Every finding on record at Memorial Medical Nursing and Rehabilitation

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for two of two refuse containers (dumpsters used for recyclable refuse) on the loading dock. The facility failed to ensure there were no soiled briefs on the loading dock and construction materials around both recycling dumpsters. This failure could place residents at risk of illness from exposure to germs and diseases carried by vermin and rodents. The findings include: Observation on 8/2/26 at 10:00 a.m. of the dumpster site (2 dumpsters) revealed near one of the dumpsters was a bag of briefs with one brief on the ground, construction debris, and a surgical glove. During an observation and interview on 8/2/26 at 10:05 a.m. the FSS stated she confirmed the debris and bag of briefs on the ground and the surgical glove. The FSS stated the bag of briefs and the soiled brief on the ground could attract flies and lead to cross contamination. The FSS stated she had no explanation for the items outside the dumpster. During a joint observation and interview on 8/2/26 at 10:36 a.m., LVN C stated: she confirmed the bag of briefs and surgical glove on the ground near the dumpster. LVN C stated the items could have fallen off when the dumpsters were empty or a the homeless might have entered the dumpsters and emptied items on the ground. LVN C stated the briefs on the ground was an IC issue and could lead to cross contamination if flies landed on the briefs/surgical glove. LVN D stated she confirmed the bag of briefs and surgical glove on the ground. LVN D stated she had no explanation for the items on the ground. LVN D stated flies could land on the briefs and lead to an IC problem and could cause cross contamination concerns. During an observation and interview on 8/2/26 at 12:05 p.m., the Administrator stated as for the sanitation and cleanliness of the dumpster site, the facility had to keep the grounds clean. The Administrator stated the homeless community and people who dumped construction debris were responsible for the condition of the dumpster grounds at the time of the surveyor's visit. The Administrator stated the facility had no policy on garbage disposal. During an interview on 8/2/26 at 2:41 p.m., the Maintenance Director stated he saw the construction debris around one of the dumpsters that needed to be off the ground on 8/2/26 in the afternoon. The Maintenance Director stated daily rounds were made of the dumpster site, but he was off on the weekend. The Maintenance Director stated that he did not know whether any staff on the weekend (8/1-8/2/26) had checked on the condition of the dumpster dock. The Maintenance Director stated the construction debris resulted from someone in the community dumping it. Record review of the facility's Sanitation Inspection policy, dated 2026 read, It is the policy of this facility.to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.The facility did not have a policy specific to the sanitation of the dumpsters or the ground around the dumpsters or provided said policies by time of exit on 8/5/26 at 5:45 p.m.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen observed for food service sanitation and safety, in that:The kitchen failed to store, and date food products with an opening and discard date.These failures could place residents who eat meals from the kitchen at risk for spread of infections, food contamination, and food borne illness.The findings include:Based on observation on 8/2/26 from 9:35 a.m. to 10:25 a.m., the kitchen revealed:---bag of potato chips opened was left on a kitchen shelf with no discard date.---in the cooler, 5 pudding dishes and a pan containing 9 sausage patties with no open date or expiration date visible.---milk refrigerator when pulled out for cleaning revealed dirt. a creamer container present and stains of the floor During an interview on 8/2/26 at 10:30 a.m., the FSS confirmed the above observations and stated. the bag of chips opened and the pudding dishes and pan of sausage not dated with open and discard date, the FSS stated a staff might have forgotten to follow procedures. During a telephone interview on 8/3/26 at 1:36 p.m., the Dietician stated she did monthly audits of the kitchen. She could not provide any comments on the negative findings concerning the kitchen found by the surveyor. Her expectation was that kitchen staff date when a food item was opened and an expiration date documented; as well as food stored in the refrigerator or cooler. Also, she stated her expectation was that staff store food correctly. During an interview on 8/3/26 at 2:00 p.m., the Administrator stated by observation he confirmed the negative findings in the kitchen and would make remedies. The Administrator stated he expected kitchen staff, to comply with regulations involving the kitchen. The Administrator offered no explanation for the negative findings in the kitchen involving sanitation and safety. The Administrator stated he expected staff to store and label food correctly and follow any recommendations from the Dietician. Record review of the facility's kitchen cleaning scheduled dated 8/2/26 revealed the daily cleaning addressed items that needed to be cleaned daily.Record review of facility's Diet Type Report, dated 8/4/26, revealed five residents did not eat from the kitchen (1 tube feeding and 4 NPO).Record review of the facility's Sanitation Inspection policy, dated 2026 read, It is the policy of this facility.to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.Record review of the FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines, dated 2022, paragraph 3.304.11, read: .Food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to. contamination. [no mention in the Code about storage and labeling]

Based on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 5 ( Resident # 61) resident's reviewed for residents' personal refrigerators. The personal refrigerator in Resident's #61 room contained an unlabeled, undated food item. This deficient practice could put residents at risk of foodborne illness from consuming spoiled food. Findings included : Record review of Resident #61's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (lung disease that makes it difficult to breathe), Peripheral Vascular Disease (condition in which blood vessels in legs become narrow ), and Schizoaffective Disorder(condition with loss of touch with reality and severe emotional highs and lows). Record review of Resident # 61's Quarterly MDS assessment, dated 07/01/2026, revealed a BIMS score of 13, indicating the resident was cognitively intact. Observations on 8/03/2026 at 9:10 a.m. revealed that the personal refrigerator for Resident #61 contained potato salad that was unlabeled and undated. Interview with Resident #61 on 8/03/2026 at 9:15 a.m. revealed that a family member had brought her the potato salad a couple of days ago but could not recall the exact date.Further observations on 8/03/2026 at 9:55 a.m. of the personal refrigerator of Resident # 61 revealed that the unlabeled, undated storage container was still present. Interview with LVN A on 8/03/2026 at 11:00 a.m. revealed he was the assigned nurse for Resident # 61 and confirmed there was an unlabeled/undated potato salad in the personal refrigerator for Resident # 61. He added that nursing administration was responsible for removing undated and unlabeled food items from residents' personal refrigerators daily; He added that Resident # 61 risked food-borne illness by possibly consuming food that was unlabeled and undated.Interview with ADON G on 08/03/26, at 1:30 p.m., the ADON confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled food. ADON G stated that all nursing staff were not responsible for removing undated, unlabeled food items from residents' refrigerators daily; that was the responsibility of the families. The DON stated that families sometimes bring food for residents without notifying the nursing staff, so it is not dated or labeled. Record review of the facility policy, Use and Storage of Food Brought in by Visitors , 2025, revealed: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident

Based on observation, interview and record review, the facility failed to ensure that resident bedrooms measured at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms for 11 of 12 resident rooms (Rooms 104, 105, 106, 107, 109, 110, 111, 112, 113, 114 & 115) on 1 of 4 units (South hall) reviewed for environment.The facility failed to ensure eleven of twelve (11 of 12) semiprivate resident rooms on the South hall had at least 80 square feet per resident (Rooms 104, 105, 106, 107, 109, 110, 111, 112, 113, 114 and 115).This deficient practice could place residents at risk of being crowded and could compromise resident privacy.The findings were:Record review of the HHS Bed Classification form 3740, dated 08/05/2026, revealed that rooms 104, 105, 106, 107, 109, 110, 111, 112, 113, 114 and 115 were licensed for 2 beds.Record review of a facility document titled, Room Size Waiver for Facilities, dated 08/05/2026 and received 08/05/2026 at 03:38 PM, revealed rooms 104, 105, 106, 107, 109, 110, 111, 112, 113, 114 and 115 did not measure 80 square feet per resident. Record review of the facility's resident roster, dated 08/01/2026, reflected 1 resident occupied room [ROOM NUMBER], 1 resident occupied room [ROOM NUMBER], 1 resident occupied room [ROOM NUMBER], 1 resident occupied room [ROOM NUMBER], no residents occupied room [ROOM NUMBER], 1 resident occupied room [ROOM NUMBER], no residents occupied room [ROOM NUMBER], 2 residents occupied room [ROOM NUMBER], 1 resident occupied 113, and no residents occupied 114 and 115. Life Safety Code staff member took room measurements of Rooms 104, 105, 106, 107, 109, 110, 111, 112, 113, 114 and 115 and revealed the room measurements as follows:room [ROOM NUMBER] - 127.76 square feet equaling 63.88 square feet for each residentroom [ROOM NUMBER] - 127.54 square feet equaling 63.77 square feet for each residentroom [ROOM NUMBER] - 122.55 square feet equaling 61.27 square feet for each residentroom [ROOM NUMBER] - 128.62 square feet equaling 64.31 square feet for each residentroom [ROOM NUMBER] - 125.46 square feet equaling 62.73 square feet for each residentroom [ROOM NUMBER] - 120.78 square feet equaling 60.39 square feet for each residentroom [ROOM NUMBER] - 108.78 square feet equaling 54.39 square feet for each residentroom [ROOM NUMBER] - 128.05 square feet equaling 64.025 square feet for each residentMeasurements for room [ROOM NUMBER], 105, and 106 were not taken.During an interview on 08/05/2026 at 03:20 PM, the ADM revealed he filled out the room size waiver and it was important for resident rooms to be at least 80 square feet per resident in multiple resident bedrooms so there is sufficient space to meet the needs of ambulatory residents, accessibility standards were met for adequate space for residents with physical disabilities, and the health and safety of the residents were not adversely affected. During an email communication on 08/11/2026 at 10:08 AM with the ADM reflected We have remeasured rooms 104, 105, 106. and 104, 105, 106 measured under 160 sq feet.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one of one kitchen, reviewed for safe and sanitary environment. Storage Closet had broken and missing tiles, was dirty, mop sink and floor had a black substance, and cleaning chemicals were loosely stored.Food cart storage area had an exposed floor molding hole about four feet long exposing the drywall.Two dirty vents, one in the kitchen and one in the dishwashing area contained a black substance.Floor molding broke about 3 feet in length long in the food cart storage area exposing a hole in the wall.Based on observation on 8/2/26 from 9:35 a.m. to 10:25 a.m., the kitchen revealed:---1 of 4 over lights in the dishwashing room was not working.---there was exposed pipe about 4 feet long hanging in the dishwashing room from the ceiling with no function.---the washing room tile rail was broken near the ceiling.---5 out of 12 overhead ceiling lights were not working.---1 overhead ceiling cover was missing.---2 overhead ceiling covers were broken These failures could lead to residents experiencing a diminished quality of life if environmental issues cross contaminated food or environmental particles fell on the food or liquids served from the kitchen The findings include: During an interview on 8/2/26 at 10:30 a.m., the FSS confirmed the above observations and stated: the ceiling covers and lights need fixing so that the kitchen staff had better work conditions. The FSS stated the overhead ceiling light needed to be fixed to avoid the light shattering and glass falling on food. The FSS stated she had no idea why there was a hanging pipe in the dishwashing room and the tile rail needed repairs to avoid ceiling tiles falling from the ceiling. The FSS stated the vents needed cleaning. The FSS stated no work order existed for the items that needed repair or fixing in the kitchen. The FSS stated she was not aware of the floor molding broken about 4 feet in length long in the food cart storage area exposing a hole in the wall; and had not done a WO. During an interview on 8/2/26 at 11:00 a.m., the Housekeeping Supervisor stated the Maintenance Department was responsible for maintenance in the kitchen and the cleanliness of the grounds. The Housekeeping Supervisor confirmed he saw numerous broken ceilings covers in the kitchen and two vents with dirty substances. During an interview on 8/2/26 at 2:41 p.m., the Maintenance Director stated he saw all the items that needed fixing or repaired in the kitchen and no work orders were present for the identified deficiencies. The Maintenance Director stated the primary areas needed to be addressed immediately were broken light covers, one light with no cover, a dirty vent in the kitchen and removal of a pipe in the dishwashing room. The Maintenance Director stated it was the first time he saw floor molding broken about 4 feet in length long in the food cart storage area exposing a hole in the wall. The Maintenance Director stated the kitchen staff had not done a WO regarding the floor molding. During a telephone interview on 8/3/26 at 1:36 p.m., the Dietician stated she made monthly audits of the kitchen. She stated in the July 2026 audit that the issue that surfaced was dirty vents and no other environmental concerns. During an observation on 8/4/26 at 4:40 p.m., the kitchen Storage Closet for cleaning supplies and equipment revealed a foul odor in the room. Further observations revealed: 4-5 broken tiles bulging from the floor, missing tiles exposing a black substance, a dirty room, black substance on the mop sink, a black substance in various locations in the room, a dirty fan, and cleaning supplies not orderly stored. During an interview on 8/4/26 at 4:42 p.m., the FSS stated the odor was from bleach. The FSS stated the closet was dirty and needed better organization. The FSS stated there was a black substance on the mop sink and floor; and tiles were broken or missing. The FSS stated her expectation was for the closet to be clean, in good repair, and orderly arranged. The FSS stated no WO was filed with maintenance for the repair of the floor in the closet. The FSS did not provide an explanation for the unsanitary, dirty, and need for repair of Storage Closet. The FSS stated the risk to the residents was that the Storage Closet was need the Cooler and cross contamination could occur. During an interview on 8/4/26 at 4:45 p.m., Kitchen Aide A stated she entered the Storage Closet once per week to get cleaning supplies. She stated she noticed the broken bulging tiles on the floor and other parts of the floor missing tiles with a black substance. She described the black substance as mold. Kitchen A stated the broken tiles could present an accident hazard to staff. Kitchen Aide A stated there should not be any mold in the Storage Closet and it needed to be kept cleaned and in good repair. During an interview on 8/4/26 at 4:47 p.m., Kitchen Aide B stated he visited the Storage Closet for cleaning supplies and had seen the broken tiles and missing tiles in the Storage Closet. He described the black substance in the mop sink and in many locations in the Storage Closet as dirt. He stated the Storage Closet should not be this way because it presented a hazard and could cause an accident to kitchen staff; and cross contamination could result from the conditions in the Storage Closet. During an interview on 8/4/26 at 4:55 p.m., the Administrator stated he confirmed there were broken tiles and missing tiles in the kitchen's Storage Closet. The Administrator stated he had no explanation for the condition of the closet and would address the issues needing repairs. The Administrator stated the environmental issues in the kitchen would be addressed and he had no further comments. During an interview on 8/5/26 at 8:29 a.m., the Maintenance Director stated he was not aware of the missing tile and broken tiles in the kitchen Storage Closet. The Maintenance Director stated he had been employed in the facility for about one year. He stated that he relied on [NAME] to do repairs, and the kitchen staff had never told him about issues in the Storage Closet or other repair issues in the kitchen. Record review of facility's Maintenance Log from 2/1/26 to 8/4/26 revealed no [NAME] for repair of the kitchen Storage Closet and other areas in the kitchen. Record review of the facility's Sanitation Inspection policy, dated 2026 read, It is the policy of this facility.to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.Record review of the FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines, dated 2022, paragraph 3.304.11, read: .Food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to. contamination.[no mention of storage or labeling]

Based on observation, interviews, and record reviews, the facility failed to maintain effective pest control for one of one kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.The findings include: During an observation on 8/2/26 at 2:40 p.m., in the kitchen a roach was seen climbing down the wall near the milk refrigerator. Further observation revealed the floor underneath the refrigerator was dirty and a creamer container was on the floor. During an interview on 8/2/26 at 2:41 p.m., the Maintenance Director stated he saw the roach on the kitchen wall crawling down the wall near the milk refrigerator. The Maintenance Director stated that spraying was done monthly and PRN. The Maintenance Director stated the kitchen needed to be sprayed to avoid cross contamination of food, liquids, utensils, plates, table tops and all cooking surfaces. During an interview on 8/2/26 at 2:45 p.m., the FSS stated that it was the first time she had heard about a roach in the kitchen. The FSS stated the kitchen was sprayed once per month and PRN. The FSS stated she confirmed that the floor under the milk refrigerator was dirty. During an interview on 8/2/26 at 3:02 a.m., LVN G stated that pests and rodents should not be in the kitchen because it could lead to cross contamination leading to illness. She stated that spraying was done monthly and PRN. She had occasionally seen flies in the facility. She reported the flies, date unknown, to the Administrator and Maintenance Director. During an interview on 8/2/26 at 3:27 p.m., The IP (LVN H) stated that rodents and pests should not be in the kitchen because residents do not want pests or rodents in their food. She stated that a WO had been put in PCC for flies near resident rooms and hallways about one month ago. The IP stated that flies could carry bacteria. The IP stated the spread of bacteria could cause cross contamination. During an interview on 8/2/26 at 3:36 p.m., the Housekeeping Supervisor stated that flies and rodents should not be in the kitchen or in the facility. The Housekeeping Supervisor stated that the presence of pests in the kitchen could lead to bacteria and cross contamination. The Housekeeping Supervisor stated that the facility did pest spraying monthly and PRN. The Housekeeping Supervisor stated the last time he had seen flies was about two months ago. During an interview on 8/2/26 at 3:38 p.m., the Administrator stated: the pest contractor came out monthly and PRN. The Administrator stated that QAPI PIP was on pest control program was initiated April 2026. The Administrator stated the goal of the PIP was to decrease pest control sightings and improved environmental compliance and decrease resident concerns. The Administrator stated that there were two grievances filed by a resident and FSS from April 2026 to July 2026: on 5/17/26 Resident #108 filed a pest control grievance and on 6/9/26, the FSS filed a grievance because of bugs in the dirty dish room. The Administrator stated both grievances were acted upon and the pest company responded. The Administrator stated that roaches in the kitchen could lead to an unsatisfactory experience for residents. During a telephone interview on 8/3/26 at 1:36 p.m., the Dietician stated she was not aware of pests in the kitchen. The Dietician stated the FSS had not informed her of pest issues in the dish washing area as a grievance filed with the Administrator on 6/9/26. During an interview on 8/3/26 at 3:09 p.m., The FSS stated she filed a grievance on 6/9/26 that she saw one to two roaches in the dishwashing area and dietary staff had expressed concerns about pests in the kitchen. The FSS stated the Administrator addressed the issue by pest spraying on 6/10/26. Record review of the facility's Pest Company invoice dated 6/10/26 revealed a pest spray was done fire ants in the exterior of the facility and American Roach, German Roaches, Nuisance Ants in the kitchen interior, dining hall, break room, and common area. During an interview on 8/3/26 at 3:20 p.m., Resident [NAME] stated he filed a grievance on 5/17/26 because he saw three to four roaches in the common dining hall. The Resident stated the grievance was filed with the Administrator. Record review of the facility's Pest Company invoice dated 5/19/26 revealed a pest spray was done fire ants in the exterior of the facility and American Roach, German Roaches, Nuisance Ants in the kitchen interior, dining hall, break room, and common area. Record review of the facility's Sanitation Inspection policy, dated 2026 read, It is the policy of this facility.to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.Record review of the facility's Pest Control Program policy, dated 2026, read: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 1 of 5 residents (Resident # 7 ) reviewed for call light. Resident # 7's call light was not placed within reach . This failure could place residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. The findings included: Record review of Resident's #7's face sheet, dated 8/04/2026, revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included: Hemiplegia (left side; limited movement on left side of body), Congestive heart failure (condition where the heart can not pump blood as well as it should, leading to swelling) and Repeated falls (when a person falls more than once over a period) Review of Resident # 7s Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, suggesting the resident is cognitively intact. Record review of Resident # 7's care plan dated 2/8/2026 revealed keep call light within reach of resident Observation and interview on 8/03/2026 at 10:38 AM of Resident #7's room revealed that the call light was not visible. Further observation revealed Resident #7's call light was clipped to the room divider curtain. Resident #7 stated that he did not have a call light and did not know where his call light was. Interview on 8/3/2026 at 10:40 AM with CNA C, confirmed Resident #7s call light was clipped to room divider curtain; she stated she forgot to place it within reach of Resident # 7 when she provided incontinent care this morning.CNA C stated lack of accessibility of a call light could negatively affect any resident if they needed assistance. Interview on 8/03/2026 at 10:50 am with LVN A , he stated Resident #7's call light was out of reach of Resident #7. However, he confirmed that it was not normal nursing practice for one resident to be left without a call light. LVN A remarked that the absence of the call light could constitute potential harm if the resident needed assistance in an emergency. Interview on 8/4/26 at 12:00 PM with ADON H, she stated the facility had a call light policy and staff has been in-serviced many times to keep call light within residents' reach. ADON H also confirmed that Resident # 7's care plan addressed the need for a call light within reach. She said she did not know why it was not within Resident # 7's reach but would ensure all staff was in-serviced on this process again. Record review of facility policy. Call Lights: Accessibility and Timely Response , dated 2025 , revealed Staff will ensure the call light is with in reach of resident and secured , as needed .

