Every finding on record at Marquis Autumn Hills Memory Care

Based on observation, interview, and record review it was determined the facility failed to provide functional call lights for 3 of 3 sampled residents (#s 20, 21, and 26) reviewed for accommodation of needs. This placed residents at risk for not being able to call for assistance. Findings include: The facility's 1/2016 Assessment for Ability to Make Use of Electric Call System policy instructed facility staff to assess residents for call light use at admission and when a significant change occurred. The policy instructed facility staff to document identified call light safety risks in the resident's record.a. Resident 20 was admitted to the facility in 2/2024 with diagnoses including unspecified dementia.Resident 20's 8/30/25 revised care plan revealed she/he used a pressure sensitive call light pad. b. Resident 21 was admitted to the facility in 8/2025 with diagnoses including unspecified dementia and repeated falls.Resident 21's 2/14/26 revised care plan did not include information related to call light use. c. Resident 26 was admitted to the facility in 6/2019 with diagnoses including Alzheimer's disease.Resident 26's 8/18/23 Call Light Safety Assessment revealed the resident was aware and able to use a call light. On 2/23/26 at 10:26 AM, 2/24/26 at 8:25 AM, and 2/25/26 at 9:25 AM Residents 20, Resident 21, and Resident 26 were observed to have their call lights unplugged from the call light box in their rooms, and no alternative means to call for assistance.On 2/24/26 at 2:21 PM Staff 9 (CNA) stated residents were to have functional call lights and stated she did not know why Resident 20, Resident 21, and Resident 26 did not have functional call lights. She stated staff were always present in the unit and the residents without functional call lights were either independent with care or sought out staff when they needed assistance. On 2/25/26 at 10:24 AM Staff 7 (RN) stated every resident was supposed to have a functional call light. She stated she did not know the reason Resident 20, Resident 21, or Resident 26 did not have functional call lights. Staff 7 stated the staff did regular rounding to check on residents and were close enough to hear residents yelling for help.On 2/25/26 at 11:00 AM Staff 8 (Maintenance Director) stated he was notified of new admission call light placement needs before a resident was admitted to the facility and stated he was notified through an internal facility system for broken or missing call lights. Staff 8 stated he painted Resident 26's room on 2/22/26, removed the call light, and forgot to replace it. He stated Resident 21 should have a functional call light but could not identify why one was not in place. Staff 8 stated Resident 20's call light was removed when he replaced the batteries in the call light box on 2/24/26. Staff 8 acknowledged the lack of functional call lights for Residents 20, 21 and 26. On 2/26/26 at 1:32 PM Staff 2 (DNS) acknowledged functional call lights were required for all residents.

Based on interview and record review it was determined the facility failed to provide adequate monitoring of antipsychotic medication use for 1 of 5 sampled residents (#16) reviewed for medications. This placed residents at risk for adverse side effects of antipsychotic medication. Findings include: Resident 16 was admitted to the facility on [DATE] with diagnoses including vascular dementia with agitation and depression.A 1/12/26 physician order revealed Resident 16 was prescribed quetiapine 75 MG (an antipsychotic medication) twice daily.A review of Resident 16's medical record revealed no indication an Abnormal Involuntary Movement Scale (AIMS) (used to identify if symptoms/side effects of psychoactive medication use were present) assessment was completed.On 2/26/26 at 3:58 PM Staff 2 (RNCM/DNS/IP) stated Resident 16 was already on an antipsychotic medication upon admission, so her understanding was Resident 16 did not require an AIMS completed until six months after admission.On 2/26/26 at 4:10 PM Staff 11 (Regional RN Consultant) stated Resident 16 required an AIMS assessment completed upon admission and every six months as the resident received antipsychotic medication. Staff 11 confirmed Resident 16 did not have an AIMS completed upon admission.

Based on observation, interview and record review it was determined the facility failed to ensure assistance was provided with dressing and personal hygiene for 1 of 3 sampled residents (#9) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include:Resident 9 was admitted to the facility on [DATE] with diagnoses including delusional disorders.The 2022 [NAME] Standards of Care indicated the following:-Staff were required to change residents' clothing each day. -Staff were required to shave residents as needed. The 10/2025 Care Plan indicated the following:-Resident 9 required supervision and assistance to complete dressing.-Ensure clothing and footwear was clean.-Provide assistance with dressing after resident attempted each step. -Pick out a couple appropriate outfits and offer me choices.The Kardex indicated Resident 9 required constant supervision with cueing and minimal physical assistance during shaving.The 11/2025 Quarterly MDS indicated Resident 9 had a BIMS score of 6 which indicated the resident was cognitively severely impaired. The 2/25/26 Medical Record indicated Staff 9 (CNA) provided assistance to complete personal hygiene. From 2/24/26 through 2/26/26 from 8:00 AM to 4:00 PM, Resident 9 was observed wearing the same blue sweater, sweatpants and socks. Resident 9's beard was long with white and brown hair. Resident 9's mustache was thick and overgrown down to her/his top lip. On 2/24/26 at 1:27 PM, Resident 9 acknowledged her/his long beard and stated she/he had not shaved. Resident 9 stated she/he allowed staff to shave her/his beard. On 2/25/26 at 9:11 AM, Resident 9 was resting in bed. Resident 9 stated he was unsure when she/he last changed clothes or shaved her/his beard. On 2/25/26 at 1:30 PM, Resident 9 was observed leaving the facility for an outing and was wearing the same clothes she/he wore all day the previous day. On 2/26/26 at 9:44 AM, Staff 9 stated Resident 9 was independent and cooperative. Staff 9 stated Resident 9 required staff to set up personal hygiene supplies including clothes daily. Staff 9 stated she was unable to shower her/him or set up supplies because she was busy with other residents. On 2/26/26 at 10:01 AM Staff 7 (RN) stated Resident 9 was redirectable, cooperative and did not refuse care. Staff 7 stated Resident 9 was able to complete daily personal hygiene independently. Staff 7 stated she expected staff to set up personal hygiene supplies, including clothing daily. Staff 7 stated staff notified her if residents refused care. Staff 7 stated Resident 9 did not refuse personal hygiene assistance during the week. On 2/26/26 at 11:23 AM, Staff 2 (RNCM/DNS/IP) stated she monitored the medical electronic system to ensure personal hygiene tasks were completed and followed up with staff if incomplete documentation was observed. Staff 2 stated Resident 9 was cooperative and redirectable and did not refuse care. Staff 2 stated she felt disturbed to hear Resident 9 was wearing the same clothes for the last three days because she/he was redirectable and completed personal hygiene.

Based on interview and record review it was determined the facility failed to provide residents with a written bed hold notification, including reserved bed hold payment, at the time of transfer to the hospital for 1 of 1 sampled resident (#5) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include:Resident 5 was admitted to the facility in 4/2024 with diagnoses including diabetes and heart disease.A review of Resident 5's clinical record revealed she/he was transferred to the hospital on the following dates: 11/19/25, 11/29/25, 12/2/25, 12/21/25, and 2/10/26. No evidence was found in Resident 5's clinical record to indicate written notice of the facility's bed hold policy was provided to the resident or her/his representative when she/he was transferred to the hospital.On 2/26/26 at 3:47 PM Staff 10 (LPN Resident Care Manager) stated upon transfer to the hospital, the charge nurse was to open an assessment in the resident's medical record and provide the resident with a bed hold notification.On 2/27/26 at 10:01 AM Staff 2 (RNCM/DNS/IP) confirmed a written bed hold notification was not provided to Resident 5 or her/his representative at the time of transfer to the hospital on the specified dates.

Based on interview and record review it was determined the facility failed to honor the resident's right to be free from physical abuse from other residents for 1 of 6 sampled residents (#2) reviewed for abuse. This placed residents at risk for physical abuse. Findings include: Resident 2 admitted to the facility in 3/2025 with diagnoses including Alzheimer's disease. Resident 2's 3/17/25 Admission MDS revealed she/he had a BIMS of 9, which indicated moderate cognitive impairment. Resident 3 admitted to the facility in 8/2023 with diagnoses including dementia. Resident 3's 2/24/25 Quarterly MDS revealed she/he had a BIMS of 12, which indicated moderate cognitive impairment. An 4/19/25 facility Investigation Summary and Conclusion revealed on the morning of 4/19/25 Resident 2 and Resident 3 were in their shared room asleep when Resident 2 woke up and turned on the overhead light. Resident 3 woke up and became angry, swore at Resident 2, and pushed her/him back onto her/his bed. Resident 3 then went to the common television room to complain about the overhead light being on. The facility moved the residents to different rooms. Neither resident was injured during the incident. Resident 2's 4/19/25 Resident to Resident Event Assessment revealed Resident 2 was interviewed after the incident and stated Resident 3 cursed at her/him when the bedroom light was turned on. Resident 2 stated Resident 3 then shoved her/him hard onto the bed and attacked her/him because she/he turned on the light. Resident 2 stated the incident scared her/him and she/he complained of left shoulder pain later in the day. Resident 3's 4/19/25 Resident to Resident Event Assessment revealed Resident 3 was interviewed after the incident and stated Resident 2 stood over her/his bed yelling and Resident 3 then pushed Resident 2 onto her/his bed. On 5/15/25 at 7:51 AM Staff 6 (CNA) stated she worked on 4/19/25 and recalled the incident between Resident 2 and Resident 3. Staff 6 stated she found Resident 3 screaming about pushing Resident 2 because she/he turned the light on. Resident 2 was very scared and wanted to be out of the shared room. The two residents were then separated. On 5/15/25 at 1:25 PM Resident 3 stated she/he and Resident 2 had many issues because they shared a room and Resident 2 turned the light on every night. Resident 3 stated on 4/19/25 Resident 2 woke her/him up when she/he turned the light on. Resident 3 stated the two residents then went back and forth turning the light on and off until she/he shoved Resident 2 onto the bed. On 5/15/25 at 1:32 PM Resident 2 stated Resident 3 was upset because she/he said the light was in her/his face and then Resident 3 shoved Resident 2 down on the bed. Resident 2 stated she/he was afraid at the time but felt safe now because the facility moved her/him out of the shared room. Resident 2 stated she/he felt abused by Resident 3 and no longer interacted with her/him. On 5/15/25 at 4:51 PM Staff 11 (LPN) stated on 4/19/25 she was called to the room Resident 2 and Resident 3 shared. Staff 11 stated Resident 3 was upset and stated she/he pushed Resident 2 because Resident 2 turned on the light. Staff 11 stated Resident 2 was upset and reported being scared. On 5/15/25 at 2:50 PM Staff 2 (DNS) stated she investigated the 4/19/25 event and concluded the incident met the definition of abuse. The deficient practice was identified as Past Noncompliance based on the following: On 4/19/25, the deficient practice was identified by the facility and was corrected when the facility implemented the following to prevent further incidents of resident to resident abuse: 1. Resident 2 and Resident 3 were separated, 2. The facility implemented auditing through alert charting, 3. The facility reviewed and updated Resident 2 and Resident 3's care plans.

