at 0600 hours (6:00 AM) on 5-24-18. -Additional staffs were identified at 0800 hours on 5-24-18 who have not yet received in-service training and were notified from 0810-0900 hours on 5-24-18 that they will not be able to work until in-service on proper temperature range is completed. Logs will be kept on all in-service training. -At 1430 hours on 5-23-18 calibration in-service was completed and signed off by maintenance staff. -At 1430 hours on 5-23-18 proper temperatures in each room and not taking a average temperature for the building was completed and signed by maintenance staff. -At 1445-1505 hours recognizing water temperatures, reporting hot temperatures and temperature range in-services were completed by department heads and present staff was completed and signed at 1510 hours on 5-23-18. -At 1740-1600 (sic) hours recognizing water temperatures, reporting hot temperatures and temperature range in-services were completed by on coming Nurse prior to starting their shift was completed and signed at 1610 hours on 5-23-18. -At 2010-2030 hours recognizing water temperatures, reporting hot temperatures and temperature range in-services were completed by on coming staff who have not yet received in-service prior to starting their shift was completed and signed at 0610 hours on 5-24-18. -Maintenance started a log at 1700 hours on 5-23-18 for water temperatures in every room and shower room that has access to water. Temperatures will be tested and logged in every room and shower room that has access to water for every hour until temperatures are within acceptable range. After temperatures are within acceptable range then every room and shower room that has access to water will be tested every four hours until in compliance. -Maintenance started testing 1700 hours on 5-23-18 all temperatures of water in every room and shower that has access to water on an hourly basis. -Maintenance started testing at 2300 hours (11:00 PM) on 5-23-18 all temperatures of water in every room and shower room that has access to water every four hours. Maintenance will be in-serviced on taking proper temperatures in each room and not taking an average temperature for the building. -Owner and Administrator in-serviced Maintenance staff at 1420 hours on 5-23-18 on taking proper temperatures in each room and not taking an average temperature for the building. D.O.N. will immediately interview and observe all residents [MEDICAL CONDITION] potential [MEDICAL CONDITION] document in nurses notes and weekly skin checks -D.O.N. and nursing staff starting skin checks observation and interviews were started at 1620 hours on 5-23-18. -D.O.N. and nursing staff competed skin checks observation and interviews at 1735 hours (5:35 PM) on 5-23-18. -D.O.N. charting on all completed skin checks observation and interviews at 1810 hours (6:10 PM) on 5-23-18. This was signed by the Administrator on 5/24/18 at 10:20 AM Prior to leaving the facility on 5/24/18, the surveyors confirmed the components outlined above in the written plan of action had been implemented. During the survey on 5/24/18 the surveyors confirmed removal of the Immediate Jeopardy situation as of 5/24/18. Deficient practice with the potential for more than minimal harm remained for the risk of injury. Findings include: Immediate Jeopardy: 1) Resident 12 was admitted to the facility on with [DIAGNOSES REDACTED]. On 5/21/18 at 9:10 AM, an interview was conducted with resident 12 related to the hot water temperature. Resident 12 stated that when the certified nurses assistants (CNA's) gave him a shower that a couple of times they scalded me, the water was so hot. (Note: all temperatures listed are in Fahrenheit.) On 5/23/18 at 10:40 AM, the water temperature was taken in the main bathroom where residents shower. The thermometer read 122.5 degrees. At 10:50 AM, the thermometer's calibration was checked and it read 31.3 degrees in an ice slurry. At 11:00 AM, the handsink shared between rooms [ROOM NUMBERS] was checked. The water temperature read 128 degrees. The handsink temperature was checked between room [ROOM NUMBER] and 110. The water temperature read 128 degrees. At 11:20 AM, room the handsink shared between rooms [ROOM NUMBERS] was checked. The water temperature read 148 degrees. The Maintenance Director was asked to accompany surveyor and observe the temperatures. He observed the temperature of the handsink between rooms [ROOM NUMBERS] and the thermometer read 150 degrees. He stated the goal temperature was 102 degrees. The temperature for the handsink for rooms [ROOM NUMBERS] was rechecked with the Maintenance Director and it read 136 degrees. The Maintenance Director stated that during the winter months he had to