Based on observation, interview, and record review the facility failed to provide a comfortable and homelike environment including comfortable and safe temperature levels for 1 of 1 common area in the NW hallway. The facility failed to ensure the temperature in the NW hallway common area was not above 81 degrees on 08/04/2026, 05:19 PM-05:27 PM. This failure could place any residents at risk of living in an unsafe environment and result in feelings of dissatisfaction. The findings were:During observations of the ambient temperature in the common area in the NW hallway, the following was revealed on 08/04/2026:05:19 PM: 81.6 degrees Fahrenheit05:20 PM: 81.5 degrees Fahrenheit05:22 PM: 81.3 degrees Fahrenheit05:23 PM: 81.5 degrees Fahrenheit05:26 PM: 82.2 degrees Fahrenheit05:27 PM: 82.5 degrees Fahrenheit During a combined interview on 08/03/2026 at 05:08 PM, the Maintenance Director revealed he checked ambient temperature monthly and as needed. The ADM revealed he had concerns with the temperatures in the facility and they maintain it between 71 and 81 degrees Fahrenheit per regulation. During an interview on 08/04/2026 at 05:26 PM, the ADM revealed it was important to make sure the temperature was not above 81 degrees Fahrenheit to avoid discomfort and he added that he made sure residents were hydrated in this condition. Record review of the facility's policy Resident Rights, dated 2026, reflected . 8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. A temperature log for the facility was requested on 08/03/2026 at 05:08 PM and 08/04/2026 at 05:26 PM. It was not received.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to independently perform activities of daily living received the necessary assistance to maintain personal hygiene and dignity for one (Resident #61) of 8 residents reviewed for activities of daily living.The facility failed to provide timely incontinent care to Resident #61 after the resident activated her call light requesting assistance following a bowel movement. The resident remained soiled with bowel movement for approximately 30 minutes while waiting for staff assistance.This failure placed the residents at risk for discomfort, impaired skin integrity, and compromised dignity. Record review of Resident #61's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (lung disease that makes it difficult to breathe), Peripheral Vascular Disease (condition in which blood vessels in legs become narrow ), and Schizoaffective Disorder(condition with loss of touch with reality and severe emotional highs and lows).Record review of Resident # 61's Quarterly MDS assessment, dated 07/01/2026, revealed a BIMS score of 13, indicating the resident was cognitively intact.Record review of Resident 61's care plan, dated 12/10/2025, revealed the resident required extensive assistance from one staff member with activities of daily living.During an observation on 8/4/2026 at 10:20 AM, Resident #61 was observed in her room with her call light activated. Resident #61 stated she had experienced a bowel movement and needed staff assistance to be cleaned and changed. Resident #61 remained in her room with the call light activated while awaiting assistance.Continued observation on 8/4/2026 revealed that approximately 30 minutes elapsed before staff entered Resident #61's room to aid. During this period, Resident #61 remained soiled with bowel movement . Observation on 8/4/2026 at 10:50 AM revealed CNA C was observed assisting Resident #61 with incontinent care.Interview on 8/4/2026 at 10:30 AM, Resident #61 stated she had a bowel movement and activated her call light because she needed assistance to be cleaned and changed. The resident stated she was unable to clean and change herself without staff assistance. Resident #61 stated she waited approximately 30 minutes after activating her call light before staff responded, and at times it was one hour or more. Resident # 61 stated she remained soiled with bowel movement while waiting for staff and expressed that she was uncomfortable and wanted to be cleaned. Resident # 61 stated she depended on facility staff to assist her with incontinent care and expected staff to respond when she activated her call light for assistance. Interview on 8/4/2026 at 10:50 AM, CNA C stated she was assigned to provide care to Resident #61. CNA C stated that when Resident #61 activated her call light, she was occupied in another resident's room providing care and was unable to respond immediately. CNA C stated that when she became available, she responded to Resident 61's room and provided the necessary incontinent care. CNA C acknowledged that Resident #61 had experienced a bowel movement and required staff assistance to be cleaned and changed, stating residents who require assistance with incontinent care depend on staff to respond to their needs and provide care. CNA C stated she was aware Resident #61 waited approximately 30 minutes for assistance but explained the delay occurred because she was providing care to another resident. Interview on 8/4/2026 at 11:05 AM, ADON G stated residents who require assistance with activities of daily living, including incontinent care, are expected to receive assistance from staff when needed. ADON G stated staff are expected to respond to resident call lights in a timely manner, determine the resident's needs, and provide incontinent care as necessary. The ADON stated a resident who is dependent on staff for incontinent care should not be left soiled with bowel movement while waiting for assistance. ADON acknowledged that Resident #61 required extensive assistance from staff and that waiting approximately 30 minutes for staff to respond to the call light while the resident remained soiled with bowel movement was not consistent with the facility's expectations for timely care. The DON stated prolonged exposure to urine or feces could cause discomfort, skin irritation, and increase the risk for impaired skin integrity. Record review of facility policy. Activities of daily living, dated 2025, revealed, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene

Based on record review, observation, and interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 8 residents (Resident #34) reviewed for accidents and hazards. The facility failed to ensure Resident #34 was transferred via mechanical lift by 2 staff members on 08/04/2026. This failure could place residents at risk of falls and/or injury The findings included:Record review of Resident #34's admission record, dated 08/04/2026, reflected a [AGE] year-old male initially admitted on [DATE] and re-admitted [DATE] with diagnoses including hemiplegia and hemiparesis (loss of physical function on one side of the body due to brain or spinal cord injury) following cerebral infarctions (happens when blood vessel that takes blood to the brain gets blocked) affecting left non-dominant side. Record review of Resident #34's quarterly MDS assessment, dated 05/19/2026, reflected a BIMS score of 11 out of 15, indicating moderate cognitive impairment. It further reflected Resident #34 was dependent for chair/bed-to-chair transfer. Record review of Resident #34's care plan, last reviewed 05/05/2026, reflected [Resident #34] has an ADL self-care performance deficit r/t Limited Mobility due to CVA (medical emergency that happens when blood flow to part of the brain stops or gets blocked).', revised on 09/16/2022, with intervention TRANSFER total assistance x2 staff support with [mechanical lift], revised 04/23/2024. During an observation and interview on 08/04/2026 at 08:58 AM, CNA L was observed transferring Resident #34 via mechanical lift by himself. ADON G was walking by and was asked if CNA L should be transferring Resident #34 via mechanical lift alone and she stated no. Resident #34 was still in his sling attached to the mechanical lift and was lying in bed. ADON G stopped CNA L and revealed that they would have to get another staff member to help him finish the transfer process. ADON G ensured that Resident #34 was okay and revealed it was important to have 2 people transfer via mechanical lift for assistance and there was a potential risk if something fell during the transfer. ADON G revealed CNA L was trained to transfer a resident via mechanical lift with 2 people. During an interview on 08/04/2026 at 11:55 AM, CNA L revealed he had been working at the facility for a few weeks and was trained on operating the mechanical lift. He revealed he did not ask for help because everyone was busy. He revealed it was important to have 2 people to transfer Resident #34, so he did not fall and break something. During an interview on 08/05/2026 at 03:20 PM, the ADM revealed his expectation for using the mechanical lift were for 2 people to use it for transferring residents for resident safety. During an interview on 08/05/2026 at 05:30 PM, the ADM revealed that he reviewed Resident #34's for incidents and accidents and the resident did not have anything related to transfers or falls in the past 6 months. Record review of the facility's incidents and accidents report, dated 08/02/2026 reflected Resident #34 had no incidents involving falls. Record review of the facility's policy Safe Resident Handling/Transfers dated 2025, reflected All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employee that assist them. 11. Resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice, for 1 of 3 residents (Resident # 7) reviewed for oxygen in that: The Facility failed to ensure Resident #7's nebulizer tubing was bagged and not on floor. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications. Findings included : Record review of Resident's #7s face sheet, dated 8/04/2026, revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included: Hemiplegia Left side (limited movement on left side of body), Congestive heart failure (condition where the heart can not pump blood as well as it should, leading to swelling) and Repeated falls (when a person falls more than once over a period) Review of Resident # 7s Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, suggesting the resident is cognitively intact. Record review of Resident #7's Physician monthly orders dated August 2026 revealed an order start date of 02/1/26: albuterol and ipratropium solution 0.5-2.5 mg / 3ml four times a day/ per nebulizer [COPD medication]. Observation on 8/03/26 at 12:20 p.m. revealed that Resident # 7 's nebulizer tubing was unbagged and on the floor. Interview with Resident # 7 on 8/03/26, at 12:30 p.m., revealed only certain nurses bag the nebulizer tubing at this facility, depending on the nurse and he does not know how the nebulizer tubing ended up on the floor. Interview with LVN A on 8/03/26, at 1:10 p.m., stated he was assigned to Resident # 7. It was revealed that it was every nurse's responsibility to bag the nebulizer tubing and ensure it was not on the floor. However, he forgot to bag it this morning after giving Resident #7 his nebulizer treatment and does not know how the nebulizer tubing ended up on floor. LVN A stated the Resident was at risk of possible respiratory infection due to the nebulizer tubing being unbagged. Interview with ADON on 8/04/26 at 1:30 p.m., it was revealed that Resident #7 should have had their nebulizer tubing bagged by the day shift nurse. The ADON mentioned that she needed to determine why the nebulizer tubing for Resident #7 was not bagged. She also stated that she oversaw this task and assured she would monitor it for compliance. ADON stressed that Resident #7 was at risk of respiratory infection due to unbagged nebulizer tubing on floor. Record review of facility policy. Infection Prevention, dated 2025, revealed All staff shall demonstrate competence in relevant infection control practices.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional standards for 1 of 4 medication carts observed. Specifically, the west hall Nurse Medication Cart contained eight loose, unidentifiable medication pills that were not stored in labeled packaging and could not be traced to a specific medication or resident.This failure placed residents at risk for receiving incorrect medications, incorrect dosages, or medications with compromised integrity, which could result in adverse drug reactions or lack of therapeutic effect. Findings included : Observation on 08/03/2026 at 9:10 a.m. of the west hall Medication Cart revealed eight loose pills located inside a drawer of the Nurse Medication Cart. The pills were not contained in manufacturer packaging, were not labeled, and did not identify the medication name, strength, or resident for whom they were prescribed.During an interview on 08/03/2026 at 9:28 a.m. with MA B, she confirmed the presence of loose pills in the medication cart drawer. CMA B stated the pills likely fell out during her morning medication pass. MA B acknowledged that all medications are required to remain in properly labeled packaging at all times and should never be stored loose in the medication cart. MA B further stated that loose medications could lead to medication errors, loss of medication integrity, or inability to identify the correct medication.During an interview on 08/04/2026 at 11:30 a.m. with the Assistant Director of Nursing (ADON), she stated medication carts must not contain loose medications under any circumstances. The ADON stated it is the responsibility of the assigned medication aide to ensure all medications are properly secured, labeled, and stored immediately following each medication pass. The ADON further stated charge nurses are expected to conduct bi-weekly medication cart audits to ensure proper storage, organization, and medication security. The ADON acknowledged that the presence of loose pills in the medication cart was not consistent with facility expectations and could result in medication errors or compromised medication safety.Record review of the facility policy titled Medication Storage, dated 2003, revealed, in part, Medication on our premises will be stored according to manufacturer recommendations.

Based on interview and record review, the facility failed to maintain complete and accurately documented clinical records for one (Resident #73) of 6 residents reviewed for medication administration. The facility failed to transcribe a physician-ordered medication onto Resident #73's Medication Administration Record. As a result, the medication was not reflected on the MAR as an active medication available for staff to document administration. The findings inclued : Record review of Resident #73s face sheet, dated 08/04/2026, revealed the resident was a [AGE] year old male, originally admitted to the facility on [DATE], with diagnoses of depression (mood disorder characterized by persistent feelings of sadness, loss of interest) , Congestive heart failure (chronic condition where the heart is unable to pump blood effectively), and Atrial Fibrillation(irregular heart rhythm). Record review of Resident #73's quarterly MDS assessment, dated 6/21/2026, revealed the resident's BIMS score was 13 out of 15, which indicated the resident's cognition was intact Record review of Resident #73's monthly physician orders for August 2026 revealed an order for Bactrim 800 mg / 100 mg, administer one tablet by mouth daily for 14 days; however, the order was not noted on the MAR. Further record review revealed there was no corresponding entry on the MAR identifying the medication, dosage, route, frequency, or scheduled administration time as ordered by the physician. Interview on 8/3/2026 at 10:37 AM, LVN A stated physician medication orders were expected to be transcribed onto the resident's MAR to ensure MAs had an accurate record of medications ordered and administered. LVN A reviewed Resident #73's physician order and MAR and acknowledged that Bactrim 800 mg / 100 mg had been ordered but was not transcribed onto the MAR. Interview on 8/3/2026 at 3:00 PM, ADON G stated all current physician medication orders were expected to be accurately reflected on the resident's MAR. ADON reviewed Resident #73's physician order and MAR and confirmed that the order for Bactrim 800 mg / 100 mg was not transcribed onto the MAR. The DON stated the MAR should accurately reflect the resident's current medication orders to provide a complete and accurate clinical record. Record review of the facility policy, Medication Administration, 2025, revealed: Ensure that the six rights of medication administration are followed: f. Right documentation

Based on observation, interview, and record review, the facility failed to 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 for 1 of 8 residents (Resident #81) reviewed for infection control in that: The facility failed to ensure Resident #81's catheter bag was touching the floor under Resident #81's bed. This deficient practice could place residents at risk of infection.The findings were: Record review of Resident #81's admission record, dated 08/02/2026, reflected a [AGE] year-old male initially admitted [DATE] and readmitted [DATE], with diagnoses which included neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems). Record review of Resident #81's care plan, undated, reflected Enhanced barrier precautions r/t an indwelling medical devices: Foley Catheter (a device that drains urine from the urinary bladder into a collection bag outside of the body). Record review of Resident #81's annual MDS assessment, dated 05/04/2026, reflected a BIMS could not be conducted and the resident had short-term, long-term problems, and severely impaired cognitive skills for daily decision making. It further revealed that the resident had an indwelling catheter. During an interview and observation on 08/02/2026 at 02:40 PM, Resident #81's foley catheter tubing was clipped to his bed frame, and the bottom of the catheter bag was upright with the bottom touching the floor. CNA I confirmed Resident #81's catheter bag was touching the floor, and it should be off the floor to prevent contamination. She was not aware of why it was touching the floor. During an interview on 08/02/2026 at 03:32 PM, ADON H revealed Resident #81's catheter bag should not touch the floor because the floor was a dirty surface and the bag could be contaminated and cause the resident illness. During an interview on 08/05/2026 at 03:20 PM, the ADM and ADON G revealed the catheter care for Resident #81 included keeping the collection bag off the floor to decrease the risk of infection. They revealed they fixed this issue and that Resident #81's catheter bag needed to be in a basin so it was not touching the floor. Record review of the facility's policy Catheter Care, dated 2026, reflected It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care. Record review of the facility's policy Infection Prevention and Control Program, dated 2026, reflected This facility has established and maintains 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 as per accepted national standards and guidelines.