Based on observation, interview, and record review it was determined the facility failed to ensure medication storage areas were secured and free of expired medication for 1 of 1 medication cart and 1 of 1 medication storage room reviewed for safe medication storage. This placed residents at risk for misappropriation of medications, adverse medication consequences and diminished treatment efficacy. Findings include: The facility's Storage of Medication Policy, revised ,d+[DATE], stated, The Facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 1. On [DATE] at 1:49 PM the Intemediate Care medication cart outside of room [ROOM NUMBER] was unlocked and unattended. On [DATE] at 1:53 PM Staff 4 (CMA) confirmed the cart was unlocked and unattended. On [DATE] at 1:00 PM Staff 1 (Administrator) was informed of these findings. No Additional information was provided. 2. On [DATE] at 7:44 AM a multidose bottle of Lorazepam (a controlled antianxiety medication) was found in the locked medication refrigerator with an expiration date of [DATE]. On [DATE] at 7:44 AM Staff 5 (LPN) confirmed the Lorazepam was expired. On [DATE] at 1:00 PM Staff 1 (Administrator) was informed of these findings. No Additional information was provided.

Based on observation, interview, and record review it was determined the facility failed to implement Enhanced Barrier Precautions for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to infections. Findings include: The facility's undated Isolation - Categories of Transmission-Based Precautions policy indicated Enhanced Barrier Precautions were to be used for residents with catheters and complex wounds. On 10/21/24 Staff 1 (Administrator) provided a list of residents with catheters which included Residents 2, 8, and 14. On 10/22/24 at 12:38 PM Resident 2 and Resident 14's rooms were observed with no signage to indicate they were on Enhanced Barrier Precautions. At this time Staff 8 (CNA) stated there were no residents with precautions on the hall. On 10/22/24 at 2:10 PM Resident 8's room was observed with no signage to indicate she/he was on Enhanced Barrier Precautions. On 10/22/24 at 2:16 PM Staff 2 (DNS) stated the facility implemented Enhanced Barrier Precautions for Resident 2, Resident 8, and Resident 14 due to catheter use. Staff 2 stated there were no signs or indicators about Enhanced Barrier Precautions on the resident rooms at this time because the facility was waiting for blue sticker dots be delivered. Staff 2 further stated the facility did not store PPE in the hallways, but it was available to staff in the spa. Staff 2 went to the spa on the ICF hall to show the PPE storage and discovered the hospital gowns were not stored there. Staff 7 (CNA) offered assistance to Staff 2 and stated none of the residents on the ICF hall had precautions of any kind. Staff 2 told Staff 7 the facility were to follow Enhanced Barrier Precautions for all residents with an indwelling catheter. Staff 7 stated she was not aware and the facility staff were not doing that. Staff 2 then confirmed the facility did not implement Enhanced Barrier Precautions.

Based on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at risk for being uniformed of psychotropic medication. Findings include: Resident 9 was admitted to the facility in 8/2024 with the diagnoses including vascular dementia. The 10/22/24 Physician Orders revealed an order for Duloxetine (antidepressant)to be administered daily. The medical record revealed no evidence risk and benefit information for Duloxetine was reviewed with Resident 9. On 10/24/24 at 11:05 AM Staff 6 (LPN Resident Care Manager Support) acknowledged risk and benefit information related to the use of Duloxetine was not provided to Resident 9.

Based on interview and record review it was determined the facility failed to assess significant weight loss for 1 of 2 sampled residents (#11) reviewed for nutrition. This placed residents at risk for additional weight loss. Findings include: Resident 11 admitted to the facility in 5/2023 with diagnoses of vascular dementia and malnutrition. A 5/2/23 Nutrition Care Plan revealed Resident 11 was at risk for impaired nutrition due to severe malnutrition and vascular dementia with a goal of Resident 11 maintaining or increasing her/his weight to above 167 pounds. The interventions for Resident 11 included a referral to a dietitian for evaluation and recommendations as needed. A 5/12/24 Dietitian Assessment revealed Resident 11 weighed 157.4 pounds and weight gain was beneficial. A 7/23/24 Provider Progress Note revealed Resident 11 weighed 164.9 pounds, her/his weight was stable for the last six months, no additional interventions were put in place. An 8/21/24 Provider Progress Note revealed Resident 11 weighed 164.8 pounds, her/his weight was stable for the last six months, no additional interventions were put in place. A 9/24/24 Provider Progress Note revealed Resident 11 weighed 156.4 pounds, her/his weight was down 10 pounds over the last month and seven pounds over the last six months. No additional interventions were put in place. A review of the 7/2024 through 10/2024 Progress Notes revealed no additional assessments of Resident 11's weight loss. An 10/11/24 Quarterly MDS indicated Resident 11 did not have weight loss and weighed 159 lbs. An 10/11/24 Summary Dietary revealed Resident 11 currently weighed 158.6 pounds, and over the last 180 days Resident 11 had significant weight loss. An 10/17/24 Summary Nursing assessment did not address Resident 11's weight loss. Resident 11's Weights and Vitals Summary revealed the following weights: - 4/12/24: 178.3 pounds - 7/12/24: 164.4 pounds - 9/13/24: 157 pounds - 10/11/24: 158 pounds - 10/14/24: 157.4 pounds - 10/18/24: 152.4 pounds - 10/23/24: 150 pounds On 10/22/24 at 2:48 PM Staff 6 (Resident Care Manager Support) reviewed Resident 11 and stated she did not identify weight loss on the 10/11/24 MDS but confirmed Resident 11 did have over a 10 percent weight loss in the last six months. Staff 6 stated when weight loss was identified she was to notify the provider, the family, make a registered dietitian referral, and add the resident to the Nutrition at Risk list. On 10/23/24 at 9:52 AM Staff 10 (Registered Dietitian) stated she was last at the facility on 10/18/24 and did not see Resident 11. Staff 10 stated she expected to be notified of any significant weight loss. Staff 10 confirmed she did not assess Resident 11 since 5/2024, but her/his goal was to maintain or increase her/his weight. Staff 10 stated the facility should have notified her of Resident 11's weight loss. Staff 10 stated when notified of a resident with significant weight loss she assessed her/him to see what else was going on. Staff 10 stated Resident 11 had a diagnosis of congestive heart failure so the facility needed to ensure the weight loss was not fluid related. On 10/24/24 at 11:23 AM Staff 3 (Regional RN) stated when weight loss was identified the staff were to make a referral to the registered dietitian, add the resident to nutrition at risk, and do a nutrition and weight assessment; Staff 3 confirmed these interventions were not in place for Resident 11.

Based on interview and record review it was determined the facility failed to offer pneumococcal immunizations for 1 of 5 sampled residents (#27) reviewed for immunizations. This placed residents at risk for lack of vaccination. Findings Include: Resident 27 admitted to the facility in 2/2024 with diagnoses including chronic pain. Resident 27's immunization records did not indicate if she/he was assessed for, offered, or declined a pneumococcal vaccination following admission to the facility. On 10/24/24 at 12:06 PM Staff 3 (Regional RN) stated the medical record showed no documentation the facility offered a pneumococcal vaccination to Resident 27.