turn the water heater up to compensate for the pipes getting cold. He stated that since the weather had been getting warmer, it was likely time for him to adjust the water heater back down. When the Maintenance Director was asked if he had any concern about residents who were confused and had access to such hot water, he acknowledged there was a concern. At 11:30 AM an interview was conducted with the owner of the facility and the Administrator. The administrator stated the temperatures were measured weekly. The owner stated that each room should be measured and documented individually. The owner was unaware that an average of the temperatures was what was recorded on the log. The owner and Administrator were informed of the water temperature of 150 degrees. The owner acknowledged that 150 degrees was too hot. A log of temperature audits for the facility was requested from the Maintenance DDirector. The Maintenance Director brought the temperature logs for the month of (MONTH) (YEAR) and it went as follows: a) Week 1 103 b) Week 2 104 c) Week 3 103 d) Week 4 102 The Maintenance Director stated he measured the temperature in all of the rooms and recorded the average. The Maintenance Director stated he did not have a log of the individual room temperatures. A record of the last year of temperatures was requested and provided. The entirety of the log looked similar to the recording above, a single temperature for each week. The Maintenance Director brought the thermometer he used to take the temperatures. His thermometer and this surveyor's thermometer measured the sink between rooms [ROOM NUMBERS] simultaneously. This surveyor's thermometer read 150 degrees and the Maintenance Director's thermometer read 100 degrees. When asked if they calibrated their thermometers, the Maintenance Ddirector and owner stated they were not aware that thermometer required calibration. The facility's thermometer was then put in ice and it read 20 degrees. At 11:40 AM, the water heaters were observed. There were two water heaters. One emptied into the other as the hot water was used. There was one pipe extending out of the main water heater into the facility. On that pipe, a mixing valve was observed. The mixing valve was observed to lack a thermometer. The Maintenance Director was present. He was asked how he measured the temperature of the water as it exits the water heater and he stated it was by frequent testing and tweaking the valve. It was observed that the main water heater was set at Very Hot (the highest setting). At 11:43 AM, the charge nurse on duty was requested to make a list of resident who were independently ambulatory and confused. Of the rooms of 101 and 103, 3 of the 4 residents were ambulatory and confused. Of the rooms of 107 and 109, 3 of the 5 were ambulatory and confused. Of the rooms of 108 and 110, all were ambulatory and confused. At 11:47 AM, the owner stated that the hot water had been shut off and the water heaters had been drained. At 11:55 AM, the Maintenance Director revealed that multiple new thermometers had been purchased. At 12:04 PM, an interview was conducted with resident 17. Resident 17 stated she showered by herself. Resident 17 stated sometimes the water got real hot and was like fire. At 12:06 PM an interview was conducted with resident 18. Resident 18 stated he showered himself. Resident 18 stated I'm too fast for the hot water. Resident 18 stated he had to move out of the way of the hot water At 12:07 PM an interview was conducted with resident 23. Resident 23 stated that sometimes the water got too hot and would hurt her skin. At 12:08 PM an interview was conducted with resident 29. Resident 29 stated that sometimes the water was so hot she had to step out of the stream. Potential for Harm 1) Resident 186 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/22/18 a record review was conducted. The following was identified in the nursing progress notes: a) 3/30/18 Res (resident) alert, confused, tried to jump fence, redirected . A review of the incident log revealed that this incident was not documented or investigated. On 5/24/18 at 9:45 AM, an interview was conducted with the director of nursing (DON). The DON stated that resident 186's adjustment to the facility was difficult. The DON stated resident 186 had a lot of wandering episodes. The DON stated if wandering escalated to the point a resident attempted to jump the fence, she would expect that to be considered an incident that would require an investigation. The DON stated she was not aware of any attempts to jump the fence by resident 186. When the progress note dated 3/30 was revealed, she stated she was not aware of the occurrence. 2) Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/18 at 3:31 PM, an observation was made of resident 23. Resident 23 was observed ambulating independently down the hallway while dragging the right foot. Resident 23's gait appeared unsteady and a mobility device was not utilized. Foot wear was tennis shoes. A dressing was observed on resident 23's left knee. On 5/21/18 resident 23's medical records was reviewed. Review of the incident reports revealed the following: a. On 2/24/18, the resident was found outside on the ground. Resident 23 stated, I slipped on the ice. Injuries included 1 millimeter (mm) by 1 mm scrap (sic) on left hand and scraps (sic) on left knee. Pain medication was provided. Corrective action identified was to inform the maintenance staff to investigate the patio for ice, no ice was observed. The resident was documented as not utilizing a walker. Interventions identified in the progress note stated, pt (patient) educated on safety and staff assistance. Pt continues to go to smoking area on non-scheduled smoke breaks. Cue/reminders and redirection required and effective. No documentation could be found that the physician and family was notified. b. On 5/20/18, the resident fell forward on her knees, scraped both knees, left hand and left elbow. Left knee wound was cleansed with normal saline, [MEDICATION NAME] was applied and a 4 X 4 island dressing was applied. Corrective action was documented as resident refused walker. No new interventions were identified. The physician and family was notified. Review of the progress notes revealed additional falls identified on the following dates: a. 4/22/18: 1400 (2:00 PM military time) smoke; pt with this RN (registered nurse) ambulating outside. Pt lost gait walking heat 1st . stabalized (sic). staff on both sides pt then assisted to floor, unable to hold self up. No injuries noted. No c/o (complaints of) pain. VSS (vital signs stable). Will report and continue to monitor. No new interventions were identified. No documentation could be found that the physician and family was notified. b. 4/20/18: (resident's name) stood up from couch with full mug in hand. As she stood mug started to spill, (resident's name) lost balance trying to upright mug, falling forward onto knees. Fall witnessed by this nurse. Assisted resident, full ROM (range of motion) to BLE (bilateral lower extremities). Superficial scrapes to BLE/knees. No tx (treatment) necessary. Notified Dr. (doctor), no new orders. Discussed safety with (resident's name), she agreed that she will keep mug on table rather than in hand, so she can stand without difficulty. (resident's name) ambulating without complaint. No documentation could be found that the family was notified. c. 3/6/18: Pt and other going out to look for smoke, fall (sic) in TV, no walker use, will continue to monitor. No new interventions were identified. No documentation could be found that the physician and family was notified. d. 2/29/18: Pt fell off toliet (sic) seat to floor, Pt told to use light and walker, will continue to monitor. No new interventions were identified. No documentation could be found that the physician and family was notified. e. 2/26/18: Res (resident) sat on the floor in her room layed down on floor and stated she fell on her knees. She needed a pain pill as she had so much pain in her knees- assisted to stand-walked down to dining room- she kept yelling for pain pill for her knees. explained to res- no way did she fall on her knee's as she was on her back- she stated- I rooled (sic) onto my back-explained she would have to use her knees to roll over- she stated - well they still hurt. Res walked down to dinning (sic) room. When it became time for next smoke break - she hurried outside to get her smoke no pain noted. No new interventions were identified. No documentation could be found that the physician and family was notified. Review of the Fall Risk assessment completed on 2/8/18 and 2/22/18 has a score of 6, 10 or above indicated a HIGH RISK. Review of MDS admission assessment on 2/21/18 revealed a Care Area Assessment (CAA) that triggered for falls. Review of the care plan revealed no focus area for falls. On 5/22/18 at 3:01 PM, an interview was conducted with resident 23. Resident 23 stated she fell all the time and injured her knees and hands, so the facility provided her with a walker today. Resident 23 stated that she felt like it helped her with ambulating. On 5/24/18 at 9:54 AM, an interview was conducted with the DON. The DON stated that she would expect to see a care plan for falls. The DON was informed of the CAA for falls and the additional falls without an incident report or new interventions. No additional information was provided.