Based on observation, interview and record review, the facility failed to ensure the resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system for 1 of 8 residents (Resident #70) reviewed for working call lights. The facility failed to ensure Resident #70 had a call light that was functioning properly on 08/03/2026. This failure posed a risk for residents' care needs not being met, potential for falls and injuries or pain. The findings were:Record review of Resident #70's care plan, last reviewed 06/10/2026, reflected a [AGE] year old female with a diagnosis of encephalopathy (any disease, damage, or malfunction of the brain that alters how it works) At risk for altered in mental status and changes in mood (agitation) r/t encephalopathy with interventions Implement fall precautions, such as c) call light within reach Record review of Resident #70's quarterly MDS assessment, dated 07/14/2026, reflected a BIMS score of 06 out of 15, indicating severe cognitive impairment. It revealed she needed partial/moderate assistance with upper body dressing, lower body dressing, and putting on/taking off footwear. It revealed that she needed a helper to assist only prior to or following the activity for sit to stand, chair/bed-to-chair transfer, and toilet transfer. Record review of the facility's incidents and accidents report, dated 08/02/2026 reflected no incidents (to include falls) involving Resident #70. During an observation and interview on 08/03/2026 at 11:18 AM, Resident #70 was lying in bed, pressed her call light, and it was not working. CNA J confirmed Resident #70's call light was not working and had not noticed it was not working until now. Resident #70 was not aware of when it stopped working and she had still been receiving care that she needed. CNA J revealed it was important to keep call lights within reach of residents, and that Resident #70 was a fall risk and needed the call light for help as needed. Resident #70 denied any falls due to not receiving help. During an interview on 08/05/2026 at 03:20 PM, the ADM and ADON G revealed they fixed Resident #70's call light. They revealed there was no work order for this call light and it was important to have call lights working so that the needs for residents were met. Record review of the facility's policy Call Lights: Accessibility and Timely Response, dated 2025, 9. Ensure the call system alerts staff members directly or goes to a centralized staff work area.

Based on interviews, observation, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 3 of 6 residents (Residents #3, #4, and #5) reviewed for care plans. 1.The facility failed to update Resident #3's care plan to reflect Resident #3 had a behavior of refusing showers.2.The facility failed to update Resident #4's care plan to reflect refusal of medication and care, verbal and physical aggressive behaviors, and psych service interventions put in place following an incident on 2/12/2026.3.The facility failed to update Resident #5's care plan to reflect suicidal ideation symptoms following an incident on 1/9/2026. This failure could place residents at risk of not having their needs met and not receiving appropriate care. Findings included:1.Record review of Resident #3's admission record, dated 03/06/2026, reflected a [AGE] year-old male admitted on [DATE] with diagnoses to include Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills), cognitive communication deficit, need for assistance with personal care, impulse disorder, and major depressive disorder. Record review of Resident #3's quarterly MDS assessment, dated 01/09/2026, reflected Resident #3 had a BIMS score of 9 out of 15, indicating moderate cognitive impairment. Record review of Resident #3's care plan, undated, reflected no mention of Resident #3 refusing showers. Record review of Resident #3's bathing task in the last 30 days, undated, reflected Resident #3 had two baths completed in the last 30 days on 02/21/2026 and 03/03/2026. Resident #3's bathing task reflected Resident #3 refused eight baths in the last 30 days on 02/07/2026, 02/10/2026, 02/14/2026, 02/17/2026, 02/19/2026, 02/26/2026, 02/28/2026, and 03/05/2026. Record review of the facility's grievances reflected Resident #3 had complaints of not being changed and not being showered., dated 02/21/2026. Interview and observation on 03/06/26 at 01:27 PM, Resident #3 revealed that he was not receiving showers and denied that he refused showers. He appeared well-kempt (description for someone that is neat, tidy, well-groomed, or well-maintained) with no foul odor. Interview on 03/06/2026 at 03:23PM, LVN C revealed Resident #3 refused showers sometimes even when the staff offered at different times in the day and after some encouragement too. He revealed Resident #3's refusal of showers should be documented in the care plan so that it did not look like they were not offering Resident #3 showers. Interview on 03/06/26 at 04:36PM, the DON revealed shower refusals should be documented because it's the resident's right to refuse. She further revealed that it can help our staff know to encourage Resident #3 to shower. She revealed it was important so we can respect his rights, but the facility still tried to make sure Resident #3 was clean and hygienic. 2. Review of Resident #4's admission record, dated 3/06/2026, reflected a [AGE] year-old female admitted [DATE]. Her diagnoses included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills), anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues), depression mood disorder characterized by persistent feelings of sadness, loss of interest, and range of emotional physical problems), and spastic hemiplegia affecting left nondominant side (condition characterized by muscle stiffness and weakness on one side of the body). Review of Resident #4's admission MDS, dated [DATE], reflected a BIMS score of 03, indicating severely impaired cognition. The MDS reflected Resident #4's functional abilities of self-care and mobility as totally dependent on staff and required the use of a manual wheelchair. The MDS reflected Resident #4 did not exhibit physical or behavior symptoms directed toward others. Resident #4's active diagnoses under neurological category included Alzheimer's Disease, Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke and Hemiplegia (complete or near-complete paralysis on one side) or Hemiparesis (partial weakness on one side of the body) and under the psychiatric/mood disorder category included Anxiety Disorder and Depression (other than bipolar) and she was taking antidepressants. Further review of Resident #4's admission MDS reflected care area was triggered, and care planning revisions occurred on 2/23/2026 for t cognitive loss/dementia, communication, falls, and psychotropic drug use. Further review reflected no review or revision addressing Resident #4's psychosocial well-being, physical and verbal behavioral symptoms directed towards others and her refusal of medications and care. Review of Resident #4's care plan, dated 2/11/2026 and revised 2/14/2026, reflected Resident #4 had cognitive impairment as evidenced by impaired decision making, impaired orientation, impaired communication related to language barrier, Spanish speaking only, potential for adverse side effects related to antidepressant medications sertraline and mirtazapine. Further review of care plan revealed no review of revision following the MDS assessment on 2/20/2026, which triggered Care Areas including Cognitive Loss/Dementia, Communication, and Psychotropic Drug Use. During an observation and interview 3/06/2026 at 3:16 PM Resident #4 she was observed lying down on her bed and periodically moving to a sitting position. She was Spanish speaking, her bed was positioned low, she had a fall mattress near her bed. Resident #4 was dressed well, groomed appropriately, no odors, and wearing a sun hat. A wheelchair was near her bed, the call light was within reach. Resident would say it was cold, she would smile, and she was observed sitting up, stretching her arms and out and reaching around her bed with little force. She said she did not know the residents and she just arrived here. The resident was confused and had limited words. She did not engage with surveyor during the interview. Her thought process was limited. Review of Resident #4's progress note dated, 2/25/2026 documented by RN E Resident [Resident #4] became physically aggressive during ADL care while CNA was assisting with personal care, resident [Resident #4] struck CNA with open hand, but CNA was able to avoid being struck. Care was paused immediately by CNA and resident [Resident #4] was redirected using calm verbal cues and reassurance. CNA allowed resident [Resident #4] space to de-escalate. After redirection, resident [Resident #4] became less agitated and care was provided. Behaviors monitored and interventions implemented as needed. Review of Resident #4's progress note dated, 2/20/2026 documented by, RN D Resident [Resident #4] noted to be verbally and physically aggressive toward staff during attempts to provide ADL care. When staff approached to assist with hygiene and dressing, resident [Resident #4] became verbally insulting, yelling and making derogatory statements. Upon continued attempts to provide care, resident [Resident #4] attempted to hit, push, and grab at staff. Staff maintained safety, stepped back, and avoided further escalation. Staff continued with calm approach, reassurance, and redirection. Family notified of [Resident #4's] behaviors and ongoing refusal of care. Family member arrived in facility and assisted with calming resident [Resident #4]. With family presence and reassurance, resident [Resident #4] allowed staff to complete ADL care without further aggression. Resident [Resident #4] continues to require frequent redirection due to cognitive impairment. Review of Resident #4's progress note dated 2/17/2026 documented by, RN E [Resident #4] Refused x 3 attempts. Resident [Resident #4] confused per usual self. Resident [Resident #4] combative with staff. Review of Resident #4's progress note dated 2/13/2026 documented by, RN F [Resident #4] refused all medications. Review of Resident #4's progress note dated, 2/12/2026 documented by, RN D Went inside the resident's [Residents #4 and #5] room to check on them when [Resident #5] told me to be careful with her roommate [Resident #5] because she slapped her face. Separated the residents [Residents #4 and #5], assessed them, and informed physician, ADON and relatives of what happened. Vital signs are stable, no pain or any discomfort, no injuries sustained. Review of an incident report titled, #619 Resident to Resident dated 2/12/2026 documented by RN D reflected the following: Incident Description: Nursing Description: Went inside the resident's room to check on them when Resident # told me to be careful with her roommate because she slapped her face. Resident Description: Resident said that she's just trying to eat breakfast inside her room while her roommate keeps on mumbling words she doesn't understand and then slapper her in the face. Immediate Action Taken: Separated both the residents, assed both the residents and put Resident #4 in front of the nurse's station. Injuries Observed at Time of Incident: No Injuries observed at time of incident. Review of Resident #4's progress note dated, 2/11/2026 documented by, RN D Resident [Resident #4] refused to have her weight checked. Resident [Resident #4] is being aggressive with staff. Review of Resident #4's progress note dated, 2/11/2026 documented by, Nurse Practitioner Patient [Resident #4] is a poor historian due to cognitive and psychiatric impairment. Nursing reports baseline agitation and confusion. Baseline agitation and cognitive impairment complicate history-taking and care coordinator. Record review of facility's policy Comprehensive Care Plans, dated 05/05/2025, reflected 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. 3.Review of Resident #5's admission record, dated 3/05/2026, reflected a [AGE] year-old female admitted [DATE] and re-admitted on [DATE]. Her diagnoses included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills), major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities), recurrent, moderate, suicidal ideations (tendency to experience suicidal thoughts or behaviors repeatedly over time), repeated falls, and cognitive communication deficit (impairment in mental processes). Review of Resident #5's quarterly MDS, dated [DATE], reflected a BIMS score of 05, indicating severely impaired cognition. The MDS reflected Resident #5 completed functional abilities of self-care with some help and completed mobility independently without assistance and the use of a manual wheelchair. Resident #5 did not exhibit physical, or behavior symptoms directed toward others. Resident #5's active diagnoses under Heart/Circulation category included: Coronary Artery Disease (CAD); under Neurological category included: Alzheimer's Disease; and under Additional active diagnoses category included: other abnormalities of gait and mobility, muscle weakness, cognitive communication deficit, repeated falls and she was taking antidepressants. Further review of the quarterly MDS reflected no review or revision addressing Resident #5's psychosocial well-being, physical and verbal behavioral symptoms directed towards others and her refusal of medications and care. Review of Resident #5's care plan, dated 6/11/2024, reflected Resident #5 had physical functioning deficit related to muscle weakness [initiated 7/19/2024]. Record review further reflected Resident #5 was care planned for physically abusive behavior of cursing, yelling and throwing items due to agitation with a goal that Resident #5 would be able to be redirected if physically/verbally aggressive through the next review date and interventions included change rooms, document behaviors in the clinical record, and obtain antianxiety medication [initiated 1/13/2026 and revision 1/19/2026]. Record review reflected Resident #5 had the potential for adverse side effects related to antidepressant medications [revision 1/31/2026]. Resident #5 has impaired communication related to cognitive communication deficit [revision 7/19/2024]; Resident #5 has potential for complications related to dementia [revision 5/18/2025]; Resident #5 refused care as evidence by choosing to leave items unbagged at bedside with interventions to include identify root cause of refusal and always use clear communication before attempting to attend to the person's self-care [revision 7/31/2024]. Further review of the care plan reflected no review or revision addressing Resident #5's psychosocial well-being following the suicidal ideation incident on 1/9/2026. Review of Resident #5's LMHC-Psychology Progress visit, dated 2/11/2026, reflected the following: LCSW met with resident [Resident #5] to address symptoms of mental health diagnoses, adjustment to current facility, and the need for increased social cognitive engagement. Resident [Resident #5] was receptive to communication today. She denied SI/HI/AVH. Review of Resident #5's physician note dated 1/9/2026 documented by Psychiatric Mental Health Nurse Practitioner reflected the following: Pt [Resident #5] seen via telehealth. Pt [Resident #5] consents to evaluation. Pt [Resident #5] reports overall mood is good. Denies depression or anxiety today. Reports eating and sleeping well. Pt [Resident #5] currently on 1:1 after it was reported she voiced wanting to kill herself. Pt [Resident #5] denied saying this when evaluated by her nurse. No plan was present at time of evaluation by nurse. Pt [Resident #5] denies active or passive SI at this time of evaluation. When asked if she made SI statements earlier, states she voiced that earlier because I got upset but I didn't mean too. Denies plan, intent, or access to means at this time. Protective factors reviewed. Safety plan discussed. Pt [Resident #5] has not displayed any suicidal gestures per staff. Pt [Resident #5] is not a threat at this current moment. Will d/c 1:1 at this time. Staff instructed to contact provider for return of SI thoughts. Orders given to increase Sertraline from 50mg to 100mg PO QD. Also seen to follow up on recent physical altercation within the facility with former roommate. Pt [Resident #5] unable to provide details of incident at this time. States that's just the problem, I don't know what happened when asked about reported incident. Pt and roommate were separated. Pt [Resident #5] was moved to a different room. Facility to continue to investigate incident. Pt [Resident #5] with NO further aggressive behaviors following incident. Review of Resident #5's progress note dated 1/9/2026, documented by RN D reflected the following: Behavior(s)- Describe behaviors noted throughout shift: This nurse informed by another nurse that while walking down the hallway, the resident [Resident #5] stated, I am going to kill myself, and then walked away. This nurse immediately located the resident [Resident #5] and assessed for safety. Upon assessment, the resident [Resident #5] denied even making the above statement and denied any suicidal ideation, intent, or plan. Resident [Resident #5] appeared to be in good spirits, calm, and cooperative at the time of assessment. No signs of emotional distress noted. Resident [Resident #5] stated she never said that and continued to deny the comment throughout the interaction. Antecedent: Resident [Resident #5] was walking down hallways Intervention: This nurse immediately located the resident [Resident #5] and assessed for safety. Upon assessment, the resident [Resident #5] denied even making the above statement and denied any suicidal ideation, intent, or plan. Resident [Resident #5] appeared to be in good spirits, calm, and cooperative at the time of assessment. No signs of emotional distress noted. Review of an incident report titled, #593 Resident to Resident dated 1/8/2026 reflected the following: Incident Description: Nursing Description: Patient [Resident #5] verbally and physically aggressive towards roommate. The nurse observed patient [Resident #5] calling roommate derogatory names and punched roommate in the jaw because [Resident #5] wanted the curtain closed and the roommate wanted it open. Patient [Resident #5] was moved from room [room number] to [room number]. Resident Description: Resident unable to give description. Immediate Action Taken: [Resident #5] was moved to another room. Head to toe assessment was completed. DON and ADM aware. Police report completed. Doctor was made aware. Injuries Observed at Time of Incident: No Injuries observed at time of incident. During an interview on 3/05/2026 at 6:20 PM, the Regional Nurse said due to the recent loss of employees and transition of new employees including the ADM, DON, and ADON, she was assigned to the facility on a temporary basis. She said she understood the MDS assessment, but she did not update them. She said the MDS was required to be initiated and updated with interventions when needed. She said by not updating MDS assessments it could reduce the care that was required for a resident. She said she was aware of the resident-to-resident incident on 2/12/2026 involving Residents #4 and #5. She said Resident #5 accused Resident #4 of slapping her. She said Resident #4 was taken to the nurse's station for observation, the aggressor was Resident #4. She said there were no marks. She said the secondary incident on 1/9/2026 regarding Resident #5 and suicidal ideation behaviors was also discussed. She said Resident #5 was assessed by staff, placed on 1:1 supervision, the Psychiatric Mental Health Nurse Practitioner also evaluated Resident #5 following the incident, the PCP evaluated the resident, the LCSW followed up with Resident #5 and determined there were no concerns. She said the resident also said she was upset and said something she should not have said. She said she could not recall why the documented behaviors for Residents #4 and #5 were not updated on their care plan, but this would be taken care of today. During a telephone interview on 3/05/2026 at 6:53 p.m., the MDS Coordinator said she assisted on a part-time basis with MDS assessments and was part of IDT. She said she initiated and revised MDS assessments. She said the assessments helped the facility and staff understand what care needs were provided for a specific resident. She said she was aware of Residents #4 and Resident #5's incident on 2/12/2026 of resident-to-resident abuse. She said the IDT meeting did occur, and interventions were noted in the meeting, but she was not clear as to why the MDS assessments were not updated. She said Resident #5's 1/9/2026 incident of physical and verbal symptoms and incident of suicidal ideation symptoms were reviewed by the IDT and interventions were implemented but were not updated in her MDS assessment. She said the facility's Social Worker would have more details about MDS assessments but was out of town and could not be reached. The MDS Coordinator said she recalled an IDT meeting discussing Resident #5's behaviors, but she did not understand why it was not documented and believed the team made an error and failed to document during the IDT. She said interventions were in place for the resident and she could not speak on the failure to update the MDS assessment with behaviors, but that it would be worked on. She said she could not recall why the documented behaviors for Resident #4 and Resident #5 were not updated on their care plan, but this would be taken care of today. During an interview on 3/06/2026 at 10:45 AM, ADON B said care plans provided the nursing staff with specific care for residents. She said care plans should be updated frequently and with important information for each resident. She said the nursing staff could not provide quality care without this information, and it could be harmful to residents. ADON B said staff were good at conducting shift changes and relaying pertinent information to the oncoming staff. She said she recalled the incident regarding Resident #5 on 1/9/2026, resident-to-resident physical altercation and suicide ideation. She said Resident #5 required partial assistance depending on what mood she was in, she thought she was going home, she cursed staff and was verbally aggressive. She said when Resident #5 was on a rampage she did not care if someone was an employee or resident. ADON B said typically Resident #5 would become verbally aggressive three times out of the month, she did have interventions in place. She said she did have an incident where she was monitored a while back. She said the staff knows when Resident #5 was having a rough day or if in a good mood it will be a good day. She said Resident #5 would be verbally aggressive and start saying things she did not mean and did not recall shortly after. She said Resident #5 did receive psych services and medications to help her with her mood. She said these behaviors had been addressed during the IDT, but she was not sure why they had not been updated in the resident's care plan. During interview on 3/5/2026 at 1:53 PM, CNA H said Resident #4 could be verbally aggressive, the first day she arrived she started swinging to hit the staff when they provided her with care. CNA H said Resident #4 was confused and not sure where she was. She said now the resident was on medications she was calmer. She said she