Based on interview and record review it was determined the facility failed to act upon complaints of hip pain and rule out significant injury after multiple falls for 1 of 3 sampled residents (#3) reviewed for falls. As a result, Resident 3 experienced prolonged pain over a period of four weeks, and a delay in diagnosis of hip fracture requiring hospitalization and surgery. The hip fracture was not diagnosed until 8/5/23, 31 days after her/his fall on 7/4/23. Findings include: Resident 3 was admitted to the facility in 3/2023, with diagnoses including stroke and dementia. Resident 3's care plan dated 2/28/23 noted she/he was was a fall risk due to impaired mobility, gait unsteadiness and decreased safety awareness due to her/his cognitive impairment. The care plan indicated Resident 3 had experienced falls in 3/2023 and 6/2023. Resident 3's Progress Notes revealed she/he experienced three falls on 7/4/23, 7/8/23 and 7/9/23. The 7/4/23 Post Fall Assessment revealed Resident 3 attempted to stand, fell and hit her/his head and hip and reported pain in her/his back, left side of her/his head, left hip and right shoulder. The 7/8/23 Post Fall Assessment revealed Resident 3 attempted to stand, fell and complained of pain in her/his left hip. The facility provider was notified and ordered a hip and spine x-ray. The 7/9/23 Post Fall Assessment revealed Resident 3 attempted to self transfer, fell from the chair she/he was seated in and was observed to slide to the floor by staff. Resident 3 complained of pain everywhere. On 7/11/23, a progress noted written by Staff 3 (RCM) stated the x-ray was canceled by the service provider. Resident 3's 7/2023 and 8/2023 Progress Notes documented the following dates she/he experienced pain: - 7/4/23 at 6:31 PM: Resident complained of pain - 7/4/23 at 8:59 PM: Resident had a non witnessed fall this evening. Resident stated she/he hit her/his head and hip .Resident also complained of pain to lower lateral left back and right shoulder. - 7/5/23 at 2:34 AM: Resident complained of pain all over. - 7/5/23 at 12:46 PM: Resident this morning complained of discomfort from fall, resident just had scheduled medication. - 7/6/23 at 2:10 PM: Post fall, no injuries noted, complained of leg pain. - 7/7/23 at 1:15 AM: Resident complained of pain in her/his legs. - 7/7/23 at 10:54 AM: Resident states only pain is related to her/his legs especially during wound care. - 7/8/23 at 10:38 AM: Medication given for leg pain per LN (licensed nurse). 6/10 pain scale. - 7/8/23 at 1:05 PM: Resident took a shower today, complained of legs burning after shower .There is some increased generalized weakness, accompanied by general aches/pains after shower. - 7/8/23 at 3:12 PM: Resident had a fall this afternoon during shift change. Resident was following another resident and lost her/his balance and fell in the common area. She/he did not hit her/his head, but does complain of pain in her/his left hip where she/he fell . - 7/9/23 at 4:42 AM: Resident was sleeping in the living room tonight .she/he tried to stand on her/his own and slid off the chair .Pain pill given for complaints of generalized pain. - 7/10/23 at 7:45 AM: Resident complained of 6/10 pain. - 7/11/23 at 7:46 AM: Resident complained of pain. - 7/12/23 at 12:23 PM: Post multiple falls, resident per baseline, noted pain in legs. - 7/14/23 at 4:18 PM: Resident complained of back pain. - 7/15/23 at 9:41 AM: Resident complained of pain per LN 7/10. - 7/16/23 at 8:24 AM: Resident complained of leg pain 6/10 per LN. - 7/16/23 at 12:51 PM: Resident was pulling at Unna boots, complained of burning on the right leg. - 7/17/23 at 8:30 AM: Resident complained of leg pain. - 7/18/23 at 1:51 AM: Resident complained of pain in her/his legs. - 7/19/23 at 1:51 AM: Resident complained of pain in her/his legs. - 7/19/23 at 4:57 AM: Resident appeared to be restless, she/he complained of pain in her/his legs. - 7/20/23 at 1:34 AM: Resident complained of pain in her/his legs. - 7/20/23 at 5:20 AM: Resident refused to sleep in her/his bed. She/he stated that she/he was uncomfortable in bed she/he complained of pain in her/his legs. - 7/21/23 at 2:15 AM: Resident complained of pain in her/his legs. - 7/21/23 at 4:44 AM: Resident appeared to be restless/anxious all NOC. She/he was given a snack, complained of pain in her/his legs. - 7/22/23 at 5:40 AM: Please rule out pain as contributing factor; complaint of pain when Unna boots had to be reapplied. - 7/22/24 at 10:28 AM: Resident complained of burning leg pain once during shift. - 7/22/23 at 11:11 AM: Resident complained of pain in both legs. - 7/24/23 at 1:03 AM: Resident complained of pain in her/his legs. - 7/24/23 at 9:31 AM: Resident complained of pain in both legs. - 7/24/23 at 12:42 PM: Resident up this morning, calling out for help constant, pain medications have been offered for legs pain. - 7/25/23 at 9:07 AM: Complained of leg pain. - 7/26/23 at 7:40 AM: Resident complained of pain 6/10 per LN. - 7/27/23 at 1:30 AM: Resident complained of pain in her/his legs. - 7/27/23 at 9:55 AM: PRN Administration was ineffective. Continue complaints of back pain. - 7/27/23 at 10:02 AM: Resident complained of leg pain per LN. - 7/28/23 at 1:30 AM: Resident complained of pain in her/his legs. - 7/28/23 at 4:21 PM: Resident complained of lower back pain. - 7/28/23 at 8:11 PM: Resident was observed restless this evening, frequently standing, grimacing, complained of leg pain. - 7/29/23 at 11:24 AM: Complained of leg pain. - 7/29/23 at 4:50 PM: Resident had complaint of back pain. - 7/29/23 at 7:35 PM: Resident expressed pain when staff raised legs to install new dressings. - 7/30/23 at 3:14 AM: Resident is complaining of her/his legs are burning and her/his back hurts. Medicated with PRN Norco at 11:30 PM, appears to have no effect .at this time she/he appears anxious, continuously asking us to not hurt her/him or why we hate her/him. - 7/30/23 at 12:57 PM: Resident awake all morning, constant asking for assist, crying out, trying to walk without assist in dining. - 7/31/23 at 1:43 AM: Resident complained of pain in her/his legs. - 7/31/23 at 12:19 PM: Complained of back pain. - 7/31/23 at 11:58 PM: Resident complained of pain in her/his legs. - 8/1/23 at 7:39 AM: Resident complained of pain 8/10 per LN. - 8/2/23 at 5:51 AM: Increase complained of pain noted, resident slept on and off throughout the NOC complaining of pain in her/his legs. - 8/2/23 at 8:24 AM: Report stated that patient didn't sleep well last night due to pain. Made multiple changes to RX for pain on 8/1/23, but she/he no longer has any PRN pain RX. Messaged nurse practitioner to request possible PRN. - 8/2/23 at 8:29 PM: Resident has been uncomfortable, grimacing, calling out in pain in her/his left hip and leg off and on for several hours. Occasionally re-directable but she/he returns to complaints of pain after a few minutes. She/he does not want to lay down, she/he will not keep her/his legs elevated. Family is very worried that the current dose/frequency of medication is not effective, they note she/he is rarely vocal about pain. - 8/2/23 at 10:14 PM: PRN did not control pain, resident continues to call out, wince in pain, is tense, restless. - 8/3/23 at 5:40 AM: Resident has been up all shift in her/his wheelchair .continues to call out, try to get up unassisted and call out in pain. She/he told this LN her/his pain is in the lower back, left hip or left leg at different times She/he had her/his PRN dose at 2030 but continues to complain of pain. - 8/3/23 at 2:23 PM: Resident was re-evaluated and it was determined current pain regimen was ineffective Resident was sitting in her/his wheelchair, again identifying that her/his bilateral lower extremities were in pain. - 8/3/23 at 3:39 PM: New orders to start oxycodone [a pain medication] 5 mg every 6 hours scheduled and Norco 5/325 BID for breakthrough pain. There is to be 3 hours between the oxycodone and Norco doses. - 8/4/23 at 2:58 AM: Resident appeared to be restless when assisted to bed at the beginning of this shift complaining of back pain and leg pain. - 8/4/23 at 1:53 PM: Resident anxious at times, asking staff to sit with her/him. Complaint of back pain. - 8/4/23 at 10:37 PM: Resident started fidgeting, complained of left hip pain, restless, calling out for help .Received order for left hip x-ray STAT. - 8/5/23 at 2:06 AM: X-ray results: Acute Superiorly Displaced Subcapital Fracture of the Left Femoral Neck - Orders to send to ED for evaluation and treatment. Resident 3's 7/2023 MAR documented she/he was administered PRN Norco (a pain medication) 5/325 mg a total of 42 doses on the following dates: -On 7/1/23 - 1 time; -On 7/3/23 - 1 time; -On 7/4/23 - 2 times; -On 7/5/23 - 1 time; -On 7/6/23 - 1 time; -On 7/7/23 - 1 time; -On 7/8/23 - 1 time; -On 7/9/23 - 1 time; -On 7/10/23 - 2 times; -On 7/11/23 - 1 time; -On 7/14/23 - 1 time; -On 7/15/23 - 1 time; -On 7/16/23 - 2 times; -On 7/17/23 - 1 time; -On 7/18/23 - 1 time; -On 7/19/23 - 1 time; -On 7/20/23 - 1 time; -On 7/21/23 - 2 times -On 7/22/23 - 2 times; -On 7/23/23 - 2 times; -On 7/24/23 - 2 times -On 7/25/23 - 1 time; -On 7/26/23 - 1 time; -On 7/27/23 - 2 times; -On 7/28/23 - 2 times; -On 7/29/23 - 3 times; -On 7/30/23 - 2 times; -On 7/31/23 - 3 times. Staff 3 was not available for interview during the survey period. On 4/8/24 at 9:23 AM, Witness 2 (Complainant) stated Resident 3 complained of pain while in the facility after she/he experienced several falls. Witness 2 stated she had to yell to facility staff over the phone to get x-rays and this was when the hip fracture was discovered. On 4/9/24 at 1:10 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated the x-rays should have been rescheduled immediately after the service provider initially canceled on 7/11/23.