was familiar with her care and interventions in place to help her de-escalate. At times residents' behaviors would be listed in their plan of care and it would be important to be aware of how to help them. She said at times she will not review the care plan, but the team does an excellent job with shift change and relaying all the information needed to care for a resident including Resident #4. CNA H said she recalled Resident #4's resident-to-resident incident with Resident #5 vaguely. CNA H said Resident #5 was not assigned to her unit. She said Resident #4 slapped Resident #5, but there were no marks. She said Resident #5 was on North 1 unit, she did provide visual care and supervision at times, she said she did have behavior concerns and got mad when offering to wash her hair. CNA H said if she had residents making suicidal statements she was to report it immediately to the charge nurse. During an interview on 3/06/2026 at 12:41 PM, MA A said when Resident #4 arrived at the facility she was verbally and physically aggressive. She said interventions included her children visiting daily and this helped her to calm down her behaviors. She said Resident #4 had also been provided with medications that have assisted with behaviors and with time she had gotten used to the facility. During an interview on 3/06/2026 at 3:00 PM, Physical Therapy said Resident #4 could be verbally aggressive towards staff, especially during the afternoon, sundown. She said in the morning Resident #1 was in a good mood, but in the afternoon, she seemed more agitated. She said she was assisting her with transfer training, wheelchair mobility, neuro with weight shift and reaching. She said Resident #4 has a fear of standing or falling and cannot stand up on her own. She said someone would have to be within reach for her to hit them and said she did not have the ability to reach out and intentionally hit someone. She said she worked with Resident #5 previously and she tends to shut down if physical therapy becomes challenging. She said she has not witnessed Resident #5 become verbally or physically aggressive. Physical Therapy said the nursing staff work with the residents appropriately. She said they helped the residents de-escalate if they were having a rough day. During an interview on 3/06/2026 at 3:19 PM, CNA I said care plans are necessary for staff to know what care a resident requires. She said the team helped each other and during shift change she was provided with all the details and anything new to care for a resident. She said Resident #4 was normally physically aggressive and verbally aggressive towards her when she provided care. She said you would have to be within reach for her to physically hit you. She said the in-services on de-escalation techniques are helpful. She said if she was patient she could help de-escalate. During an interview on 3/06/2026 at 3:35 PM, CNA J said care plans help the staff provide the best possible care to the residents. She said without care plans being updated the staff could miss something and not provide necessary care for a resident. She said when she is providing care to a challenging resident who is abusive, she opts to provide care with a second staff member present. She said the staff should not need to endure abuse from residents. During a joint interview on 3/06/2026 at 4:25 PM, ADON K and DON said care plans are the responsibility of the MDS Coordinator and acute concerns are currently handled by Regional Nurse. She said the regional team consisting of the MDS Coordinator and MDS Coordinator L are helping with MDS assessments and care plans as there have been a lot of staff transitioning out of the facility. She said IDT meetings are held by department heads, ADON, DOR, SW, and ADM. DON said care plans are important to ensure continuity of care for residents. She said care plans are for nurses and aids, and should include total care, likes, dislikes, needs, 2-person assistance, behaviors, multiple wandering episodes. DON said there have been a high turnover of DONs recently, nobody solid. ADON K said she has been tasked with DON responsibilities with this high turnover. She said care plans generate general concerns and are used by the nursing staff to provide resident care. She said this is how the nursing staff and aids communicate with one another. She said the nursing staff and aids will review the care plan for interventions and she will review if the interventions are appropriate for residents. ADON K said she will ensure psych consultation and other interventions are added to care plans. She said all staff have access to the care plans. During an interview on 3/06/2026 at 5:31 PM, the Senior Director said that if the residents have behaviors staff will work to identify what works for them. She said if a resident has physical or verbal aggression behaviors the team would get together to see what approaches will help the resident and incorporate interventions. The Senior Director said she would not be able to provide surveyor with information on specific care plans at this time as LMSW, who normally handles the care plans, was on vacation and out of the country. She said at this time there were regional resource staff that were at the facility helping to ensure care plans were updated accurately and timely. The Senior Director said that multiple things, not just one thing, several factors showing a decline or change could warrant a significant change. She said that she does not believe verbal and physical aggression along with psych service and medication management would trigger a significant change but would review Resident #1 and Resident #5's care plans and update with specific interventions today. During an interview on 3/06/2026 at 6:36 PM, the Former ADM said if there is a cognitive change in status, any change in ADLs, regress of care, change of behavior, psych interventions and medications would be considered a significant change. She said she was unsure why Residents #4 and #5's care plans had not been updated to reflect their current behaviors and intervention. She said it was important to have accurate care plans as it was important to provide complete care for residents. Record review of facility document titled, MDS 3.0 Completion, dated October 2025, reflected the following: Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Record review of facility document titled, Abuse, Neglect and Exploitation, dated 7/25/2025, reflected the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours (for an injury of unknown origin involving serious bodily injury) to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 2 of 6 Residents (Residents #4 and #5) reviewed for abuse. 1.The facility failed to report an allegation of resident-to-resident abuse of Resident #5, when Resident #4 slapped Resident #5 in the face on 2/12/2026. 2.The facility failed to report an allegation of suicidal ideation symptoms for Resident #5 on 1/9/2026. This deficient practice could place residents at risk of harm by not having their abuse and neglect incidents investigated. Findings included:1.Review of Resident #4's admission record, dated 3/06/2026, reflected a [AGE] year-old female admitted [DATE]. Her diagnoses included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills), anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues), depression mood disorder characterized by persistent feelings of sadness, loss of interest, and range of emotional physical problems), and spastic hemiplegia affecting left nondominant side (condition characterized by muscle stiffness and weakness on one side of the body). Review of Resident #4's admission MDS, dated [DATE], reflected a BIMS score of 03, indicating severely impaired cognition. The MDS reflected Resident #4's functional abilities of self-care and mobility as totally dependent on staff and required the use of a manual wheelchair. Review of Resident #4's care plan, dated 2/11/2026 and revised 2/14/2026, reflected the resident had cognitive impairment as evidenced by impaired decision making, impaired orientation, impaired communication related to language barrier, Spanish speaking only, potential for adverse side effects related to antidepressant medications sertraline and mirtazapine. Review of Resident #4's progress note, dated 2/12/2026 documented by RN D, Went inside the residents' [Residents #4 and #5] room to check on them when [Resident #5] told me to be careful with her roommate [Resident #4] because she slapped her face. Separated the residents [Residents #4 and #5], assessed them, and informed physician, ADON and relatives of what happened. Vital signs are stable, no pain or any discomfort, no injuries sustained. During an observation and interview 3/06/2026 at 3:16 PM Resident #4 she was observed lying down on her bed and periodically moving to a sitting position. She was Spanish speaking, her bed was positioned low, she had a fall mattress near her bed. Resident #4 was dressed well, groomed appropriately, no odors, and wearing a sun hat. A wheelchair was near her bed, the call light was within reach. Resident would say it was cold, she would smile, and she was observed sitting up, stretching her arms and out and reaching around her bed with little force. She said she did not know the residents and she just arrived here. The resident was confused and had limited words. She did not engage with surveyor during the interview. Her thought process was limited. Record review of an incident report titled, # 619 Resident to Resident, dated 2/12/2026 documented by RN D, reflected the following:Incident Description:Nursing Description: Went inside the resident's room to check on them when Resident #5 told me to be careful with her roommate because she slapped her face.Resident Description: Resident #5 said that she's just trying to eat breakfast inside her room while her roommate (Resident #4) keeps on mumbling words she doesn't understand and then slapped her in the face.Immediate Action Taken: Separated both the residents (Residents #4 and #5), assed both the residents and put Resident #1 in front of the nurse's station.Injuries Observed at Time of Incident: No injuries observed at time of incident. 2. Review of Resident #5's admission record, dated 3/05/2026, reflected a [AGE] year-old female admitted [DATE] and re-admitted on [DATE]. Her diagnoses included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills), major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities), recurrent, moderate, suicidal ideations (tendency to experience suicidal thoughts or behaviors repeatedly over time), repeated falls, and cognitive communication deficit (impairment in mental processes). Review of Resident #5's quarterly MDS, dated [DATE], reflected a BIMS score of 05, indicating severely impaired cognition. The MDS reflected Resident #5 completed functional abilities of self-care with some help and completed mobility independently without assistance and the use of a manual wheelchair. Review of Resident #5's care plan, dated 6/11/2024, reflected Resident #5 had physical functioning deficit related to muscle weakness [initiated 7/19/2024]. Record review further reflected Resident #5 was care planned for physically abusive behavior of cursing, yelling and throwing items due to agitation with a goal that Resident #5 would be able to be redirected if physically/verbally aggressive through the next review date and interventions included change rooms, document behaviors in the clinical record, and obtain antianxiety medication [initiated 1/13/2026 and revision 1/19/2026]. Record review reflected Resident #5 had the potential for adverse side effects related to antidepressant medications [revision 1/31/2026]. Review of Resident #5's Psychiatry Follow Up, dated 2/24/2026, reflected the following,: Per behavioral notes review, no agitation or acute psychiatric symptoms documented over the past month. Chart review shows pt [Resident #5] involved in recent resident to resident incident with roommate on 2/12/26. It was reported that patient [Resident #5] was slapped in the face by her roommate. No injuries sustained. Vitals were stable. Both residents were separated. Patient [Resident #5] reported no pain or distress afterwards. Pt [Resident #5] does not mention incident on exam. When asked how things are going in the facility, states good. Pt [Resident #5] does not recall incident at this time. Reports feeling safe in facility. No acute mood disturbances or behavioral concerns reported. Facility continued to investigate. Review of Resident #5's LMHC-Psychology Progress visit, dated 2/11/2026, reflected the following,: LCSW met with resident [Resident #5] to address symptoms of mental health diagnoses, adjustment to current facility, and the need for increased social cognitive engagement. Resident [Resident #5] was receptive to communication today. She denied SI/HI/AVH. Review of Resident #5's physician note, dated 1/9/2026, documented by Psychiatric Mental Health Nurse Practitioner reflected the following, Pt [Resident #5] seen via telehealth. Pt [Resident #5] consents to evaluation. Pt [Resident #5] reports overall mood is good. Denies depression or anxiety today. Reports eating and sleeping well. Pt [Resident #5] currently on 1:1 after it was reported she voiced wanting to kill herself. Pt [Resident #5] denied saying this when evaluated by her nurse. No plan was present at time of evaluation by nurse. Pt [Resident #5] denies active or passive SI at this time of evaluation. When asked if she made SI statements earlier, states she voiced that earlier because, I (Resident #5) got upset but I (Resident #5) didn't mean too. Denies plan, intent, or access to means at this time. Protective factors reviewed. Safety plan discussed. Pt [Resident #5] has not displayed any suicidal gestures per staff. Pt [Resident #5] is not a threat at this current moment. Will d/c 1:1 at this time. Staff instructed to contact provider for return of SI thoughts. Orders given to increase Sertraline from 50mg to 100mg PO QD. Also seen to follow up on recent physical altercation within the facility with former roommate. Pt [Resident #5] unable to provide details of incident at this time. States that's just the problem, I don't know what happened when asked about reported incident. Pt and roommate were separated. Pt [Resident #5] was moved to a different room. Facility to continue to investigate incident. Pt [Resident #5] with NO further aggressive behaviors following incident. Review of Resident #5's progress note, dated 1/9/2026, documented by RN D, reflected the following,: Behavior(s)- Describe behaviors noted throughout shift: This nurse informed by another nurse that while walking down the hallway, the resident [Resident #5] stated, I am going to kill myself, and then walked away. This nurse immediately located the resident [Resident #5] and assessed for safety. Upon assessment, the resident [Resident #5] denied even making the above statement and denied any suicidal ideation, intent, or plan. Resident [Resident #5] appeared to be in good spirits, calm, and cooperative at the time of assessment. No signs of emotional distress noted. Resident [Resident #5] stated she never said that and continued to deny the comment throughout the interaction.Antecedent: Resident [Resident #5] was walking down hallwaysIntervention: This nurse immediately located the resident [Resident #5] and assessed for safety. Upon assessment, the resident [Resident #5] denied even making the above statement and denied any suicidal ideation, intent, or plan. Resident [Resident #5] appeared to be in good spirits, calm, and cooperative at the time of assessment. No signs of emotional distress noted. Review of an incident report titled #593 Resident to Resident dated 1/8/2026 reflected the following:Nursing Description: Patient [Resident #5] verbally and physically aggressive towards roommate. The nurse observed patient [Resident #5] calling roommate derogatory names and punched roommate in the jaw because [Resident #5] wanted the curtain closed and the roommate wanted it open. Patient [Resident #5] was moved from room [room number] to [room number].Resident Description: Resident unable to give description.Immediate Action Taken: [Resident #5] was moved to another room. Head to toe assessment was completed. DON and ADM aware. Police report completed. Doctor was made aware.Injuries Observed at Time of Incident: No injuries observed at time of incident. During an interview on 3/05/2026 at 6:20 PM, the Regional Nurse said she was aware of the resident-to-resident incident on 2/12/2026 involving Residents #4 and #5. She said Resident #5 accused Resident #4 of slapping her. She said Resident #4 was taken to the nurse's station for observation, the aggressor was Resident #4. She said Resident #5requested to be moved and she was relocated to another room in a different unit. She said this incident was not reported to the State, but it was documented as a resident-to-resident incident. She said it was alleged, nobody witnessed, and after head-to-toe assessment was completed on both residents, staff could not tell if it was true. The Regional Nurse said there were no marks. She said the secondary incident on 1/9/2026 regarding Resident #5 and suicidal ideation behaviors was also discussed. She said Resident #5 was assessed by staff, she was placed on 1:1 supervision, the Psychiatric Mental Health Nurse Practitioner also evaluated Resident #5 following the incident, PCP evaluated the resident, LCSW followed up with Resident #5 and determined there were no concerns. She said the resident also said she was upset and said something she should not have said. She said this incident would not be reported to the State. She said the ADM usually reported to the State and the DON in-service on specific topics addressing incidents. She said she was provided with details of the incident, and she made a recommendation to report or not report. She said ultimately it was the ADM's decision to accept her recommendation or not and to follow through with the report if it was reported. She said for this incident it was her recommendation not to report because she could not tell if it happened or not and there were no concerns with the residents. The Regional Nurse said the facility policy was to report any ANE within the hour. During a telephone interview on 3/05/2026 at 6:53 PM, the MDS Coordinator said ANE allegations were reported immediately to the Abuse Coordinator, the ADM. She said the IDT reviewed the physical and verbal incidents of 1/9/2026 and 2/12/2026 and the suicidal ideation incident on 1/9/2026 but and said she did not believe they required reporting. During an interview on 3/06/2026 at 10:45 AM, ADON B revealed she was knowledgeable on ANE, Resident Rights, and de-escalation techniques and provided examples. She said depending on the situation, resident to resident incidents, employee to resident incidents would need to be reported to the State. She said if an ANE allegation was reported to her she would report it to her ADM immediately and the ADM would be required to report it to the State within 2 hours. She said failure in this process could be bad for residents and could result in harm to them. During an interview on 3/5/2026 at 1:53 PM, CNA H revealed she was knowledgeable on ANE, Resident Rights, and de-escalation techniques and provided examples. CNA H said if residents made suicidal statements she was to report it immediately to the charge nurse. During an interview on 3/06/2026 at 12:41 PM, MA A revealed she was knowledgeable on ANE, Resident Rights, and de-escalation techniques and provided examples. During an interview on 3/06/2026 at 5:31 PM, the Senior Director said she was aware of the incidents involving Resident #4 and Resident #5 and although their care plans were not updated with specific interventions the facility provided the residents with interventions that were captured in the incident reports, progress notes, and psych notes. The Senior Director said all potential allegations of ANE would be reported to the Abuse Coordinator, ADM. She said she reviewed the provider letter and encouraged the ADM and management team to follow the letter carefully, following reporting timeframes of 2 hours. She said the ADM needed to complete the provider investigation report within 5 days. She said if a resident reported to the nursing staff that another resident was physically aggressive towards them or wanted to hurt themselves this would warrant an abuse report. During an interview on 3/06/2026 at 6:36 PM, the Former ADM said she provided ANE training to her nursing staff and in-services covered resident to resident-initiated abuse and neglect, identifying signs of aggression, resident rights, and reporting incidents of ANE. She said staff were to report any allegations or suspicions to the abuse coordinator, her when she was in the position, now it would be to the interim ADM. She said she would review reporting incidents based on the provider letter and within 2 hours if ANE and 24 hours other self-report items. She said the impact of staff not reporting allegations or suspicions of ANE she would not be aware of and unable to report to the State. She said this failure could put the residents at risk of being abused. She said allegations of aggressive behavior would be reported. The Former ADM said aggressive behaviors and suicidal statements would be reported to the charge nurse, the MD would be notified and discussed with the IDT immediately. The Former ADM said she was aware of Resident #5's resident-to-resident abuse report on 1/9/2026 as she submitted it to the state and followed through with an investigation. She said she was not made aware of the incident of Resident #5regarding SI on 1/9/2026 or the incident of Resident #4 and Resident #5 resident-to-resident abuse on 2/12/2026. She said had she been made aware of the incidents she would have reported them to the State and completed a provider investigation report. Record review of facility document titled, Abuse, Neglect and Exploitation, dated 7/25/2025, reflected the following: Policy:It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Policy Explanation and Compliance Guidelines: I. The facility will develop and implement written policies and procedures that: b. Establish policies and procedures to investigate any such allegations. 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, V. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse, mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. VII Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The Administrator will follow up with government agencies during business hours, to confirm the initial report was received and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 6 residents (Residents #4 and #5) reviewed for assessments. 1.The facility failed to accurately reflect physical and verbal behavioral symptoms directed toward others on Resident #4's admission MDS, dated [DATE]. 2.The facility failed to accurately reflect physical and verbal behavioral symptoms directed toward others on Resident #5's significant change MDS, dated [DATE].3.The facility failed to accurately reflect Section D - Mood on Resident #5's quarterly MDS, dated [DATE], following her suicidal ideation symptoms on 1/9/2026 that implemented psych medications. These failures could place residents at risk for inadequate care due to inaccurate assessments. Findings included:1. Review of Resident #4's admission record, dated 3/06/2026, reflected a [AGE] year-old female admitted [DATE]. Her diagnoses included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills), anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues), depression mood disorder characterized by persistent feelings of sadness, loss of interest, and range of emotional physical problems), and spastic hemiplegia affecting left nondominant side (condition characterized by muscle stiffness and weakness on one side of the body). Review of Resident #4's admission MDS, dated [DATE], reflected a BIMS score of 03, indicating severely impaired cognition. The MDS reflected the resident's functional abilities of self-care and mobility as totally dependent on staff and required the use of a manual wheelchair. The MDS reflected Resident #4 did not exhibit physical or behavior symptoms directed toward others. Resident #4's active diagnoses under neurological category included Alzheimer's Disease, Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke and Hemiplegia (complete or near-complete paralysis on one side) or Hemiparesis (partial weakness on one side of the body) and under the psychiatric/mood disorder category included Anxiety Disorder and Depression (other than bipolar) and she was taking antidepressants. Further review of Resident #4's admission MDS reflected care area was triggered, and care planning revisions occurred on 2/23/2026 for t cognitive loss/dementia, communication, falls, and psychotropic drug use. Further review of the admission MDS reflected no review or revision addressing Resident #1's psychosocial well-being, physical and verbal behavioral symptoms directed towards others and her refusal of medications and care. Review of Resident #4's care plan, dated 2/11/2026 and revised 2/14/2026, reflected Resident #4 had cognitive impairment as evidenced by impaired decision making, impaired orientation, impaired communication related to language barrier, Spanish speaking only, potential for adverse side effects related to antidepressant medications sertraline and mirtazapine. Further review of care plan revealed no review of revision following the MDS assessment on 2/20/2026, which triggered Care Areas including Cognitive Loss/Dementia, Communication, and Psychotropic Drug Use. During an observation and interview 3/06/2026 at 3:16 PM Resident #4 she was observed lying down on her bed and periodically moving to a sitting position. She was Spanish speaking, her bed was positioned low, she had a fall mattress near her bed. Resident #4 was dressed well, groomed appropriately, no odors, and wearing a sun hat. A wheelchair was near her bed, the call light was within reach. Resident would say it was cold, she would smile, and she was observed sitting up, stretching her arms and out and reaching around her bed with little force. She said she did not know the residents and she just arrived here. The resident was confused and had limited words. She did not engage with surveyor during the interview. Her thought process was limited. Review of Resident #4's progress note, dated 2/25/2026 documented by RN E, Resident [Resident #4] became physically aggressive during ADL care while CNA was assisting with personal care, resident [Resident #4] struck CNA with open hand, but CNA was able to avoid being struck. Care was paused immediately by CNA and resident [Resident #4] was redirected using calm verbal cues and reassurance. CNA allowed resident [Resident #4] space to de-escalate. After redirection, resident [Resident #4] became less agitated and care was provided. Behaviors monitored and interventions implemented as needed. Review of Resident #4's progress note dated, 2/20/2026 documented by, RN D, Resident [Resident #4] noted to be verbally and physically aggressive toward staff during attempts to provide ADL care. When staff approached to assist with hygiene and dressing, resident [Resident #4] became verbally insulting, yelling and making derogatory statements. Upon continued attempts to provide care, resident [Resident #4] attempted to hit, push, and grab at staff. Staff maintained safety, stepped back, and avoided further escalation. Staff continued with calm approach, reassurance, and redirection. Family notified of [Resident #4's] behaviors and ongoing refusal of care. The family member arrived in facility and assisted with calming resident [Resident #4]. With family presence and reassurance, resident [Resident #4] allowed staff to complete ADL care without further aggression. Resident [Resident #4] continues to require frequent redirection due to cognitive impairment. Review of Resident #4's progress note, dated 2/17/2026 documented by, RN E, [Resident #4] Refused x 3 [three times] attempts. Resident [Resident #4] confused per usual self. Resident [Resident #4] combative with staff. Review of Resident #4's progress note, dated 2/13/2026 documented by, RN F, [Resident #4] refused all medications. Review of Resident #4's progress note, dated, 2/12/2026 documented by, RN D, Went inside the resident's [Residents #4 and #5] room to check on them when [Resident #5] told me to be careful with her roommate [Resident #4] because she slapped her face. Separated the residents [Residents #4 and #5], assessed them, and informed physician, ADON and relatives of what happened. Vital signs are stable, no pain or any discomfort, no injuries sustained. Record review of an incident report titled, #619 Resident to Resident, dated 2/12/2026 documented by RN D, reflected the following:Nursing Description: Went inside the resident's room to check on them when Resident #5 told me to be careful with her roommate (Resident #4) because she slapped her face.Resident Description: Resident #5 said that she's (Resident #5) just trying to eat breakfast inside her room while her roommate (Resident #4) keeps on mumbling words she doesn't understand and then slapped her in the face.Immediate Action Taken: Separated both the residents, assed both the residents and put Resident #4 in front of the nurse's station.Injuries Observed at Time of Incident: No injuries observed at time of incident. Review of Resident #4's progress note, dated, 2/11/2026 documented by, RN D, Resident [Resident #4] refused to have her weight checked. Resident [Resident #4] is being aggressive with staff. Review of Resident #4's progress note, dated, 2/11/2026 documented by, the Nurse Practitioner, Patient [Resident #4] is a poor historian due to cognitive and psychiatric impairment. Nursing reports baseline agitation and confusion. Baseline agitation and cognitive impairment complicate history-taking and care coordinator. 2. Review of Resident #5's admission record, dated 3/05/2026, reflected a [AGE] year-old female admitted [DATE] and re-admitted on [DATE]. Her diagnoses included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills), major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities), recurrent, moderate, suicidal ideations (tendency to experience suicidal thoughts or behaviors repeatedly over time), repeated falls, and cognitive communication deficit (impairment in mental processes). Review of Resident #5's quarterly MDS, dated [DATE], reflected a BIMS score of 05, indicating severely impaired cognition. The MDS reflected Resident #5 completed functional abilities of self-care with some help and completed mobility independently without assistance and the use of a manual wheelchair. Resident #5 did not exhibit physical, or behavior symptoms directed toward others. Resident #5's active diagnoses under Heart/Circulation category included: Coronary Artery Disease (CAD); under Neurological category included: Alzheimer's Disease; and under Additional active diagnoses category included: other abnormalities of gait and mobility, muscle weakness, cognitive communication deficit, repeated falls and she was taking antidepressants. Further review of the quarterly MDS reflected no review or revision addressing Resident #5's psychosocial well-being, physical and verbal behavioral symptoms directed towards others and her refusal of medications and care. Review of Resident #5's care plan, dated 6/11/2024, reflected the resident had physical functioning deficit related to muscle weakness [initiated 7/19/2024]. Record review further reflected Resident #5 was care planned for physically abusive behavior of cursing, yelling and throwing items due to agitation with a goal that Resident #5 would be able to be redirected if physically/verbally aggressive through the next review date and interventions included change rooms, document behaviors in the clinical record, and obtain antianxiety medication [initiated 1/13/2026 and revision 1/19/2026]. Record review reflected Resident #5 had the potential for adverse side effects related to antidepressant medications [revision 1/31/2026]. Resident #5 has impaired communication related to cognitive communication deficit [revision 7/19/2024]; Resident #5 has potential for complications related to dementia [revision 5/18/2025]; Resident #5 refused care as evidence by choosing to leave items unbagged at bedside with interventions to include identify root cause of refusal and always use clear communication before attempting to attend to the person's self-care [revision 7/31/2024]. Further review of the care plan reflected no review or revision addressing Resident #5's psychosocial well-being following the suicidal ideation incident on 1/9/2026. Review of Resident #5's Psychiatry Follow Up, dated 2/24/2026, reflected the following, Per behavioral notes review, no agitation or acute psychiatric symptoms documented over the past month. Chart review shows pt [Resident #5] involved in recent resident to resident incident with roommate on 2/12/26. It was reported that patient [Resident #5] was slapped in the face by her roommate. No injuries sustained. Vitals were stable. Both residents were separated. Patient [Resident #5] reported no pain or distress afterwards. Pt [Resident #5] does not mention incident on exam. When asked how things are going in the facility, states good. Pt [Resident #5] does not recall incident at this time. Reports feeling safe in facility. No acute mood disturbances or behavioral concerns reported. Facility continued to investigate. Review of Resident #5's LMHC-Psychology Progress visit, dated 2/11/2026, reflected the following, LCSW met with resident [Resident #5] to address symptoms of mental health diagnoses, adjustment to current facility, and the need for increased social cognitive engagement. Resident [Resident #5] was receptive to communication today. She denied SI/HI/AVH. Review of Resident #5's physician note, dated 1/9/2026, documented by Psychiatric Mental Health Nurse Practitioner reflected the following, Pt [Resident #5] seen via telehealth. Pt [Resident #5] consents to evaluation. Pt [Resident #5] reports overall mood is good. Denies depression or anxiety today. Reports eating and sleeping well. Pt [Resident #5] currently on 1:1 after it was reported she voiced wanting to kill herself. Pt [Resident #5] denied saying this when evaluated by her nurse. No plan was present at time of evaluation by nurse. Pt [Resident #5] denies active or passive SI at this time of evaluation. When asked if she made SI statements earlier, states she voiced that earlier because, I (Resident #5) got upset but I (Resident #5) didn't mean too. Denies plan, intent, or access to means at this time. Protective factors reviewed. Safety plan discussed. Pt [Resident #5] has not displayed any suicidal gestures per staff. Pt [Resident #5] is not a threat at this current moment. Will d/c 1:1 at this time. Staff instructed to contact provider for return of SI thoughts. Orders given to increase Sertraline from 50mg to 100mg PO QD. Also seen to follow up on recent physical altercation within the facility with former roommate. Pt [Resident #5] unable to provide details of incident at this time. States that's just the problem, I don't know what happened when asked about reported incident. Pt and roommate were separated. Pt [Resident #5] was moved to a different room. Facility to continue to investigate the incident. Pt [Resident #5] with no further aggressive behaviors following incident. Review of Resident #5's progress note, dated 1/9/2026, documented by RN D, reflected the following, Behavior(s)- Describe behaviors noted throughout shift: This nurse informed by another nurse that while walking down the hallway, the resident [Resident #5] stated, I am going to kill myself, and then walked away. This nurse immediately located the resident [Resident #5] and assessed for safety. Upon assessment, the resident [Resident #5] denied even making the above statement and denied any suicidal ideation, intent, or plan. Resident [Resident #5] appeared to be in good spirits, calm, and cooperative at the time of assessment. No signs of emotional distress noted. Resident [Resident #5] stated she never said that and continued to deny the comment throughout the interaction.Antecedent: Resident [Resident #5] was walking down hallwaysIntervention: This nurse immediately located the resident [Resident #5] and assessed for safety. Upon assessment, the resident [Resident #5] denied even making the above statement and denied any suicidal ideation, intent, or plan. Resident [Resident #5] appeared to be in good spirits, calm, and cooperative at the time of assessment. No signs of emotional distress noted. Review of an incident report titled #593 Resident to Resident dated 1/8/2026 reflected the following:Incident Description:Nursing Description: Patient [Resident #5] verbally and physically aggressive towards roommate. The nurse observed patient [Resident #5] calling roommate derogatory names and punched roommate in the jaw because [Resident #5] wanted the curtain closed and the roommate wanted it open. Patient [Resident #5] was moved from room [room number] to [room number].Resident Description: Resident unable to give description.Immediate Action Taken: [Resident #5] was moved to another room. Head to toe assessment was completed. DON and ADM aware. Police report completed. Doctor was made aware.Injuries Observed at Time of Incident: No injuries observed at time of incident. During an interview on 3/05/2026 at 11:48 AM, CNA G said Resident #5 was independent, required minimal supervision, she was sometimes in her moods, tried to escape, did not know where she was, and becomes verbally and physically aggressive towards staff. She said she was not aware of any incidents involving Resident #5as she worked in another unit for the last 2-3 months. During an interview on 3/05/2026 at 6:20 PM, the Regional Nurse said that due to the recent loss of employees and transition of new employees including the ADM, DON, and ADON, she was assigned to the facility on a temporary basis. She said she understood the MDS assessment, but she did not update them. She said the MDS was required to be initiated and updated with interventions when needed. She said by not updating MDS assessments it could reduce the care that was required for a resident. She said she was aware of the resident-to-resident incident on 2/12/2026 involving Residents #4 and #5. She said Resident #5 accused Resident #4 of slapping her. She said Resident #4 was taken to the nurse's station for observation, the aggressor was Resident #4. She said there were no marks. She said the secondary incident on 1/9/2026 regarding Resident #5 and suicidal ideation behaviors was also discussed. She said Resident #5 was assessed by staff, placed on 1:1 supervision, the Psychiatric Mental Health Nurse Practitioner also evaluated Resident #5 following the incident, the PCP evaluated the resident, the LCSW followed up with Resident #5 and determined there were no concerns. She said the resident also said she was upset and said something she should not have said. During a telephone interview on 3/05/2026 at 6:53 p.m., the MDS Coordinator said she assisted on a part-time basis with MDS assessments and was part of IDT. She said she initiated and revised MDS assessments. She said the assessments helped the facility and staff understand what care needs were provided for a specific resident. She said she was aware of Residents #4 and #5's incident on 2/12/2026 of resident-to-resident abuse. She said the IDT meeting did occur, and interventions were noted in the meeting, but she was not clear as to why the MDS assessments were not updated. She said Resident #5's 1/9/2026 incident of physical and verbal symptoms and incident of suicidal ideation symptoms were reviewed by the IDT and interventions were implemented but were not updated in her MDS assessment. She said the facility's Social Worker would have more details about MDS assessments but was out of town and could not be reached. The MDS Coordinator said she recalled an IDT meeting discussing Resident #5's behaviors, but she did not understand why it was not documented and believed the team made an error and failed to document during the IDT. She said interventions were in place for the resident and she could not speak on the failure to update the MDS assessment with behaviors, but that it would be worked on. During an interview on 3/06/2026 at 10:45 AM, ADON B said she recalled the incident regarding Resident #5 on 1/9/2026, resident-to-resident physical altercation and suicide ideation. She said Resident #5 required partial assistance depending on what mood she was in, she had the tendency to think she is going home, she cursed staff and was verbally aggressive. She said when Resident #5 was on a rampage she did not care if someone was an employee or resident. ADON B said typically Resident #5 would become verbally aggressive three times out of the month, she did have interventions in place. She said she did have an incident where she was monitored a while back. She said the staff knows when she was having a rough day or if in a good mood it will be a good day. She said Resident #5 would be verbally aggressive and start saying things she did not mean and did not recall shortly after. She said Resident #5 received psych services and medications to help her with her mood. She said these behaviors were addressed during the IDT, but she was not sure why they were not updated in her MDS Assessment. During an interview on 3/5/2026 at 1:53 PM, CNA H said Resident #4 could be verbally aggressive, the first day she arrived at the facility she started swinging to hit the staff when they provided her with care. CNA H said Resident #4 was confused and not sure where she was. She said now the resident was on medications was calmer. She said she was familiar with the resident's care and interventions in place to help her de-escalate. CNA H said she recalled Resident #4's resident-to-resident incident with Resident #5 vaguely. CNA H said Resident #5 was not assigned to her unit. She said Resident #4 slapped Resident #5, but there were no marks. CNA H said she was familiar with the residents who can become verbally and physically aggressive and she had been provided with de-escalation techniques that help situations. She said Resident #5 was on North 1 unit, she provided visual care and supervision at times, she said Resident #5 did have behavior concerns and got mad when offering to wash her hair. During an interview on 3/06/2026 at 12:41 PM, MA A revealed she was knowledgeable on ANE, Resident Rights, and de-escalation techniques and provided examples. She said when Resident #4 arrived at the facility she was verbally and physically aggressive. She said interventions included her children visiting daily and this helped her to calm down her behaviors. She said Resident #4 has also been provided with medications that have assisted with behaviors and with time she had gotten used to the facility. During an interview on 3/06/2026 at 3:00 PM, Physical Therapy said Resident #4 could be verbally aggressive towards staff, especially during the afternoon, sundown. She said in the morning Resident #4 was in a good mood, but in the afternoon, she seemed more agitated, so she would have conversation with her in the mornings. During an interview on 3/06/2026 at 3:19 PM, CNA I said Resident #4 was normally physically aggressive and verbally aggressive towards her when she provided care. She said you would have to be within reach for her to physically hit you. During an interview on 3/06/2026 at 3:35 PM, CNA J said the staff should not need to endure abuse from residents. She said there were a few residents who could be verbally and physically abusive to other residents and staff and all incidents should be reported. She said if she were to witness ANE she would report it immediately to her charge nurse and up to the ADM. In a joint interview on 3/06/2026 at 4:25 PM, ADON K and the DON said the regional team consisting of the MDS Coordinator and MDS Coordinator L were helping with MDS assessments and care plans as there were a lot of staff transitioning out of the facility. She said IDT meetings were held by department heads, ADON, DOR, SW, ADM. During an interview on 3/06/2026 at 5:31 PM, the Senior Director said that if the residents have behaviors staff will work to identify what works for them. She said if a resident has physical or verbal aggression behaviors the team would get together to see what approaches will help the resident and incorporate interventions. She said if behaviors were not outlined in specific MDS assessments she would not be able to provide surveyor with information at this at this time as the LMSW who normally handles the MDS assessments was on vacation and out of the country. She said at this time there were regional resource staff that were at the facility helping to ensure MDS assessments were updated accurately and timely. The Senior Director said that multiple things, not just one thing, several factors showing a decline or change could warrant an MDS change. She said that she does not believe verbal and physical aggression along with psych service and medication management would trigger a significant MDS change but would be included in the next quarterly MDS. She said IDT meetings she recalled taking place following the 1/9/2026 and 2/12/2026 incidents were not documented in the resident's electronic medical record but that it would be updated. During an interview on 3/06/2026 at 6:36 PM, the Former ADM said if there is a cognitive change in status, any change in ADLs, regress of care, change of behavior, psych interventions and medications would be considered a significant change. She said she was unsure why Resident #4 and Resident #5's MDS assessments had not been updated to reflect their current behaviors and intervention. She said it was important to have accurate MDS assessments as it was important to provide complete care for residents. Record review of facility document titled, MDS 3.0 Completion dated October 2025 reflected the following: Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. D. significant Change in Status Assessment (SCSA) - a comprehensive assessment completed within 14 days of identification of a status change that meets the requires outlined in Chapter 2 of the Versions 3.0 RAI Manual. i. A significant change is a major decline or improvement in a resident's status that: (1) will not normally resolve itself without interventions by staff or by implementing stand disease-related clinical interventions.