Based on interview and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 15 sampled residents (#2) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 2 was admitted to the facility in 1/2024 with diagnoses including dementia. Resident 2's most recent MDS assessment dated [DATE] revealed no BIMS score, which indicated she/he had severe cognitive impairment. Resident 2 had no behavioral issues documented. Resident 1 was admitted to the facility in 3/2022 with diagnoses including dementia and delusional disorder. Resident 1's most recent MDS assessment dated [DATE] revealed a BIMS score of 9, which indicated she/he had moderate cognitive impairment. Behaviors documented were physical and verbal symptoms directed toward others which placed other residents at significant risk of physical injury. Interventions were to remove her/him from the area and provide low stimulus diversional activities. On 2/23/24 the facility submitted a report which revealed on 2/23/24, Resident 1 was observed by staff standing over Resident 2 holding Resident 2's wrist. Resident 2 was lying on the couch in the living room. The residents were separated and Resident 2 was observed to have scratches on her/his face. On 4/8/24 at 1:20 PM Staff 7 (CNA) confirmed he was working the day of the incident. He stated Resident 1 needed close supervision due to her/his behaviors which included physical aggression toward other residents. Staff 7 stated he was on break when the incident occurred. On 4/10/24 at 11:57 AM Staff 6 (CNA) confirmed she was working the day of the incident. She stated she was in the living room with the residents and walked across the hall to wash her hands, then heard Resident 2 yelling. She ran into the living room and observed Resident 1 standing over Resident 2, who was lying on the couch. She observed Resident 1's hands to be on Resident 2's face. Staff 6 separated the residents and reported the incident to the charge nurse. Staff 6 stated she observed two skin tears on Resident 2's face as a result of Resident 1 grabbing Resident 2's face. On 4/8/24 and 4/9/24 both residents were observed and had no recall of the incident. On 4/10/24 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no further information.