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 2 of 6 residents (Residents #1 and #2) reviewed for medical records. 1.The facility failed to ensure MA A documented she administered medication Methocarbamol Oral Tablet 750 MG to Resident #1 on 03/03/2026 at 9:00 PM.2.The facility failed to ensure LVN C document Y instead of N on Resident #2's January 2026 Medication Administration Record on 01/14/2026 during the day and 01/15/2026 during the day. These failures could place residents at risk for inaccurate medical records. The findings included: 1.Record review of Resident #1's admission record, dated 03/06/2026, reflected a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses to include Muscle weakness and low back pain. Record review of Resident #1's quarterly MDS assessment, dated 03/02/2026, reflected Resident #1 had a BIMS of 15 out of 15 reflected intact cognition. Record review of Resident #1's care plan, undated, reflected Potential for complications r/t Medication with intervention Medications as ordered., initiated 01/31/2026. Record review of Resident #1's Medication Admin Audit Report from 03/01/2025 to 03/05/2025, dated 03/06/2026, reflected Resident #1 had a doctor's order of Methocarbamol Oral Tablet 750 MG. Give 1 tablet by mouth three times a day for muscle spasms. It further reflected Methocarbamol Oral Table 750 MG was scheduled to be administered to Resident #1 on 03/03/2026 at 9 PM but the Medication Admin Audit Report reflected Methocarbamol was administered on 03/04/2026 at 06:03 AM. Interview on 03/04/36 at 03:29PM, Resident #1 revealed she received her medications on time. Interview on 03/06/26 at 12:41PM, MA A revealed she was supposed to administer medications one hour before and one hour after a medication was scheduled to be administered. She revealed she had forgotten to document right after she administered medication because she needed to help the other staff with resident care before she clocked out from work, but she always made sure that residents were administered their medication on time to follow the doctor's orders correctly. 2.Record review of Resident #2's admission record, dated 03/04/2026, reflected a [AGE] year-old male admitted on [DATE] with diagnoses to include anxiety disorder (excessive and persistent fears or worries that interfere with daily life) and cognitive communication deficit. Record review of Resident #2's quarterly MDS assessment, dated 12/02/2025, reflected Resident #2 could not have a BIMS conducted and had both short and long-term memory problems. It further revealed his cognitive skills for daily decision making were severely impaired. Record review of Resident #2's care plan, undated, reflected, [Resident #2] takes Antianxiety medication and is at risk for adverse effects for: Anxiety with intervention Observe him/her closely for significant side effects and report to MD Sedation, Drowsiness, Ataxia (drunk walk), Dizziness, Nausea, Vomiting, Confusion, Headache, Blurred Vision, Skin Rash. Special Attention: if given with other sedatives or hypnotics, Alcohol, dated 06/11/2025. Record review of Resident #2's Order Summary Report, dated 03/06/2026, reflected, Observation: Antianxiety Medication-Observe for behavior (Specify resident's behavior). Observe for side effects: drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document: Y if resident is free of side effects. N if the resident is not free of side effects. If N document SE in the PNs. Every shift for Anti-Anxiety Monitoring. Record review of Resident #2's January 2026 Medication Administration Record reflected Observation: Antianxiety Medication-Observe for behavior (Specify resident's behavior). Observe for side effects: drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document: Y if resident is free of side effects. N if the resident is not free of side effects. If N document SE in the PNs. Every shift for Anti-Anxiety Monitoring. It further reflected LVN C marked N on 01/14/2026 during the day and 01/15/2026 during the day. Record review of Resident #2's progress notes for 01/14/2026 and 01/15/2026 reflected no side effects were documented. Interview on 03/04/26 at 03:26PM, Resident #2 did not respond to any questions. Resident #2 was observed not having any side effects/behaviors to his antianxiety medication. Interview on 03/06/2026 at 10:38 AM, ADON B revealed the way Resident #2's doctor's orders read was confusing, because they had to document yes for when resident was free of behavior and no if behaviors were observed. She revealed she was not aware of who put the wording in there but that it needed to be changed, because it was affecting nursing documentation. She revealed it would be important to clarify this so there would be less confusion and more accurate documentation. She revealed if Resident #2 had notable behaviors and they were not documenting them correctly; they could not prevent any behaviors as needed. Interview on 03/06/2026 at 03:23PM, LVN C revealed for Resident #2's doctor's orders were confusing with documenting Y for when there were no side effects and N for when Resident #2 did have side effects. He revealed if there were no side effects documented in the progress notes as the doctor's orders states, then he meant to put Y because there were no side effects noted. He revealed when he put no, he meant Resident #2 was not experiencing any side effects. He revealed this should be worded differently for better documentation. Interview on 03/06/26 at 05:29PM, the Senior Director and Regional Nurse revealed the expectation for documentation for medication administration was to document when medication was administered to show the accurate time the medication was administered and that doctor's orders were being followed correctly. They further revealed that sometimes the doctor's orders included documentation to show whether the medications were effective. They revealed they were aware that the doctor's orders for Resident #2 sounded confusing, but they were already working on improvements to the electronic medical record to include better documentation in the medication administration record. Record review of facility's policy Medication Administration, dated 05/09/2025, reflected 20. Sign MAR after administered. 22. Report and document and adverse side effects or refusals.

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 5 residents (Resident #1) reviewed for quality of care/treatment. Resident #1 was not given wound care three times in [DATE] and one time in [DATE] for a back tailbone surgical wound. This failure could result in residents needing wound care undergoing a decline in health, non-healing of pressure ulcers or wounds, exposure to infections, and a diminished quality of life.The findings include: Record review of Resident #1's face sheet, dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE] and discharged to hospital [DATE] (seizure like symptoms). Resident #1 had diagnoses which included: aftercare for a surgical wound on the tail bone (primary admission diagnosis), Type 2 diabetes, severe protein-calorie malnutrition, low blood pressure, hypertension, and history of substance use. [No diagnosis of seizures] The RP was listed as a family member.Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 11, indicative of moderate impairment in cognition. The ADLs for: B/B were incontinent with substantial to maximum assistance. Transfer and Mobility was substantial to maximum assistance. ROM: no impairments. Assistive device was a wheelchair. Record review of Resident #1's CP undated reflected: Goal of treatment for an altered skin to sacral and lower back abscess (initiated [DATE] before her re-admission on [DATE]). Interventions included: air loss mattress, barrier precautions, and weekly skin inspection. Treatment also included participation in IV infusion program to increase healing and reduce risk of infections. Record review of Resident #1' skin assessments reflected:[DATE]: abscess surgically removed L 4.0 cm X W 3.5cm X D 3.0cm.[DATE]: abscess surgically removed L 1.6 X W 1.7 X D 1.5 [assessment: improvement][DATE]: abscess surgically removed L 0.9 X 1.0 X D 0.9 [assessment: improvement][DATE]: abscess surgically removed L 0.6 X W 0.7 X D 1.0 [assessment: stable][DATE]: surgical L 0.5 X W 0.5 X D 1.0 [assessment: further improvement in L and W stale on D][DATE]th, 2026 surgical L 0.8 X W 0.8 X 1.0 [assessment D was stable L increased by 0.3 and L increased by 0.3-no major change] Record review of Resident #1's physician's orders dated [DATE], read: .Surgical Site.sacral surgical incision: Cleanse with NS/WC. Pat dry, pack with Iodoform strip and secure with dry dressing daily and PRN for soilage or removal. every day shift for wound management. Record review of Resident #1's TAR, reflected:[DATE]:---Wound care not done: [DATE],[DATE], and [DATE]. [DATE]:---Wound care not done: [DATE]. Record review of email dated [DATE] authored by a family member sent to Surveyor A reflected: --- [DATE] - Photograph documents an existing bandage that remained unchanged for an extended duration --- [DATE] - Image shows the same bandage still in place, indicating no documented dressing change since [DATE].Record review of Resident #1's Nurse's Note dated late entry [DATE] authored by RN E reflected: resident was sent to ER on [DATE] around 9:29 AM per family request and MD approval for seizure-like symptoms. Vitals were normal; and resident was able to answer simple questions. Record review of R#1's ER report dated [DATE] reflected resident presented to the ER for an altered mental state and seizure. At the ER the resident coded resulting in 5 minutes of CPR. Resident was transferred to ICU for further observation. Laboratory tests revealed resident had a UTI. ER diagnoses given to the resident were: cardiac arrest on [DATE], obstructive shock (blood clot) caused by massive pulmonary embolism (blockage in a lung artery). Resident was placed on a ventilator. Observation on [DATE] at 10:30 AM, Resident #1 was on a ventilator in an ICU bed, not alert or oriented. During an interview on [DATE] at 10:35 AM, the ICU Nurse stated the resident was admitted to the ICU for a seizure like activity, sepsis (unknown source), and cardiac arrest in the ER for respiratory failure. The ICU Nurse stated the admission was not for the resident's surgical tail bone wound. During an interview on [DATE] at 10:40 AM in the hospital, the RP stated: the family visited the resident daily while she was in the nursing home. The RP alleged the resident was not receiving proper incontinent care with feces and urine sometimes found around the tail bone surgical wound. The RP added that the resident also did not receive proper wound care around the surgical wound (tail bone on back). The RP stated he had photos that attested to the worsening of the resident's surgical wound [photos were sent to the surveyor and were considered as part of the evidence]. During an interview on [DATE] at 4:21 PM, LVN B (wound nurse stated) stated that she could not give an explanation why wound care was not documented in [DATE] with missed dates ([DATE], [DATE] and [DATE]) and [DATE]. LVN B stated she was present on [DATE], [DATE] and [DATE] working on the floors as a nurse and it should have been the back-up nurse to do the wound care as ordered by the physician on Resident #1. Regarding the missed wound care on [DATE], LVN stated she was present as a floor nurse and wound care was not done. LVN B stated she was working the halls as a nurse and did not do wound care on [DATE], and expected the back-up nurse to do the wound care for Resident #1 on [DATE]. LVN B stated she could not remember who the back-up nurse or nurses were on [DATE]. During a telephone interview on [DATE] at 4:55 PM, NP stated that Resident #1's wound to the surgical area had improved over time. The NP stated on [DATE] the wound measured 0.6 cm X 0.7 cm X 1.0 cm with underlying mining of 1.5 cm (edge of wound). The NP stated there was no infection in the wound and no signs of feces or urine being in the wound. NP stated she made weekly wound care to the residents, and the resident was not bed bound. The NP stated on [DATE], the surgical wound measured 0.8cm X 0.8 cm X 1.0 cm with no infection or signs of urine or feces being in the wound. NP stated Resident #1's surgical wound had improved and stabilized prior to her (Resident #1) going to the ER on [DATE]. The NP stated nurses needed to follow MD orders and there was no excuse for wound care not given on the days the nurses missed wound care in [DATE] and [DATE]. NP stated the missed days of wound care did not adversely affect Resident #1 surgical wound or worsen the surgical wound. During an interview on [DATE] at 9:25 AM, the DON stated: Resident #1 received incontinent care at least every shift as standard nursing practice. DON stated weekly skin assessments revealed no skin breakdown or infection due to incontinent care. The DON stated Resident #1 was treated for a surgical wound from the time of admission until discharged on [DATE] to ER. DON stated the surgical wound improved and stabilized. The DON stated on [DATE] the family requested an ER visit because the resident was having seizure-like symptoms. The DON stated vitals taken at time of transfer and were BP=127/89 (normal), pulse=106 (little elevated over 100 (resident was a smoker), respiration=23 (normal), 02 saturation =97 %, temp=98.2 (normal); glucose=247 (normal for DM). The DON stated the resident was not sent to the ER for any issues involving wound care. The DON added she only became aware of the missing wound days involving Resident #1 when presented the evidence by the surveyor. The DON stated she had no explanation for the missing wound days except that the resident's wound condition did not worsen. During an interview on [DATE] at 10:16 AM, CNA C stated: she provided ADL services to Resident #1 when the resident was in the facility. CNA C stated ADLs included: transfer and mobility bed to W/C or W/C to toilet. CNA C stated the resident never complained to her about wound care or lack of any care. The CNA stated she bathed the resident and never saw any skin breakdown or any deterioration in the peri-area. During an interview on [DATE] at 10:50 AM, the Administrator stated: there was no neglect of Resident #1 around wound care. The Administrator stated nursing staffing needed to document wound care as ordered by the physician. The Administrator stated she had no explanation for the lack of documented wound care in the TAR three times in [DATE] and one time in [DATE]. The Administrator stated the resident was sent to the ER for seizure-like symptoms on [DATE] and not for any issue involving wound care. The Administrator stated the resident was mobile and assisted by CNAs with transfer and mobility from W/C to and from bed and W/C to toilet; resident was not bed bound. Record review of the facility's Wound Treatment Management dated the year 2024 read, .Wound treatment will be provided in accordance with physician's orders, including the cleansing method, type of dressing, and frequency of dressing change. Record review of facility's Pressure Injury Prevention and Management policy dated the year 2024 read, .This facility is committed to the prevention of avoidable pressure injuries.and to provide treatment and services to heal the pressure ulcer/injury.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for one (1) of four (4) residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to ensure a cognitively impaired resident (Resident #1) had adequate supervision on 09/01/2024 which allowed him to elope from the facility from an unknown door after lunch on 09/01/2024 and was not located until 02:40 a.m. on 09/02/2024 at a local hospital. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 09/05/2024 at 04:24 p.m. The IJ template was provided to the facility on [DATE] at 05:17 p.m. While the IJ was removed on 09/08/2024 at 02:14 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for serious injuries and accidents. Findings included: Record review of Resident #1's Admission Record, dated 09/04/2024, revealed Resident #1 was a [AGE] year-old male admitted on [DATE] from an acute care hospital. Record review of Resident #1's Diagnosis Report, dated 09/04/2024, revealed Resident #1 was diagnosed with dementia (a general term for impaired ability to remember, think, or make decisions) during his stay at the facility, the onset of the diagnosis was dated 08/16/2024. Resident #1 had additional diagnoses which included: hypertension (a condition of high pressure in the vessels that carry blood from the heart to the rest of the body), muscle weakness, and alcohol use. Record review of Resident #1's MDS BIMS assessment, dated 07/02/2024, revealed a score of 2.0, indicating the resident had severe cognitive impairment. A second MDS BIMS assessment, dated 07/18/2024, revealed a score of 2.0, indicating the resident had severe cognitive impairment. Record review of Resident #1's Order Recap Report, order date: 06/26/2024 - 09/30/2024, revealed the following orders: - Add Dementia with Behaviors to diagnosis list, ordered date 07/09/2024 - May go on leave of absence with medications and responsible party, ordered date 06/26/2024 - q1hr (every one hour) checks monitoring for elopement risk every hour for elopement risk, ordered date 09/03/2024 Record review of Resident #1's Community Safety Awareness Summary assessment, dated 06/26/2024, revealed Resident #1 was moderately impaired for his ability to make decisions regarding tasks of daily living. Resident #1 was indicated to be unsafe for being capable of safely crossing the street without or without light, was not safe to leave the facility on pass, and was easily confused and could become lost. Record review of Resident #1's Elopement Risk Assessment, dated 06/26/2024, indicated Resident #1 had dementia and ambulated independently. He was cognitively impaired with poor decision-making skills, had a substance use disorder, and was at risk for elopement. He was indicated as at risk for elopement. Record review of Resident #1's Psychiatry Initial Evaluation, dated 07/09/2024, revealed Nurse reports pt (patient) with attempts to elope last week, however none this week. He was easily redirectable by staff at times of elopement attempts. He is ambulatory with no recent falls. Under Assessment and Plan, revealed 1. Dementia with behaviors: Noted recall issues and memory impairment .Pt with recent elopement attempts from facility Provide supportive cues and redirection Expect further decline secondary to disease course Orders written to add diagnosis to medical diagnosis list. Record review of Resident #1's Care Plan, accessed 09/04/2024, revealed Resident #1 with focus for having been at risk for elopement and had left the faciity on [DATE]. Focus initiated on 07/01/2024 and revised on 09/04/2024. Interventions included: Assess for risk of elopement per living center policy, initiated 07/01/2024; Involve patient in preferred activities, initiated 09/04/2024; and Redirect patients from doors, initiated 09/04/2024. Record review of Resident #1's Out of Facility Release of Responsibility Sheet, undated, revealed a document with two main columns titled, 'SIGNING OUT' and 'SIGNING IN', with each column having a location to document the date, time, and signature. Above the columns revealed, Authorization must be signed by the resident, or by the nearest relative in the case of a minor or when resident is physically or mentally incompetent. Resident #1's sheet revealed no documented dates, times, or signatures for Resident #1 signing out or signing in. Record review of Resident #1's Progress Notes, dated 09/01/2024 at 07:24 p.m. by LPN A, revealed Resident left out of building has not returned, Resident known to ask if he can go outside and be easily redirected and told only with a staff or family member. Today resident did not ask and has not been seen since eating lunch in dining room. Record review of a police report, dated 09/01/2024 at 07:47 p.m., revealed at 06:38 p.m. on 09/01/2024 the PO was dispatched to the facility for a report of a missing person and a city-wide [NAME] (be on the lookout) was issued for Resident #1. The PO spoke to LPN A, who stated Resident #1 had last been seen around 11:00 a.m. The PO contacted missing persons and a silver alert (missing persons alert for an older adult) was entered. Record review of Resident #1's Progress Notes, dated 09/02/2024 at 02:40 a.m. by LPN B, revealed Received call from [hospital staff member at local hospital] stating resident was currently in the ED (emergency department). He was brought in @ 2000 (at 08:00 p.m.) for disorientation (confused and unable to think clearly), dehydration (condition of having not enough water in the body) and intoxication (state of having an altered mood and abilities caused by alcohol or drugs). Resident underwent testing that was WNL (testing results were within normal limits or ranges). 