Based on observation, interview and record review it was determined the facility failed to evaluate the effectiveness of current interventions and revise as necessary, to provide appropriate supervision to prevent elopement for 1 of 3 sampled residents (Resident 1). This placed residents at risk for serious injury or harm. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1's elopement from the locked memory care unit and the facility's secured courtyard on multiple occasions. Resident 1 also experience a non serious closed head injury following an episode of elopement from the secured courtyard. Findings include: Review of the facility's ,d+[DATE] Safety and Supervision of Residents policy included the following: Resident-Oriented Approach to Safety *2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and the MDS. *4. Implementing interventions to reduce the accident risk and hazards shall include the following b. assigning responsibility for carrying out interventions. *5. Monitoring the effectiveness of interventions shall include the following: b. evaluating the effectiveness of interventions c. modifying or replacing interventions as needed *6. Systems Approach to Safety 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazard in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. Review of the facility's ,d+[DATE] Wandering, Unsafe Resident policy included the following: *The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. *The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. *Utilizing wander guard or similar type bracelet to alert staff [may be] necessary to ensure the safety of the resident. *Staff will institute a detailed monitoring plan, as indicated for resident who are assessed to have a high risk of elopement or other unsafe behavior. Resident 1 admitted to the facility [DATE] with diagnoses including Alzheimer's disease with behaviors, diabetes and failure to thrive. Resident one expired in the facility on [DATE] due to failure to thrive. Review of Resident 1's baseline care plan revealed the following focus, goals and interventions with corresponding dates related to Resident 1's history of wandering: *[DATE] - Focus: I may wander or exit seek and am an elopement risk related to a history of elopement, wanting to go home and cognitive impairment. The resident was also noted to have an elopement history of leaving a setting and being unable to find [MEDICATION(S)] back, cognitive impairment. *[DATE] - Goal: I will not leave my secured environment unattended or without staff knowledge each day. Intervention: I may push, scratch, kick or shove staff when they try to redirect me away from the exit/entrance doors when I am exit seeking. The [DATE] Nursing Admission Assessment signed by Staff 23 (Resident Care Manager) indicated the following for Resident 1: *No joint mobility issues in any area of her/his body. *The resident was noted as ambulatory. *The resident was a fall risk related to her/his diagnoses of Alzheimer's disease, failure to thrive and type 2 diabetes. *The resident was admitted to the facility related to her/his elopement from a previous facility and walking into traffic. *The resident ambulated through the facility with her/his four wheel walker at a very steady pace . A [DATE] Physician Progress note at 11:45 AM indicated Resident 1 had a past history of dementia and failure to thrive. The resident was noted to speak very little English, have significant memory impairment, poor judgement and overall poor safety awareness. A [DATE] IDT progress note at 5:16 AM from Staff 7 (LPN) indicated the resident slept on and off most of the night in the living room. The resident was noted to refuse to sleep in her/his room and to state she/he was going home tomorrow. The resident was noted as difficult to redirect because of the language barrier. An IDT progress note at 1:39 PM by Staff 29 indicated the resident ambulated around the locked unit and continued standing near the exit doors, attempting to follow staff out almost every time someone opened the door, raising her/his voice, pushing, showing her/his fist to staff, [and the] resident stated[,] I go home. At 10:25 PM an IDT progress note by Staff 4 (RN) indicated the resident appeared to be agitated during the evening hours and stated she/he wanted to go home. The resident was noted to push and kick staff and refused her/his evening medications. The resident was noted to be hard to redirect at times due to the language barrier. A [DATE] IDT Progress Note at 1:24 PM indicated Resident 1 had been exit seeking and came out of the unit behind staff multiples times before she/he was redirected. A [DATE] Behavior Note at 1:27 PM indicated the resident hit and kicked staff, as well as scratched them when they attempted to redirect the resident back to the locked unit. The note indicated staff would continue to re-direct. Review of Resident 1's baseline care plan revisions revealed the following updated intervention on [DATE]: If I have gotten off the secured unit, I may sit on the floor if I am fatigued or if you do not understood what I want. Please allow me time to calm down/rest and then help me up into a wheelchair. If you leave me alone, I will get up and continue to try to leave. A [DATE] SBAR progress note completed by Staff 4 (RN) at 7:56 PM indicated the following about Resident 1: Resident has been attempting to escape the whole day and succeeded. Resident was able to climb out the fence and has been complaining of neck pain since we found [her/him]. Unable to perform full body assessment as resident is refusing and was combative. The note further indicates the resident was sent out to the emergency department. A [DATE] IDT Progress Note at 11:07 PM revealed Resident 1 was sent to the emergency department for further evaluation around 8:50 PM. On [DATE] Staff 4 signed off on her portion of the [DATE] completed Elopement Assessment, and indicated the following for Resident 1: *The resident was noted as missing on [DATE] at 7:30 PM, last seen at 7:25 PM and returned by staff to the facility at 7:39 PM. *The resident was a new admission to the facility and had been exit seeking all day saying [she/he] wants to go home . *The resident placed her/himself by the entrance/exit doors from the locked unit to the ICF and attempted to elope when staff would open the door. *The resident was placed on 15 minute checks and described the intervention as unsuccessful. *Upon return to the facility, the resident stated she/he climbed the fence and wanted to go home. *The resident complained of neck pain and asked staff to call 911. The resident was sent out to the emergency department. Review of Resident 1's clinical record revealed no evidence 15 minute safety checks were implemented for the resident as of [DATE]. The [DATE] After Visit Summary from an emergency department (ED) indicated the following for Resident 1: *The resident admitted [DATE] for a fall and neck pain. *The resident was diagnosed with a non-serious closed head injury (hard blow to the head with no break to the skull) with a risk for a more serious problem, such as bruising or bleeding of the brain. *The After Visit Summary indicated the resident needed to be monitored for possible symptoms related to her/his injury, see her/his primary care physician within three to four days, and return to the emergency department for subsequent falls. Review of Resident 1's baseline care plan revision revealed the following updated interventions: [DATE] Intervention revision: Resident 1 was documented to use her/his walker to get over fences by placing her/his walker on its side and stepping onto it; climbing over fences . and attempting to follow staff out of the exit/entrance door; pushing, scratching, kicking or shoving when yelling at staff that I want to go home or when staff try redirecting me, saying I want to fly back to [my country of origin] . *[DATE] - Focus: The resident was documented to have physical behaviors such as pinching, scratching, kicking, or shoving staff when staff attempt to redirect her/him away from the exit/entrance doors when exit seeking or during care. Interventions included for staff to discuss with Resident 1 her/his options for appropriate channeling of anger,15 minutes checks, reinforce reasons for placement and to take time every shift (at least 15 minutes) to listen and allow me to vent my feelings/frustrations. A [DATE] IDT Progress Note at 3:16 AM revealed Resident 1 returned from the emergency department at around 2:05 AM and was still complaining of neck pain. The resident received PRN Tylenol, and staff were awaiting a follow up for the effectiveness of the medication. The resident was noted to return with a closed head injury. The note documented hospital discharge instructions included to send the resident back to the emergency department immediately if the resident had a recurrent fall . On [DATE] Staff 23 (Resident Care Manager) signed off on the RN/RCM Follow-up portion of the [DATE] completed Elopement Assessment, and indicated the following for Resident 1: Investigation and staff interviews complete. [Resident 1] spent the afternoon of [DATE] attempting to leave the secured unit by sneaking behind staff out the door as they went through it and [she/he] also went out the door when the dietary cart came into the unit. [She/he] was found in different areas of the facility and returned to the secured unit. [She/he] had been checked on and then five minutes later [she/he] was found to be missing with [her/his] walker outside on the secured unit patio tipped over. Staff looked throughout the secured and unsecured areas of the facility. The kitchen staff member was outside looking for [Resident 1] when he found [her/him] near the sidewalk. Staff member notified a [LN], who brought other staff and a [wheelchair] to help [her/him] back to the facility. [Resident 1] did not want to get into the [wheelchair]. [She/he] finally conceded and got up with staff assist, sat in it and was wheeled [back] to the facility and onto the secured unit. LN attempted to do an assessment however [Resident 1] flailed [her/his] arms, grabbed [her/his] neck and said call 911. [She/he] kept repeating the phrase. Family and MD were notified with orders to send [the resident] to [the] [emergency department] to evaluate. Staff 23 indicated up Resident 1's return from the ED, 15 minute checks continued, as per facility protocol. On [DATE] Staff 25 (Social Service Assistant) signed off on the Social Service portion of the [DATE] Elopement Assessment. During an interview with Resident 1, Staff 25 asked the resident where she/he wanted to be, and the resident stated not here. Staff 25 noted Resident 1 spoke very little English which made communication difficult for her/him. Staff 25 noted 15 minute checks would continue for the resident. The [DATE] facility initiated 15 [minute] check documented on [DATE] at 3:00 AM, staff began to check off and initial when Resident 1 was checked on each fifteen minutes, around the clock. The document further revealed the following for Resident 1: *On [DATE] at 2:00 PM the resident was noted to be found prior . *On [DATE] the resident was not documented to have 15 minute checks occur between the hours of 2:30 PM and 10:15 PM. *On [DATE] the resident was not documented to have 15 minute checks occur between the hours of 1:15 PM and 2:15 PM. *On [DATE] the resident was not documented to have 15 minute checks occur between the hours of 2:30 PM through 11:45 PM. [DATE] Behavior Notes revealed the following about Resident 1: *At 4:45 AM Staff 4 indicated Resident 1 returned from the emergency department tired, was assisted to bed, and placed on 15 minute checks. *At 9:58 AM Staff 25 indicated staff made her aware the resident stated she/he wanted to fly back to her/his country of origin to be with her/his brother. *At 1:04 PM Staff 26 indicated the resident had been sitting next to the exit doors for most of the shift and told staff remembers he/she would be leaving the facility tomorrow. *At 11:32 PM Staff 5 (RN) indicated the resident spent most of the evening shift by the exit doors and tried to get out every time [she/he sees an opportunity). The resident was noted to sleep a bit, woke around 8:30 PM and exited her/his room with all [her/his] stuff on [her/his] walker. The resident was noted to bang her/his walker on and kick the exit doors. The resident was noted to be redirected multiple times but to continue with behaviors. A [DATE] IDT Progress Note by Staff 26 at 1:07 PM indicated Resident 1 was seated by the exit doors and exit seeking. The resident was noted to be re-directed multiple times. A [DATE] Behavior Note by Staff 29 at 1:04 PM indicated Resident 1 followed staff off the locked unit through the exit doors, was in the ICF for some time, but easily directed back to the unit. At 10:03 PM Staff 26 documented Resident 1 sat in the hall multiple times, and asked to go back to her/his country of origin. The resident was noted to be re-directed multiple times. A [DATE] Behavior note by Staff 26 at 11:24 PM indicated Resident 1 spent most of the evening sitting by the exit doors, and followed staff off the unit a few times. The resident was noted to be redirected back to the unit multiple times. The [DATE] Abuse/AE Investigation completed by Staff 4 (Former RN) included the following Investigation summary/findings for Resident 1's [DATE] elopement over the fence, from the secured patio unit: [Resident 1] is a new admit from an acute care setting. [She/he] has a [history] of elopement from [her/his] previous unsecured facility and had been found in the street and [she/he] had also left [her/his] home and had been unable to find [her/his] way home. [Resident 1] had been in the facility four days during which [she/he] had not been consistently taking [her/his] medications, [she/he] was resistive to care and was frequently asking to go home to [her/his country of origin] which is where [she/he] is from. On Sunday [she/he] spent much of the day exit seeking from the secured unit saying [she/he] wanted to go home, staying by the door until staff came through and [she/he] would get past them on a couple of occasions. [Resident 1] was then placed on 15 minute checks. [Resident 1] had been placed in an area of high visibility and had been checked on when another CNA noticed [she/he] was no longer in an area of high visibility. [Resident 1] was not found on the unit. The other units were searched and [she/he] was not found. [Her/his] walker was found outside the back door of the secured unit patio on its side. Staff began looking outside and a kitchen staff member was outside looking for [Resident 1] when he found [her/him] near the sidewalk. Staff member notified LN who brought other staff and a [wheelchair] to help [her/him] back to the facility. The Corrective Action steps taken portion of the Abuse/AE investigation completed by Staff 4 included the following: When [she/he] returned to the facility [she/he] was on 15 minute checks [and] to be in an area of high visibility. The investigation document included a section that read, Name of witnesses/staff interviewed: (attach each individual statement. There were no staff interviews or statements attached to the investigation. The Abuse/AE Investigation was signed as complete on [DATE] by Staff 23 and Staff 14 (former Administrator). Review of Resident 1's clinical record revealed no evidence 15 minute checks were in place for Resident 1 on [DATE], prior to her/his successful elopement from the secure courtyard. A [DATE] Behavior note by Staff 7 (LPN) at 5:46 AM indicated Resident 1 woke around 3:30 AM, and proceeded to sit in the living room with a duffle bag full of clothes. The resident then attempted to follow staff out of the unit unsuccessfully. Review of Resident 1's baseline and comprehensive care plan revision revealed the following updated interventions: *[DATE] - The resident may be verbally aggressive related to . wanting to go to [country of origin] . Interventions included having the resident talk to her/his family member and receive reassurance that a move back to her/his country of origin was not possible. Additional interventions included telling Resident 1 she/he would not be going to her/his [country of origin] because of COVID-19, or to use a therapeutic fib that we are going on a different day. The [DATE] Admission MDS indicated the following for Resident 1. *Displayed physical behaviors toward others for 4 of 6 days during the 7 day assessment period. *The resident's behaviors put her/him at risk for significant risk for physical illness or injury. *The resident displayed wandering behavior for 7 of 7 days during the assessment period. * Resident 1 indicated it was very important to go outside to get fresh air when the weather is good. *Resident 1 was able to stabilize when she/he walked, without staff assistance. The resident used a four wheel walker. The [DATE] Care Area Assessment (CAA) indicated Resident 1 exhibited exit seeking behaviors, verbal and physical aggression, and rejection of care. The resident was documented to demonstrate active exit seeking by climbing fences and following staff out of doors. Staff were sometimes able to redirect her/him. A [DATE] Behavior Note by Staff 26 at 1:56 PM indicated the following: Resident 1 was found outside the secured courtyard, in the backyard shed of the facility. Resident 1's walker was found outside the back door of the locked unit by the fence. Staff 26 indicated it appeared the resident [jumped] over the fence. The Administrator was noted to be with the resident at the time of this note's composure. Family and physician were notified. On [DATE] Staff 26 signed off on her portion of the [DATE] completed Elopement Assessment for Resident 1. She noted the resident was reported as missing at 1:50 PM, last seen at 1:45 PM and returned to the facility at 2:00 PM. She noted the resident was brought to safety and [assessed] for injuries. Staff 26 noted the resident was alert, awake, and to have no [behaviors] upon her/his return to the facility. She further documented the following: [Resident 1] found in the shed on the back of [the] facility, noted [she/he] was outside prior. Found the walker by the [gate] on the back door. Possible jump over the fence. A [DATE] Social Service Note by Staff 25 at 2:57 PM indicated the following for Resident 1: Staff currently have the interventions in place of moving outdoor furniture to the center of the outdoor space away from fences, having staff wear pagers that alert them when doors leading outside are opened, monitoring [Resident 1] whenever [she/he] is outside, spending 15 minutes with [Resident 1] every shift to address any concerns he may have, and have restarted 15 minute checks to address [Resident 1's] wandering and exit seeking. Staff have completed a perimeter check of the outdoor area to look for any places where it may be easier to climb the fence. Staff have also put up boards on the area of the fence that [she/he] has gone over. Review of Resident 1's comprehensive care plan as of [DATE] did not reveal an intervention for staff to wear pagers that would alert them when the doors to the secured courtyard were opened. On [DATE] Staff 25 (LPN) completed and signed her portion of the Abuse/AE investigation related to the elopement from the facility by Resident 1 on [DATE]. The investigation included the following: On [DATE] at 3:18 PM Staff 27 (residential care facility CMA) reported she saw Resident 1 outside in the back not within the secured unit patio. She reported her findings to a staff member. The resident was escorted back in the building and went into conference room with administrator and played chess with another resident. The investigation summary documented the resident had eloped the facility in the same manner she/he did on her/his [DATE] elopement from the facility and included the following: [Resident 1] attempted to elope from [the] facility by putting [her/his] walker on its side and then standing on it and climbing over a fence just outside a door to an otherwise secure patio. Earlier in the day a staff member had seen [her/him] outside the same door with [her/his] [four wheel walker] on its side trying to climb on it and she stopped him, redirected [her/him] inside and notified [a] RN[.] [However] it was a miscommunication with the RN. [Resident 1] had been removed from 15 minute safety checks and put on one hour safety checks. A [residential care facility] (adjoined to the intermediate care facility, ICF) staff member saw [Resident 1] outside in the back near the shed and notified an ICF staff of [her/his] location. ICF staff and the administrator began looking for [her/him]. The Administrator found [her/him] inside the shed. She was able to get [her/him] to come inside the facility building. [Resident 1] did not want to return to the unit so she took [her/him] into her office and [notified the resident's representative]. [Resident 1] went into the conference room with [the] Administrator and played chess with another resident [who spoke the resident's native language]. [She/he] finally returned to the unit without incident. [Her/his] [four wheel walker] was found outside the back door on it side [,] up against the back fence with a footprint on it. It was brought back into the facility. The Corrective Action steps taken: portion of the investigation completed by Staff 25 included the following: 15 minute checks, move outdoor furniture to the center of the outdoor space away from fences, staff to wear pagers that alert them when doors leading outside are opened, monitoring [Resident 1] whenever [she/he] is outside, spending 15 minutes with [her/him] every shift to address any concerns he may have, boards to be put up on [the] fence where [she/he] climbed over[.] [The] fence [was] boarded up so [the resident would be unable to climb.] [Staff] will provide small projects. The investigation document included a section that read, Name of witnesses/staff interviewed: (attach each individual statement. There were no staff interviews or statements attached to the investigation. The Abuse/AE Investigation was signed as complete on [DATE] by Staff 23 and Staff 14, six days following Resident 1's elopement on [DATE]. It was unclear who the staff person was, noted to see the resident earlier in the day, prior to the actual elopement by the resident in the evening. The statement, However, it was a miscommunication with the RN does not indicate what the miscommunication was. Review of Resident 1's clinical record revealed no evidence the resident was removed from 15 minute safety checks and moved to one hour safety checks. On [DATE] the following revisions was added to Resident 1's care plan: *[DATE] - Goal: Resident 1's [DATE] actual elopement was added to the care plan, with a goal to decrease my episodes of elopement attempts. Interventions: Monitor me closely whenever I'm outside. On [DATE] Staff 15 (Resident Care Manager) signed her portion of the [DATE] Elopement Assessment related to Resident 1's [DATE] elopement. Staff 15 noted the resident had a prior history of elopement attempts, with one previous elopement from the facility. She also noted the resident's history of elopement at a prior facility included walking into traffic and also, leaving [her/his] home and being unable to find her/his way back. Alzheimer's disease and dementia were noted as potential contributors to the event. The investigative summary includes the following: Investigation and staff interviews complete. Earlier on [DATE] this author observed Resident 1's [four wheel walker] at the back gate earlier that morning, but moved it back to his room. Staff noted earlier attempts of [Resident 1] to climb [the] fence, staff redirected [her/him] away, staff notified RN however it was a miscommunication with [the] nurse. [Resident 1] was noted missing at 1:50 PM, staff on the RCF (Residential Care Facility) observed [Resident 1] walking in the back of the facility . [The Administrator was informed] and the ICF Resident Care Manager notified CNAs. Staff went to check on [the resident] and [she/he] was found in the shed at the back of the facility by the Administrator[.] [After] an initial brief assessment, [Resident 1] sat down on the back patio with the administrator, spoke with her[,] then they went back inside the facility to the Administrators office to talk with [Resident 1's] son. [Her/his] walker was found up against the back fence with a footprint on it along with [a] coloring book that was [poked] through the top of the fence. [Resident 1] played chess with another resident . under supervision. Review of Resident 1's clinical record revealed no evidence of staff or witness interviews related to the [DATE] Elopement Assessment. The review also failed to provide documentation regarding Staff 15's statement in the [DATE] Elopement Assessment regarding her finding Resident 1's walker up against the back fence earlier in the day on [DATE]. Review of the ,d+[DATE] CNA Behavior Monitor charting document revealed the following for Resident 1:On the early evening shift of [DATE] the resident was noted to be wandering. The charge nurse was documented to be notified. A [DATE] Behavior Note at 9:43 PM by Staff 5 (RN) indicated Resident 1 sat on her/his walker by the exit doors and refused to move. When staff attempted to redirect the resident she/he swung her/his hands and slapped Staff 5 with force over and over. The resident was noted to eventually be redirected and calm for the remainder of the evening shift. A review of Behavior Notes for [DATE] revealed the following: *At 6:56 AM Staff 7 (LPN) indicated Resident 1 awoke at 12:30 AM and went into another resident's room and placed her/himself in their chair. When staff attempted to redirect the resident, she/he became agitated/aggressive and swung a belt at staff. The resident then set the belt down and clenched her/his fists, scowling at staff. The resident was noted to eventually calm down and seated her/himself in the living room. *At 2:12 PM Staff 29 (RN) indicated a few moments prior to the composition of the note, Resident 1 was found stacking up chairs in the garden area right next to the fence. The resident was redirected back inside the unit. *At 8:07 Staff 26 noted Resident 1 to be very active and re-directed multiple times. Staff 25 completed and signed off on her portion of the Elopement Assessment for Resident 1's [DATE] elopement on [DATE]. Staff 25 included the following information: *Resident 1 states she/he was trying to go home and indicated she/he was in pain. The resident pointed to her/his thighs when asked the location of her/his pain. *Resident 1 frequently stated she/he wants to go home to her/his country of origin. *Resident 1 was currently unable to visit her/his family due to COVID-19 visitation restrictions. *Resident 1 sometimes became verbally and physically aggressive with staff when she/he tried to exit seek. *Staff were noted to complete 15 minute checks and monitor her/him closely when she/he was outside. *Staff wore pagers with alerts about doors opening. *A board covered the fence where she/he eloped. The [DATE] Behavior assessment was initiated on [DATE],and documented Resident 1 had exit seeking behavior in the facility she/he was in prior to admission. The resident was documented to elope from the previous facility and was found in the middle of the street when [she/he] was found. The resident's behavior since her/his admission to the facility was noted as problematic due to her/his continued exit seeking and episodes of elopement, and included the following for Resident 1: *The resident displayed exit seeking behaviors several times each day across shifts. *The resident would become upset and/or distressed because she/he wanted to go home . *The resident would sit on her/his four wheel walker by the entrance/exit doors and attempt to follow staff out of the doors into the ICF. *The resident would look for opportunity to elope when staff members were preoccupied with other tasks. *The resident had been physically aggressive toward staff when they tried to redirect her/him away from the exit doors. *The resident endangers [her/himself] when unsupervised. *The resident climbed the fence in the outdoor courtyard and eloped the facility by placing her/his four wheel walker up against the outdoor courtyard fence to climb over it. *The resident's exit seeking behavior caused her/him physical injury and put [her/him] in danger. *The resident had extensive bruising and complained of head and neck pain after a successful elopement from the courtyard on [DATE] and was sent to the emergency department. A [DATE] Activity 1:1 Note by Staff 24 at 3:24 PM indicated the following: today we tried to get [Resident 1] out of the unit to see if that would help [her/him] with feeling like [she/he was not locked up], it was a good time. [She/he] sat by the nursing station and [made] collage art. [She/he] was out of the unit at the nursing station for about 2.5 hours. A [DATE] Behavior Note by Staff 26 at 6:33 PM indicated the following for Resident 1: During the 15 minute check, resident [was] found standing on top of [her/his] walker and holding [onto] the [gate] [in] the backyard. Staff redirected and brought [her/him] back inside the unit. Continue [to] monitor for elopement. A [DATE] Behavior Note by Staff 26 at 1:23 PM indicated Resident 1 was found outside in the secured courtyard, trying to move the chairs close to the fence. The resident was redirected to the dining room for lunch. 15 minutes checks were noted to continue. A [DATE] Behavior Note by Staff 7 at 5:02 AM indicated the following for Resident 1: Monitoring resident for elopement. At the beginning noc shift, staff saw resident attempting to unlock the back door, CNA easily redirected [her/him]. [She/he] went to [her/his] room and appeared to be sleeping comfortably the rest of night. Continued with 15 minute checks. A [DATE] Behavior Note by Staff 5 at 9:47 PM indicated Resident 1 had been trying to look for ways out. The resident was noted to try to open the door by the sink in the dining room, and tried to go out to the courtyard. The resident pointed at the fence in the courtyard and said, house. The resident was redirected by staff, and Staff 5 indicated the resident would continue to be monitored. A [DATE] Behavior Note by Staff 7 at 6:58 AM indicated the following for Resident 1: Monitoring resident for elopement. Resident woke up at about 3:15 AM. [She/he] was offered a hot beverage and a sandwich. [She/he] ate quietly. [Her/his] mood suddenly changed, [she/he] appeared to be agitated/aggressive. [She/he] was attempting to open the [secured unit's exit doors] when staff attempted to redirect [her/him] [she/he] started kicking and hitting. [She/he] also attempted to hit staff with [her/his] walker and to stab staff with a pen. [She/he] took rackets from the activities basket and attempted to hit staff with them. Resident did not show [signs or symptoms] of pain. Staff 7 indicated 15 minute checks would be continued. <[TRUNCATED]

Based on interview and record review, it was determined the facility failed to adequately monitor a closed head injury for 1 of 3 residents (#1) following an accident. This placed residents at risk for bruising or bleeding of the brain. The facility's 10/20/19 Alert Charting - Clinical Assessment policy included the following for incidents, falls and elopements: *Alert charting to continue for a minimal of 48-72 hours post event or as determined by [Resident Care Manager]. *For fall with suspected head injury complete neurological evaluation per policy. Resident 1 admitted to the facility 5/27/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's 5/2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/28/20 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was noted to speak very little English, have significant memory impairment, poor judgement and overall poor safety awareness. The 5/28/20 Nursing Admission Assessment indicated Resident 1 admitted to the facility with no history of pain. The 5/31/20 Elopement Assessment indicated Resident 1 eloped from the secured courtyard of the locked memory care unit between 7:25 and 7:30 PM. The resident was documented to be found by facility staff at 7:39 PM. According to the assessment, [she/he] flailed [her/his] arms and grabbed [her/his] neck and said, call 911. A 5/31/20 IDT Progress note at 11:07 PM revealed Resident 1 was sent to the emergency department (ED) for further evaluations around 8:50 PM. The 5/31/20 After Visit Summary from the ED indicated the following for Resident 1: *The resident admitted [DATE] for a fall and neck pain. *The resident was diagnosed with a non-serious closed head injury (hard blow to the head with no break to the skull) with a risk for a more serious problem, such as bruising or bleeding of the brain. *The After Visit Summary indicated the resident needed to be monitored for possible symptoms related to her/his injury, see her/his primary care physician within three to four days, and return to the emergency department for subsequent falls. A 6/1/20 IDT Progress Note at 3:16 AM revealed Resident 1 returned from the emergency department around 2:05 AM and still complained of neck pain. The resident was documented to receive PRN Tylenol (pain reliever), and staff were awaiting a follow up for the effectiveness of the medication. Review of Resident 1's 6/1/2020 through 6/30/2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *6/1/20 at 3:32 AM - pain level was noted to be a 6 out of ten. *6/12/20 at 4:56 PM - pain level was noted to be a 4 out of ten. Review of Resident 1's 6/1/2020 clinical record revealed no indication the resident was followed with up with to determine the effectiveness of her/his 6/1/20 and 6/12/20 administrations of PRN Tylenol. Review of Resident 1's 6/1/20 through 6/4/20 clinical record revealed no evidence neurological checks were completed as a follow up for possible complications related to her/his closed injury. Review of Resident 1's 6/1/20 through 6/4/20 Progress Notes did not reveal alert charting was completed to monitor the residents close head injury. On 4/12/21 at 12:22 PM Staff 23 acknowledged there were no documented neurological checks completed for Resident 1 upon her/his return from the ER following her/his 5/31/20 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She further indicated the expectation of alert charting was staff monitored resident injuries every day, and each shift, for three days. Staff 23 stated the following about the resident [She/he was on alert charting but it was not consistent related to [the] head injury. Staff 23 also acknowledged the alert charting related to the resident's return from the ED was not completed every shift for three days.

Based on interview and record review it was determined the facility failed to ensure residents were free from sexual abuse for 2 of 4 sampled residents (#s 1 and 3) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility Abuse, Neglect, and Exploitation policy, last revised 1/2021, indicated sexual abuse is defined as any form of nonconsensual sexual contact including but not limited to inappropriate touching, sodomy, sexual coercion .May be in the form of of touching (of) the sexual or intimate parts for the purpose of arousing or gratifying the sexual desire of either party. The facility Preventing Resident Abuse policy, last revised 1/29/21, indicated: 2. Our abuse prevention/intervention program includes, but is not limited to, the following: j. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect. k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. o. Identifying areas in the facility that may make abuse and/or neglect more likely to occur (e.g., secluded areas) and monitoring these areas regularly. Resident 2 admitted to the facility in 6/20 with [DIAGNOSES REDACTED]. The 7/6/20 MDS indicated Resident 2 had a BIMS of 3 (indicating severe cognitive impairment). The 6/29/20 Admission Social Services assessment indicated Resident 2 had a history of [REDACTED]. The assessment indicated Resident 2 was sexually inappropriate with female residents, made sexually inappropriate comments, tried to guide female residents into her/his room, got into female resident beds, and/or sat close and touched female residents. The 7/1/20 care plan indicated Resident 2 had inappropriate sexual behavior including verbal and physical aggression related to delusions and cognitive impairment. Resident 2 had a history of [REDACTED]. Progress Notes indicated Resident 2 was moved from the locked unit on 10/9/20. a. Resident 3 was admitted to the facility in 3/2020 with [DIAGNOSES REDACTED]. The 6/20/20 MDS indicated Resident 3 had a BIMS of 1 (indicating severe cognitive impairment). The 6/22/20 Social Services assessment indicated Resident 3 wandered throughout the day and required redirection from staff, had socially inappropriate behaviors, and tried to get co-residents on the locked unit to follow (her/him) by grabbing onto their arms. The 7/17/20 progress note by Staff 4 (RNCM) indicated staff informed her Resident 2 and Resident 3 were having sex. Staff 4 accompanied Staff 7 (RN) and Staff 13 (LPN) and found Resident 2 and Resident 3 in the physical act of what appeared to be consensual sex. Resident 3 was redirected away from Resident 2. Resident 3 was asked if she/he was ok and she/he responded yes. Resident 3 did not appear to be in distress and did not have injuries. The medical record did not indicate changes in baseline behaviors for Resident 3 status [REDACTED]. Progress notes indicated a history of wandering behaviors for Resident 3. There was no investigation for the 7/17/20 incident in Resident 2's electronic health record. On 2/25/21 at 12:55 PM Staff 6 (CNA) stated Resident 2 had a history of [REDACTED]. On 2/25/21 at 1:45 PM Staff 9 (CNA) stated Resident 2 had a history of [REDACTED]. 2/26/21 at 9:58 AM Staff 11 (CNA) stated Resident 2 had fluctuating sexual behaviors since admission and made sexual comments towards female staff and residents and attempts to go into female resident rooms. On 2/26/21 at 1:23 PM Staff 4 stated she recalled the incident between Resident 2 and Resident 3 on 7/17/20. She stated Resident 2 was lying in bed on her/his back naked and Resident 3 was naked on top of Resident 2 and appeared to be in the act of intercourse but there was no penetration. The residents were separated and assessed and no injuries, distress or changes in behavior were identified. Both residents were placed on alert charting and care plans were updated to keep Resident 2 and Resident 3 separated. Staff 4 was asked about the capacity to consent for Resident 2 and Resident 3 and stated Consent requires a thought process that I do not think any of our residents have. On 2/25/21 at 2:26 PM and 2/26/21 at 1:17 PM Staff 2 (DNS) stated there was no investigation completed for the incident that occurred between Resident 2 and Resident 3 on 7/17/20 and there were no assessments for the capacity to consent for Resident 2 and Resident 3 prior to the incident on 7/17/20. b. Resident 1 was admitted to the facility in 2018 with [DIAGNOSES REDACTED]. The 1/23/19 care plan indicated Resident 1 had wandering behaviors and walked throughout the locked unit into other resident rooms. The 8/16/20 Quarterly MDS indicated Resident 1 was unable to complete a BIMS (cognitive assessment) due to her/his cognitive deficits and was rarely/never understood. The 8/24/20 Social Services assessment indicated Resident 1 had a behavior of wandering and did not demonstrate an understanding of non-physical boundaries or ability to find her/his way back to a setting. The 8/26/20 care plan indicated Resident 1 had severely impaired decision making abilities and required staff to make decisions for her/him. The 9/16/20 Resident to Resident Event Assessment indicated Resident 2 was found sitting on her/his bed, Resident 1 was also laying down on Resident 2's bed with her/his dress up and her/his brief was out to the left side. Resident 2's hand was placed on Resident 1's left thigh. When Resident 2 was asked what happened the resident stated Resident 1 was her/his old friend and Resident 2 loved Resident 1. Resident 2 stated she/he kissed Resident 1, laid on the bed next to Resident 1, touched Resident 1's body, and Resident 1 touched Resident 2's body. Resident 1 was unable to be interviewed. The investigation noted Resident 1 had a history of [REDACTED]. The investigation indicated Resident 1 and Resident 2 were separated, assessed, care plans were updated, and both residents were placed on alert charting. The report further indicated no staff abuse or neglect suspected. The medical record did not indicate changes in baseline behaviors for Resident 1 status [REDACTED]. Progress notes indicated a history of wandering behaviors for Resident 1. On 2/25/21 at 12:55 PM Staff 6 (CNA) stated Resident 2 had a history of [REDACTED]. On 2/25/21 at 1:45 PM Staff 9 (CNA) stated Resident 2 had a history of [REDACTED]. 2/26/21 at 9:58 AM Staff 11 (CNA) stated Resident 2 had fluctuating sexual behaviors since admission and made sexual comments towards female staff and residents and attempts to go into female resident rooms. On 2/26/21 at 1:57 PM Staff 10 (CNA) stated she went into Resident 2's room to obtain vitals and found Resident 1 laying supine with her/his hands at her/his sides in Resident 2's bed. Resident 2 was next to Resident 1 in bed and had one hand on Resident 1's left thigh. Resident 1 had her/his dress pulled up and her/his brief was pulled partly out of the resident's hip savers (padded spandex shorts). Staff 10 stated Resident 1 and Resident 2 appeared calm, were separated immediately and assessed with [REDACTED]. Staff 10 acknowledged Resident 2 had a history of [REDACTED]. Staff 10 further stated Resident 2 was moved out of the locked unit shortly after the 9/16/20 incident with Resident 1 to prevent further incidents. On 2/25/21 at 2:39 PM Staff 3 (RNCM) stated Resident 1 was non-verbal, could not advocate for her/his needs and required staff to advocate for the resident. Staff 3 stated Resident 1 had a history of [REDACTED]. On 2/26/21 at 1:17 Staff 2 (DNS) stated there was no assessment for the capacity to consent for Resident 1 and the facility did not have a policy for the capacity to consent for sexual activity.

Based on interview and record review it was determined the facility failed to report an allegation of abuse in the required time frame for 2 of 4 sampled residents (#s 2 and 3) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility 10/2020 Abuse Investigation Policy indicated if an allegation involves abuse or has resulted in abuse the facility designee in charge of the investigation will notify the state appointed reporting authority that an investigation is being conducted. This will be done no less than two hours after the allegation is made as applicable and no later than 24 hours. Resident 3 was admitted to the facility in 3/2020 with [DIAGNOSES REDACTED]. The 6/20/20 MDS indicated Resident 3 had a BIMS of 1 (indicating severe cognitive impairment). Resident 2 admitted to the facility 6/2020 with [DIAGNOSES REDACTED]. The 7/6/20 MDS indicated Resident 2 had a BIMS of 3 (indicating severe cognitive impairment). A 7/17/20 progress note by Staff 4 (RNCM) indicated staff informed her Resident 2 and Resident 3 were having sex. Staff 4 accompanied Staff 7 (RN) and Staff 13 (LPN) and found Resident 2 and Resident 3 in the physical act of what appeared to be consensual sex. Resident 2 and Resident 3 did not appear in distress and Resident 3 was redirected away from Resident 2. On 2/26/21 at 1:23 PM Staff 4 stated she recalled the incident between Resident 2 and Resident 3 on 7/17/20. She stated Resident 2 was lying in bed on her/his back naked and Resident 3 was naked on top of Resident 2 and appeared to be in the act of intercourse but there was no penetration. The residents were separated and assessed and no injuries, distress or changes in behavior were identified. Both residents were placed on alert charting and care plans were updated to keep Resident 2 and Resident 3 separated. Staff 4 was asked about the capacity to consent for Resident 2 and Resident 3 and stated Consent requires a thought process that I do not think any of our residents have. There was no investigation for the 7/17/20 incident in Resident 2's or Resident 3's medical records. On 2/25/21 at 2:26 PM Staff 2 (DNS) stated there was no investigation completed for the incident that occurred between Resident 2 and Resident 3 on 7/17/20 and the incident was not reported to the State Survey Agency.

Based on interview and record review it was determined the facility failed to thoroughly investigate and provide documented evidence to rule out sexual abuse for 2 of 4 sampled residents (#s 1 and 3) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility Abuse Investigation Policy, last revised 10/2020, indicated: - If there is an incident or suspected incident of resident abuse .the Administrator or his/her designee will appoint a member of management to investigate the alleged incident. -Witness reports will be obtained in writing and signed and dated. Resident 2 admitted to the facility 6/2020 with [DIAGNOSES REDACTED]. The 7/6/20 MDS indicated Resident 2 had a BIMS of 3 (indicating severe cognitive impairment). a. Resident 3 was admitted to the facility in 3/2020 with [DIAGNOSES REDACTED]. The 6/20/20 MDS indicated Resident 3 had a BIMS of 1 (indicating severe cognitive impairment). A 7/17/20 progress note by Staff 4 (RNCM) indicated staff informed her Resident 2 and Resident 3 were having sex. Staff 4 accompanied Staff 7 (RN) and Staff 13 (LPN) and found Resident 2 and Resident 3 in the physical act of what appeared to be consensual sex. Resident 2 and Resident 3 did not appear in distress and Resident 3 was redirected away from Resident 2. On 2/26/21 at 1:23 PM Staff 4 stated she recalled the incident between Resident 2 and Resident 3 on 7/17/20. She stated Resident 2 was lying in bed on her/his back naked and Resident 3 was naked on top of Resident 2 and appeared to be in the act of intercourse but there was no penetration. The residents were separated and assessed and no injuries, distress or changes in behavior were identified. Both residents were placed on alert charting and care plans were updated to keep Resident 2 and Resident 3 separated. Staff 4 was asked about the capacity to consent for Resident 2 and Resident 3 and stated Consent requires a thought process that I do not think any of our residents have. There was no investigation for the 7/17/20 incident in Resident 2's or Resident 3's medical records. On 2/25/21 at 2:26 PM Staff 2 (DNS) stated there was no investigation completed for the incident that occurred between Resident 2 and Resident 3 on 7/17/20. b. Resident 1 admitted to the facility in 2018 with [DIAGNOSES REDACTED]. The 8/16/20 Quarterly MDS indicated Resident 1 was unable to complete a BIMS (cognitive assessment) due to her/his cognitive deficits and was rarely/never understood. The 8/26/20 care plan indicated Resident 1 had severely impaired decision making abilities and required staff to make decisions for her/him. The 9/16/20 Resident to Resident Event Assessment indicated Resident 2 was found by staff sitting on her/his bed, Resident 1 was also laying down on Resident 2's bed with her/his dress up and her/his brief was out to the left side. Resident 2's hand was placed on Resident 1's left thigh. When Resident 2 was asked what happened the resident stated Resident 1 was her/his old friend and Resident 2 loved Resident 1. Resident 2 stated she/he kissed Resident 1, laid on the bed next to Resident 1, touched Resident 1's body, and Resident 1 touched Resident 2's body. Resident 1 was unable to be interviewed. The investigation noted Resident 1 had a history of [REDACTED]. The report did not include the names of staff who witnessed the incident or written statements. On 2/25/21 at 2:26 PM Staff 2 (DNS) stated there were no written witness statements obtained for the 9/16/20 investigation.

Based on observation and interview it was determined the facility failed to discard expired medication for 1 of 1 medication room reviewed for medication storage. This placed residents at risk for receiving ineffective medications. Findings include: On 11/22/19 at 12:26 PM the medication storage room was observed to have three unopened multi-dose bottles of [MEDICATION NAME] suspension (medication used to treat diarrhea) with an expiration date of 10/2019 and a unopened fleet enema with an expiration date of 5/31/2019. On 11/22/19 at 12:30 PM Staff 9 (RN) confirmed three multi-dose bottles of [MEDICATION NAME] suspension and one fleet enema were expired and were expected to be removed from the medication storage room. On 11/26/19 at 2:30 PM Staff 2 (DNS) stated her expectation was all expired medications were to be removed from the medication storage room and destroyed.

Based on observation, interview and record review it was determined the facility had a medication error rate of greater than 5%. The facility's error rate was 7.69% with two errors in 26 opportunities. This placed residents at risk for inaccurate medication dosage. Findings include: a. Resident 5's 11/2019 MAR indicated [REDACTED]. On 11/25/19 the [MEDICATION NAME] inhaler manufacturer dosing recommendations indicated to wait one minute between each inhaler puff administered. The facility's 5/2010 policy on administering medication through a metered dose inhaler indicated to allow at least one minute between inhaler puffs. On 11/25/19 at 9:00 AM Staff 10 (CMA) was observed to administer two puffs of the [MEDICATION NAME] metered dose inhaler to Resident 5. The two puffs of medication were observed to be administered within five seconds between each puff. On 11/25/19 at 9:30 AM Staff 10 stated she was unaware of any spacing parameters when administering a metered dose inhaler. On 11/26/19 at 1:33 PM Staff 2 (DNS) stated her expectation and facility policy indicated there was to be a one minute wait between each inhalation of a metered dose inhaler. b. Resident 5's 11/2019 MAR indicated [REDACTED]. On 11/25/19 the [MEDICATION NAME] Aerosol inhaler manufacturer dosing recommendations indicated to wait 30 seconds or more between each inhaler puff administered. The facility's 5/2010 policy on administering medication through a metered dose inhaler indicated to allow at least one minute between inhaler puffs. On 11/25/19 at 9:15 AM Staff 10 (CMA) administered two puffs of the [MEDICATION NAME] Aerosol metered dose inhaler to Resident 5. Staff 10 administered the second dose with a two second spacing between each puff. On 11/25/19 at 9:30 AM Staff 10 stated she was unaware of any spacing parameters when administering a metered dose inhaler. On 11/26/19 at 1:33 PM Staff 2 (DNS) stated her expectation and facility policy indicated there was to be a one minute wait between each inhalation of a metered dose inhaler.

Based on observation, interview and record review it was determined the facility failed to ensure proper infection control during medication administration for 1 of 6 sampled residents (#5) reviewed for medication administration. This placed residents at risk for cross-contamination and infection. Findings include: On 11/25/19 at 9:20 AM during medication administration Staff 10 (CMA) was observed to administer to Resident 5 [MEDICATION NAME] (bowel medication), a medication dissolved in water, in a disposable plastic cup. Resident 5 was observed to drink one fourth of the dose. Staff 10 placed the used, contaminated, unlabeled plastic cup on the clean medication cart and walked away from the cart. On 11/25/19 at 9:30 AM Staff 10 stated she contaminated the medication cart and placed other residents at risk of cross-contamination by placing the used contaminated plastic cup on her clean medication cart. She acknowledged she intended to offer the medication to Resident 5 at later time. On 11/26/19 at 1:33 PM Staff 2 (DNS) confirmed contaminated items, such as used medication cups, were not to be placed on the clean medication cart. Staff 2 further stated she expected staff to discard medication cups immediately after use.