1L (liter) IV (intravenous) fluids given. Resident will be discharged . Record review of Resident #1's Hospital Notes, dated 09/04/2024, revealed Resident #1 arrived at the emergency roiagnom on [DATE] at 08:26 p.m. via EMS (emergency medical services) with complaints of weakness prior to arrival. Resident #1's stated complaint was noted as weakness with a chief complaint of fall, trauma. Per the initial comments, .patient was a poor historian and had a very confusing story where he was walking outside possibly fell and had urinated oneself. Patient states he was walking outside felt weak as though he was about to fall but was able to catch himself. Resident #1's skin was noted as warm, non-mottled (not patchy or with irregular colors), no rashes. Resident #1's laboratory results, dated 09/01/2024 at 08:57 p.m. revealed an ethyl alcohol level of 24 (a level less than 50 mg/dL would not be considered not intoxicated). A chest x-ray (a type of scan to create detailed images of your bones) and head or brain CT (a type of scan to create detailed images of your bones and soft tissues) revealed no acute injuries. Resident #1's clinical impression was noted as dehydration after exertion. Record review of Resident #1's Progress Notes, dated 09/02/2024 at 04:05 a.m. by LPN B, revealed Resident arrived to facility via EMS x 2 in stable condition via stretcher. No N/O (new orders) per discharge papers. During an interview on 09/04/2024 at 04:10 p.m. with the DON and the RECPST, the DON revealed the front facility door was unlocked on weekdays (Monday through Friday) from 08:00 a.m. to 05:00 p.m. and monitored by the RECPST. The DON stated the doorbell outside the front doors was to be used for anyone wanting to enter the facility after those hours or on the weekend and the weekend supervisor or nurses stationed at the South Nursing Station could hear the doorbell and respond. The RECPST revealed the nurses had the code to the front door alarm if the alarm was triggered and stated the alarm would automatically go off after two to three minutes. During an observation and interview with the DON on 09/04/2024 of the facility doors from 04:10 p.m. to 04:32 p.m., the facility was observed to have fourteen (14) exterior or exit doors. The front access doors and the laundry access doors each consisted of two doors for access. Additional exterior doors were noted in several resident rooms, but those doors did not have exterior access due to installed deadbolts on the doors with no handle available to operate or attempt to open. The laundry access double doors and a side access door, labeled Door #5, were observed to have a push button or push pad next to the door to disable the door's alarm. The DON revealed Door #5 had the side button and a clicker that allowed staff to disable the door's alarm. The DON revealed Door #5 was used by EMS, resident transport services including to dialysis appointments, and by the facility driver to pick up and return residents into and out of the facility. During an interview on 09/04/2024 at 04:28 p.m. with the ADMIN and the DON, they revealed it was unknown what door Resident #1 eloped from. The ADMIN revealed she did not yet have access to the facility's camera system, due to having been a new employee, and had therefore been unable to review the camera footage of the doors during her incident investigation. During an interview on 09/04/2024 at 03:18 p.m. with Resident #1, he revealed he believed he had lived at the facility for about four years and liked to leave. Resident #1 stated he left the faciity on Saturday or Sunday (he was not sure on the day of the week) with the intention of going to the bank. Resident #1 stated that he just went outside without telling anyone, through a door on the side of the building that one could go through. Resident #1 stated his bank was closed because it was a Sunday, and also stated that he couldn't find his bank or his bank's entrance. Resident #1 stated he was picked up by an ambulance and brought to a hospital. During an interview on 09/05/2024 at 09:15 a.m. and record review of the facility Incident Summary, dated 09/01/2024, the ADMIN read through the facility's Incident Summary. The Incident Summary revealed LPN A notified the ADMIN at 06:15 p.m. on 09/01/2024 that the staff were unable to locate Resident #1 and he was not present for the 05:45 p.m. medication pass. The ADMIN revealed the facility was not a locked facility but upon after-action review and to achieve the safest possible environment for the residents, the facility must secure the doors in such a way that residents that refused to follow facility protocols could be identified, alerting nursing as having left without signing out. The other solution was that noncompliant residents may be reviewed on a case-by-case basis to determine the at-risk nature of that specific resident and if the facility was capable of meeting their needs successfully. During an interview on 09/05/2024 at 10:46 a.m. with CNA C, she stated she worked Sunday, 09/01/2024 between 06:57 a.m. to 03:00 p.m. CNA C stated she did not recall seeing Resident #1 on Sunday and did not recall hearing any door alarms sounding during her shift. During an interview on 09/05/2024 at 01:34 p.m. with MA D, she stated she worked Sunday, 09/01/2024 from 02:00 p.m. to 10:00 p.m. MA D stated she provided Resident #1 with his medications on Sunday morning and remembered seeing him during the day walking to the dining room for coffee. MA D revealed she noticed around 5:30 p.m. to 6:00 p.m., while taking her assigned residents' blood pressures and issuing medications that she could not find Resident #1. MA D stated she checked Resident #1's room, the smoking area, and the dining area, the three areas Resident #1 was typically at but couldn't find him. MA D stated she then notified LPN A. MA D stated LPN A started directing staff to complete a facility search and had called the ADMIN. MA D stated she could not remember any door alarms sounding during the time Resident #1 was suspected as having gone missing. MA D revealed prior to Resident #1's elopement, he would sometimes ask her if he could check out and leave the facility, but he was easily redirected (change his focus to something else). MA D stated Resident #1 was initially antsy (anxious) when first admitted to the facility but had seemed to have calmed down. During an interview on 09/05/2024 at 01:48 p.m. with CNA E, she stated she worked Sunday, 09/01/2024 between 03:00 p.m. and 11:00 p.m. on Resident #1's hall. CNA E stated she did not recall seeing Resident #1 on Sunday and did not recall hearing any door alarms sounding during her shift. CNA E stated she observed an untouched lunch tray in Resident #1's room at the start of her shift (03:00 p.m.) and had notified the nurse, LPN A. CNA E stated she did not follow up with LPN A concerning the lunch tray because she had just started her shift and had left the follow up to the nurse. CNA E stated she believed Resident #1 was already missing at the time her shift began, 03:00 p.m. During a phone interview on 09/05/2024 at 02:13 p.m. with the Maint Dir, he stated due to having been out sick since prior to Resident #1's elopement, he had not been to the facility and had not had a chance to review the facility camera footage. He stated he was unaware of what door Resident #1 eloped from. The Maint Dir stated to his knowledge all the facility doors locked when closed and had alarms. The Maint Dir stated the only exception was the front door, which was open for visitors during work hours (Monday to Friday, 08:00 a.m. to 05:00 p.m.) and was scheduled to automatically lock and alarm at 05:00 p.m. The Maint Dir stated he would complete daily door checks during his morning rounds during the week and would sometimes check the building on Saturdays. During an observation on 09/05/2024 at 02:39 p.m. to 02:41 p.m., two facility staff were observed to separately push the button located next to Door #5, to disable the door's alarm, to exit the facility. A third staff member was observed pushing the button located next to Door #5 to let two individuals into the facility. The staff members were observed disabling the door's alarm in the view of a facility resident. During an interview on 09/05/2024 at 03:28 p.m. with CNA F, she stated she worked Sunday, 09/01/2024 between 03:00 p.m. and 11:00 p.m. on Resident #1's hall. CNA F stated she did not recall seeing Resident #1 on Sunday and was unsure of when Resident #1 had left the facility. CNA F stated she found out Resident #1 was missing around dinner time. CNA F stated during dinner tray delivery, CNA E had mentioned Resident #1's lunch tray was still in his room and untouched. CNA F stated that she had previously observed that Resident #1 would occasionally eat in the dining room. CNA F stated that she and CNA E told LPN A about Resident #1's lunch tray at that time and LPN A started making phone calls and asking staff to start searching the facility. CNA F stated she did not hear any door alarms sounding during her Sunday shift. During an interview on 09/06/2024 at 08:05 a.m. with LPN A, she stated she worked Sunday, 09/01/2024 between 07:00 a.m. and 07:00 p.m. LPN A stated she was covering the shift for another nurse and her assigned residents on Sunday were not her typical residents. LPN A stated she typically worked night shift. LPN A stated she had been assigned to Resident #1 before, but it was usually at night and he was either asleep or if he did get up, it was to go smoke. LPN A stated that the last time she recalled seeing Resident #1 on Sunday was around lunch time. She stated that he was walking the opposite way down the hall from her, and then she saw him again on her way back, eating lunch in the dining room. LPN A stated around 06:00 p.m. MA D notified her that she couldn't locate Resident #1, and Resident #1 was not supposed to be able to sign himself out without family because he had dementia. LPN A stated MA D had told her several times during the day that she was looking for Resident #1 but did not say anything about him not being able to sign himself out. LPN A stated she had known that the staff couldn't find Resident #1 but was not aware that he was not supposed to be able to sign himself out like the rest of the residents. LPN A stated she first checked the facility sign-out book and observed that Resident #1's page was blank. LPN A revealed she had not seen any interventions in place for staff to be able to identify which residents were not supposed to be able to sign themselves out. LPN A stated it was not until a shift following the incident that she observed a notice on the communication sheet that identified a different resident as not being allowed to sign himself out without family or other. LPN A stated that that was the first time she had seen a warning such as that. LPN A stated she had not considered Resident #1 an elopement risk because he would usually ask a staff member about signing out and he would allow the staff member to redirect him. LPN A stated prior to Resident #1's elopement, she had not seen any facility procedures in place to let the nursing staff know which residents were considered safe to sign themselves out. Record review of facility policy, Wandering and Elopements, dated revised March 2019, revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. An Immediate Jeopardy (IJ) was identified on 09/05/2024 at 04:24 p.m. The IJ template was provided to the facility's ADMIN, DON, and RNC on 09/05/2024 at 05:17 p.m. A plan of removal was requested. On 09/06/2024, the facility provided a plan of removal titled: Plan of Removal for Immediate Jeopardy. The following plan of removal (POR) was accepted on 09/06/2024 at 03:16 p.m. PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On September 4, 2024, an investigation was initiated at [facility name and address]. At approximately 5:15p.m on September 5, 2024, a surveyor provided verbal notification that [state name] Health and Human Services had determined the conditions at [facility name] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F-0689 - Free of Accident Hazards/Supervision/Devices Immediate Corrections Implemented for Removal of Immediate Jeopardy. On September 2, 2024, at approximately 4:05am Resident#1 returned to the facility from the Emergency Department. Action: Resident #1 is a current resident and was brought back to facility on 9/2/2024. The resident was immediately assessed by the charge nurse and a head-to-toe assessment was completed. The responsible party, physician, DON and Administrator were notified of the resident's safe return. Resident#1 was placed on 15 minutes monitor checks for safety. A community safety awareness assessment for Resident #1 was completed by the DON. IDT reviewed and interventions initiated, and care plan updated reflect elopement risk. On September 1, 2024, at approximately 9:20pm the following action was taken: Action: Education initiated Elopement risk, Abuse/Neglect/Exploitation, Signs to watch for with residents exhibiting potential for elopement, increased wandering, exit seeking, increased behaviors. Start Date: 9/1/2024 Completion Date: 9/4/2024 Responsible: Administrator Action: Signs were posted on all doors, that were not already marked as emergency exit only, instructing all visitors and residents to enter and exit through main facility entrance only. Start Date: 9/1/2024 Completion Date: 9/1/2024 Responsible: Administrator 0n September 5, 2024, at approximately 6:00pm the following actions were taken: Action: Education initiated with all staff on Elopement, Abuse and Neglect, Resident Rights, Environment Free from Accident Hazards Start Date: 9/5/2024 Completion Date: 9/5/2024 Responsible: Administrator Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on Elopement, Abuse and neglect, and Plan of removal/response to Immediate Jeopardy Citation on 9/5/2024 Start Date: 9/5/2024 Completion Date: 9/5/2024 Responsible: Administrator IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. Action: Facility reviewed and ensured Elopement Risk Assessments were complete and current for all residents. 96 of 96 residents were reviewed. All residents identified as at risk of elopement were reviewed to have appropriate interventions and plan of care in place per risk assessment. 38 of 96 residents were newly identified as at risk for elopement. Physician and responsible parties were notified of assessment results and care plan interventions. Start Date: 9/5/2024 Completion Date: 9/5/2024 Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES: Action: In-service and education was provided to facility staff regarding the process for residents who have been identified as an elopement risk and proper steps to take to assure residents remain safe without risk for elopement, including monitoring, and care plan updates. Start Date: 9/5/2024 Completion Date: 9/5/2024 Responsible Party: Director of Nursing/Designee Action: Education was provided to all staff on Elopement policy, Abuse/Neglect/Exploitation, Resident Rights, Free from Hazards, Notification of behaviors, wandering or elopement attempts, Start Date: 9/5/2024 Completion Date: 9/5/2024. Responsible Party: Director of Nursing/Designee Action: New position opened and assigned for evening and weekend monitoring by additional receptionist or security guard. Weekend receptionist or security guard will have access to resident list that will include photo of resident for identification and will verify any resident who has orders to sign self out on pass without accompaniment. Start Date: 09/06/2024 Completion Date: ongoing until position is filled Responsible Party: Administrator Action: Scheduled installation for alarms for 14 of 14 doors Start Date: 09/06/2024 Completion Date: 09/06/2024 Responsible Party: Maintenance Director/designee Action: Front doors to facility will be alarmed at all times. Access to front door will be monitored by receptionist Monday through Friday from 8am to 5pm. The South Nurses station will monitor access to the front entrance after hours and on the weekend. The receptionist will receive a current list of residents, that will include photo of resident for who may sign out without supervision, from the Director of Nurses. The list will be updated upon resident's admission, discharge, and change in status of resident condition after IDT and physician review. A copy will be available at each nurses' station. Start Date: 09/06/2024 Completion Date: 09/06/2024 Responsible Party: Administrator, Director of Nursing/Designee Tracking and Monitoring - Director of Nursing/Designee will review residents with At Risk for wandering or elopement identified or newly admitted with history of elopements to assure appropriate interventions and plan of care are in place 5 times per week beginning 9/5/2024 for 12 weeks or until sufficient compliance if found. This will be documented in daily clinical meeting with use of electronic log and reviewed monthly in QAPI meeting. - Administrator/designee will complete random audit every shift for 7 days, beginning 9/6/2024 for appropriate staff response to wandering or potentially exit seeking residents, immediate education will be provided, if necessary, then will monitor random shifts, 5 times a week for 12 weeks or until sufficient compliance if found. This will be documented on log to be reviewed in QAPI Meeting Monthly. - Administrator/designee will complete audit of exits for proper functioning of doors and alarms for proper functioning every shift for 7 days, beginning 9/5/2024 then will monitor random shifts, 5 times a week for 12 weeks or until sufficient compliance if found. This will be documented on log to be reviewed monthly in QAPI. - Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review The facility's POR Verification was as follows: During an observation on 09/06/2024 at 10:00 a.m., the R Maint Dir was observed installing new alarms on the facility front entry and exit doors. During an observation on 09/06/2024 from 10:00 a.m. to 08:00 p.m. multiple observations of observing and hearing the facility new door alarms sounding. Observations included staff and facility guests attempting to either enter or exit the facility, without the RECPST or a nurse with a door key disarming the door alarm. During an observation on 09/06/2024 at 04:33 p.m., a binder labeled Residents that may go out on pass without supervision, dated as edited on 09/06/2024 by the ADON was observed. The binder included the names and pictures of 23 residents. During an interview with the R Maint Dir on 09/06/2024 at 04:36 p.m., he stated he ordered fourteen (14) new door alarms for the facility and installed the alarms on ten (10) doors. He stated the additional four (4) doors already had a key alarm. He stated the new alarms required a key to deactivate and/or turn off the alarm and that the alarms would not stop sounding until they were deactivated. He stated that he was told the keys were to only be issued to the nurses, to put on their key rings, the charge nurse, the administrator, and the maintenance director. He stated the doors were to be alarmed at all times and they were battery powered, with the battery expected to only require replacement every 6 months to one year. During an observation and interview with the interim ADMIN on 09/06/2024 at 04:45 p.m., she showed the new job posting for a Receptionist on [a job posting website]. The job was noted to have been just posted. The job duties listed included: This position is for evening/Weekend Receptionist., Monitor the front door of the facility- who comes in/who leaves., and Complete the incident log on a daily basis. Record review of the facility POR Binder on 09/06/2024 at 06:52 p.m. revealed: a. A copy of the AD Hoc QAPI Meeting dated 09/05/2024 and noted with an agenda: IJ 6869 [sic] Review and Review Plan of Removal. Attendees were noted as: the DON, the MD, the ADMIN, and the RNC. b. A document labeled with five (5) areas to notate Staff Response to wandering or potentially exit seeking resident: 1. Have you identified any residents with new exit seeking behavior? 2. Have you identified any residents newly at risk for elopement? 3. Is any additional education needed at this time? Shift:______ Time:______ c. Seven (7) copies of the facility map, labeled Door Check and each subsequently dated from 09/05/2024 to 09/11/2024. The documents dated 09/05/2024 and 09/06/2024 reflected a X marked next to each location on the map where an exterior or exit door was located. The 09/05/2024 document was noted as completed on 09/05/2024 at 09:00 p.m. by the ADMIN. The 09/06/2024 document was noted as completed on 09/06/2024 at 11:00 a.m. and 03:00 p.m. by the interim ADMIN. d. Copies of the facility Daily Census Report, dated 09/05/2024 and 09/06/2024 with each resident named checked off. The documents were observed to be labeled by hand on each first page, Review at risk with an additional label stuck to the initial document, titled Review of residents at risk for Wandering or Elopement. e. A document labeled QAPI Addendum with the following noted under Agenda: Review facility plan of removal for Immediate Jeopardy Verification of audit completion: - DON review at risk for wandering or elopement identified or newly admitted with history of elopements to ensure appropriate interventions and plan of care are in place - 5 times a week beginning 09/05/2024 for 12 weeks - Staff response log to wandering or potentially exit seeking residents - Every shift for 7 days, beginning 09/06/2024 - 5 times a week for 12 weeks - Exit audits completed - Every shift for 7 days beginning 09/05/2024 - 5 times a week for 12 weeks Review for trends identified: Record review of in-service documents included: - Document dated 09/05/2024 at 06:52 p.m. with topic CNA's will document new behaviors in POC (Plan of Care), notify charge nurse, DON, and administrator. The in-service had 29 CNA names as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topic Nurses will document in [Electronic Medical Record, EMR] new behaviors, notify DON, Administrator, and MD Immediately. Document with 6 RN names and 9 LVN names (15 total licensed nurses) noted as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topic Wandering and Elopements. The in-service had 52 nursing and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topic Wandering and Elopements. The in-service had 58 administrative, dietary, plant (housekeeping, laundry, maintenance, driver), and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topic Abuse and Neglect. The in-service had 52 nursing and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topics Abuse and Neglect and Resident Rights. The in-service had 58 administrative, dietary, plant, and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topic Safety and Supervision of Residents. The in-service had 58 administrative, dietary, plant, and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:53 p.m. with topic Safety and Supervision of Residents. The in-service had 51 nursing and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:53 p.m. with topic Resident Rights. The in-service had 51 nursing and therapy staff names noted as having received training. - Document dated 09/06/2024 with topic Residents who can sign out on pass without being accompanied by supervision will be placed in a Binder which will be at Receptionist desk and each Nurses station. This will be maintained and updated by Nursing management when new admissions/discharges/ changes in condition or risk status change. The in-service had 111 facility staff names noted as having received training. Record review and interview with the DON and Th Dir on 09/06/2024 at an unknown time, of an undated listing of employee names divided per department and with each employee member's phone number and job title, revealed a total of 106 facility employees with an additional four (4) identified by the DON or Th Dir as gone or no longer employed. Of the four, three (3) were therapy staff and one (1) was an administrative staff. Twenty-two (22) staff were identified as not expected to be present in the facility for multiple days. Seven (7) therapy employees were identified as on vacation. Three (3) employees were out sick, one (1) from the plant department and two (2) from therapy. Eleven (11) employees were PRN (as needed), se [TRUNCATED]

Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and hazards. Resident #1 was moved rooms within the facility. Nursing staff failed to ensure the bed in the new room had side rails for bed mobility and positioning. Resident #1 rolled out of bed during care and fell to the floor hitting her head. Resident #1 was hospitalized for evaluation and treatment and diagnosed with thoracic spine compression fractures, multiple rib fractures, and subsequently expired. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm at a scope of isolated. This deficient practice could place residents at risk of falls with major injuries. The findings were: Review of Resident #1's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including Sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), Systolic Congestive Heart Failure, Alcoholic Cirrhosis of liver w/ascites (end-stage liver disease, is the impaired liver function), and Lack of Coordination. Review of Resident #1's 5-day MDS assessment, dated [DATE], revealed her BIMS was 11 reflective of moderate cognitive impairment; she required extensive assistance by 1 person for bed mobility and transfers; did not have a history of falls prior to her admission to the facility and had not had any falls while at the facility. Review of Resident #1's Care Plan initiated [DATE] revealed she was at risk for falls/injuries related to impaired mobility. One of the staff interventions was to assess Resident #1 for any adaptive equipment needed and to encourage its use if necessary. Review of Resident #1's Siderail Enabler Assessment/Consent, dated [DATE], revealed Resident #1 requested to use side rails related to physical weakness and balance deficit, would assist with bed mobility and transfers and provided a sense of security. Resident #1 elected to use two ,d+[DATE] side rails and expressed a desire to have the side rails up while in bed. Further review revealed there were no risk identified related to the use of siderails. The family member consented to the use of the Siderails. Review of Resident #1's census revealed she was moved to a room on S. Hall on [DATE]. Review of Resident #1's nurses progress note, dated [DATE], revealed The CNA yelled out for this nurse that the resident was on the floor. Resident stated she was trying to hold on to the siderail while getting changed and there was no siderail there when she reached and ended up rolling too far causing her to fall off the bed. Upon entering the resident's room this nurse assessed the resident while on the floor for injuries. A hematoma about quarter size noted to the right temple and one on the right hairline. Skin tear to R arm. Resident stated pain to the R shoulder and to the back of the head. Further review revealed Resident #1 was picked up soon after and transported to the hospital. Review of Resident #1's pain assessment post-incident, dated [DATE], revealed she was experiencing pain to her right shoulder after the fall and the pain increased with movement. Her level of pain was 6. Review of Resident #1's nurses progress note, dated [DATE], revealed an IDT meeting was held related to Resident #1's fall. The root cause analysis was identified as poor staff positioning, no side rails for mobility. Review of hospital physician progress note, dated [DATE], revealed Assessment: Status post fall from bed with right sided rib fractures. Plan: Continue to monitor on medical/surgical floor. Neurosurgery input much appreciated. Continue conservative medical management. No need for brace Analgesics as needed for pain control. T3, T8, Til thoracic spine compression fractures [(A T3 compression fracture is a type of vertebral fracture that occurs in the upper part of the spine, at the level of the third thoracic vertebra. This type of fracture is typically caused by a fall or a direct blow to the spine, and can lead to severe pain and disability. Compression fractures usually happen in the thoracic (middle) part of the spine, especially in the lower thoracic area. Providers also call them vertebral compression fractures (VCF).] Review of hospital discharge summary, dated [DATE], revealed Yesterday evening, RN called me stating patient deteriorating, pale, using accessory muscles, short of breath, desaturated and hypoxic, decreased responsiveness. I instructed RN to place patient on BiPAP, transferred to PCU, Lasix 40 mg IV x 1, and get chest x-ray. RRT called 2147 (9:47 PM), blood gas was ordered. This was relayed to the family who made patient DNR/DNI. Patient subsequently expired. Interview on [DATE] at 10:16 AM with LVN B revealed she was an Agency nurse and worked a couple of shifts at the facility through the temporary agency. She stated she started working full time at the facility 1 week ago. LVN B stated on the day Resident #1 fell , CNA C came out of the Resident's room or she yelled out. She entered Resident #1's room and the Resident was on the floor lying on her left side by the bed. The bedside table was positioned on the opposite side of the Resident. LVN B stated Resident #1 told her she was not in pain but stated she hit her head. LVN B stated she assessed Resident #1 and did not note any major injuries. Resident #1 had a hematoma to the right temple, on the hair line and red area to the back of her head. LVN B stated she called the physician and asked for a skull series. She mentioned she was not sure or could not remember if she sent Resident #1 out to the hospital. LVN B stated CNA C told her, she was providing pericare and Resident #1 turned to the left side to reach for side rail and the side rail was not there. The Resident rolled off the bed. LVN B stated Resident #1 was moved to S.hall and the bed in her new room did not have side rails. Resident #1 told LVN B her previous bed had side rails. LVN B confirmed she did not see side rails on Resident #1's bed. She stated she did not know if Resident #1 was a one or two person assist. LVN B reviewed the nurse's progress note, dated [DATE], and stated Resident #1 fell at night and she sent the Resident out after midnight. Telephone interview on [DATE] at 12:29 PM with CNAQ revealed she worked the 11PM to 7AM shift. She stated she learned Resident #1 had a fall during the 3:00 PM to 11PM shift. She reported CNA C told her Resident #1 had fallen during care. Resident #1 complained her body hurt when she was in the room. Resident #1 told her the aid who changed her needed more training because she did not know what she was doing. CNA Q stated she was in the room when CNA C was giving report to LVN B about what happened. CNA C stated she rolled Resident #1 towards the left side away from her. Resident #1 hit the bedside table and then the floor. CNA C told LVN B Resident #1 was used to having a side rail and turned to grab the side rail and it was not there. CNA C stated she turned/rolled Resident #1 from behind (her backside) and did not realize she had used that much force. CNA Q again stated Resident #1 kept complaining of pain that her body was hurting. She stated Resident #1 was sent to the hospital around midnight on the night of the fall. VM for RP, family member, requesting she return the call. Interview on [DATE] at 12:55 PM with the previous ADON R, stated the beds were typically not equipped with side rails. They installed side rails upon a Resident/family's request to use for positioning and mobility. She stated the side rail was considered an adaptive piece of equipment. It required a nursing assessment, consent, physician order and an update of the Care Plan reflecting the implementation of the side rails prior to their use. The previous ADON R stated the nursing staff who moved Resident #1 was responsible for ensuring all equipment was transferred to their new location. She stated she did not remember Resident #1 having a fall and could not provide any additional information. Interview on [DATE] at 1:10 PM with the ADM revealed she confirmed the side rails were an adaptive piece of equipment which required a physician order. She stated the previous DON S moved Resident #1 and she would have been responsible for transferring all adaptive equipment with the Resident. She stated LVN B told her CNA C rolled Resident #1 away from her (rolled the Resident from behind) while in bed, while providing care. Resident #1 fell to the other side. Interview on [DATE] at 1:15 PM with the ADM and the DOR revealed he demonstrated proper bed positioning and safe technique when rolling a resident side to side in bed during the fall in-service dated [DATE]. The ADM stated they had not provided an in-service for the use of side rails since Resident #1's fall. Interview on [DATE] at 1:21 PM with the MS stated the previous DON S would tell him when to install side rails on a bed. It required an assessment and consent prior to installation. He stated the previous DON S would also let him know when a resident was moving. He would have to remove the side rails if moving the bed to the Resident's new location because the bed did not fit through the doorway with the side rails attached. The MS stated since they did not have a DON, it would be either someone in authority to provide him instructions or he would confirm with the ADM and make sure it was ok to install the side rails. The MS stated he did not know Resident #1 was moved and learned afterwards that she needed side rails on her bed but had already been sent out to the hospital. He stated she did not return to the facility. The MS stated either she was moved after he left for the day which was after 3:30 PM or over the weekend when he was not working. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:15 PM and the Administrator was notified. The Administrator was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 6:15 PM and it included: LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Preparation and submission of this Plan of removal does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of removal is prepared and submitted solely because of requirements under state and federal laws. Verification Plan of Removal: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEPOARDY: On February 9, 2024, at approximately 4:15 p.m. the following actions were initiated upon facility identification of concern: Resident #1 was discharged from the facility on [DATE] immediately after the fall. IDENTIFICATION OF OTHERS AFFECTED: The Clinical Corporate Resource conducted a chart review and visual audit to determine if side rails were ordered or care planned for any residents who have experienced a room change in the last 90 days to validate that the side rails were in place, orders and consents were present and care plans were up to date. A visual audit of all rooms/beds was conducted by the administrator/designee to determine which residents had bed rails. There was a total of 57 residents with beds that had side rails installed. Need for these rails would be further assessed by Therapy and Nursing for appropriate number and type of rail(s) needed and rails would be removed if deemed unnecessary. Consents and orders would be obtained, and care plans updated for applicable Residents by the Corporate Clinical Resource/designee. Maintenance would install or remove rails as indicated by assessments/orders. The above would be completed by [DATE]. SYSTEMIC CHANGES AND/OR MEASURES: The Administrator/Designee would provide and document education on [DATE] to staff responsible for moving beds which would include IDT (Interdisciplinary Team) members, Nursing staff and Maintenance department on the process for ensuring that fall prevention/assistive mobility rails that were in place prior were transferred or remain in place after any room change. Education included the beds should be moved with the resident to ensure continuity of care associated with mobility rails, and who to notify if a discrepancy related to mobility rails was identified. The Administrator/Designee would educate Social Services on the requirement to communicate the need for bed rails, if applicable, on any resident for whom a bed was ordered to be provided from hospice. An Ad Hoc QAPI meeting was held with the IDT team and Medical Director to review policy on Assistive Devices and Equipment and to review the Plan of Removal/response to the Immediate Jeopardy citation on [DATE] at 5:30 p.m. Those not in attendance at education sessions due to vacation, sick leave, or casual work status would be educated upon their return, prior to their first shift worked. TRACKING AND MONITORING: The Administrator/designee would conduct audits of residents who have had a room change and/or of those who have been provided a bed from an outside agency daily for seven days, then five times per week beginning [DATE] to validate that fall prevention/assistive mobility rails that were in place prior have been transferred or remain in place after any room change and that staff were moving the bed to the new room. Any trends or concerns were/would be addressed with the Quality Assurance Performance Committee and monitoring would continue until a lessor frequency was deemed appropriate. Results of audits would be presented by the Administrator or designee at the monthly QAPI meeting with the IDT and Medical Director on or before [DATE], then monthly and as needed thereafter to identify trends and sustainability. If ongoing deficiencies or concerns were noted through the audits, resident interventions and staff education would be implemented immediately. Monitoring would not be discontinued until the facility completed three consecutive rounds of monthly monitoring that demonstrated sustained compliance as approved by the QAPI committee and Medical Director. Additional interventions, education, and monitoring would be implemented, as needed, based on the recommendations of the QAPI committee for any negative trends identified to ensure sustainability. Verification of the Plan of Removal: In an interview on [DATE] at 12:30 p.m., the Maintenance Supervisor stated he was recently in-serviced on when residents were moved from their room to a new room, staff were to make sure the resident's bed rails were moved to the new room and the resident's bed was moved with the resident. The Maintenance Supervisor stated he verified the beds that were supposed to have bed rails had rails and the beds that were not to have bed rails did not have a bed rail on the bed. The Maintenance Supervisor stated when a resident was discharged from the facility, he would remove the bed rails from the bed. When a new resident was admitted and placed in that bed, they would be assessed to see if they needed a bed rail. Then he would receive a work order to place the bed rails on the bed. The Maintenance Supervisor stated he would inspect the bed rails once a year with an audit and the bed rails would also be checked by the department heads when they did advocate rounds in the residents' rooms to ensure the bed rail was installed correctly. In an interview on [DATE] at 12:36 p.m., the Social Worker stated he was recently in-serviced on when a resident was moved from their room to a new room, a member of the IDT needed to be present to ensure the resident's old bed was moved to their new room, and to make sure the bed rails were attached if there were bed rails on the bed. The Social Worker sated if a member of the IDT was not in the facility when staff moved a resident to a new room, the nurse was to call the Administrator before the resident and their bed was moved. The Social Worker stated before bed rails were placed on a bed, he would get the consent from the resident or their responsible party, a side rail assessment would be done by the nursing staff. The Social Worker said he attended the QAPI meeting held on [DATE], the IDT team was present and the IJ situation was discussed which included the department heads, the administrator, the MDS Coordinator, the Assistant MDS Coordinator, the DOR, and the Assistant DOR. The Social Worker stated at the QAPI meeting the IJ situation was discussed and the facility's POR. In an interview on [DATE] at 12:50 p.m., the DOR stated he was recently in-serviced on making sure when a resident was moved to a new room, a member of the IDT was present to ensure the resident's bed and bed rails were moved to the new room. If the room change occurred after hours, the DOR said the nursing staff were to call the Administrator before the resident was moved. The DOR stated bed rail assessments would be done when a resident was admitted to the facility by the nursing staff, then the therapy staff would do a physical assessment to determine if the resident needed the bed rail, to make sure the bed rail did not restrict the resident's range of motion and the bed rail was correctly installed. The DOR said he attended the Ad Hoc QAPI meeting held on [DATE] around 5 p.m. The DOR stated the Social Worker, the Activity Director, the Administrator, the Maintenance Supervisor, the Assistant Director of Rehabilitation were present in person, and the Medical Director was present via telephone. The DOR said they discussed at the Ad Hoc QAPI meeting the IJ situation, to make sure the resident's adaptive equipment was transferred was transferred with the resident to their new room, the bed rails were moved with the bed to the new room, nursing staff completed their required documentation for the bed rails [bed rail assessment, bed rail consent] and the therapy department would assess the resident to determine if the bed rail was appropriate for the resident. In a telephone interview on [DATE] at 3:41 p.m., the Medical Director stated she was informed of the IJ situation on [DATE] after it was called and was present via telephone for the Ad Hoc QAPI meeting which the IJ situation was discussed and the facility's POR. In an interview on [DATE] at 4:22 p.m., the Administrator stated the nursing staff was in-serviced on the changes to the procedure for when a resident was moved into another room in the facility. The Administrator said any resident room changes would be discussed in the morning meetings and a member of the IDT would be present when the resident was moved to a new room to ensure the resident's belongings and bed with the bed rails was moved to the new room. The Administrator stated she conducted an audit on residents who had room changes that were made in the past 90 days; she checked the resident's care plan and did a visual audit to make sure that everything was moved from the residents' old room to the new room. The Administrator stated an Ad Hoc QAPI meeting was held at 5:30 p.m. on [DATE] with the Medical Director in attendance, the DOR, the Social Worker and all the department heads. The Administrator said the Ad Hoc QAPI meeting topic of discussion was the IJ situation, to discuss the process that failed, what led to the process, and what was going to be changed to ensure this did not happen again. The Administrator stated she reviewed the charts of the residents who had a room change in the past 90 days to verify if they had an assistant device, if it was moved to their new room if the resident had bed rails previously and if the resident currently had bed rails. The Administrator said she used a resident census sheet and went into each resident's room on [DATE] and documented with an x beside their name if they had bed rails. Then on [DATE] they went through the visual audit that she had done on [DATE] and looked at every resident who had bed rails, at the resident's care plans, if they had a consent and if a bed rail assessment had been completed. The Administrator stated the MDS Nurse and Therapy staff visited every resident who had a bed rail to see if the bed rail was needed or wanted. If the resident did not need or want the bed rail, it was removed by the Maintenance Director. The Administrator said she printed an audit report from the electronic clinical record system for residents who had a bed rail care plan and each resident with a bed rail was seen by the therapy staff to determine if it was safe for the resident to have them. The Administrator stated she created a spread sheet for every resident who has a bed rail to verify they had a consent, a bed rail assessment, and a care plan. The Administrator said she created another spread sheet that lists all the residents in the facility and indicates if they have a bed rail or not. The Administrator stated the IDT, the nursing staff, and the Social Worker were in-serviced on the new changes that were made when a resident is moved into a new room. The Administrator stated she created a tracking sheet for the daily monitoring that would be done in the next seven days and another tracking sheet for the monitoring that would be done five times per week. In a telephone interview on [DATE] at 5:42 p.m., the Clinical Corporate Resource stated she conducted a chart audit of every resident who had a room change to verify if the resident had a bed rail, then checked the resident's clinical record to verify they had a bed rail assessment and a care plan for the bed rail. The Clinical Corporate Resource said she assisted with the bed rail audits, with evaluation of the residents who had bed rails which was completed [DATE] and the therapy staff placed a note in the resident's progress notes for residents who had a bed rail. The Clinical Corporate Resource stated when she was in the facility she would conduct an audit to ensure the monitoring of the POR was conducted and she would visit the facility at least twice a month or more frequently if needed. Interviews with 8 day staff (3 nurses and 5 CNAs) and 5 night staff (1 nurse and 4 CNAs) on [DATE] from 2:18 p.m. to 4:05 p.m. revealed they had been in-serviced on to not move a resident to another room without notifying a member of the management staff first and a member of the IDT must be present when the resident was moved from the old room to the new room. The resident's bed from the old room, along with any other assistive devices and personal items, would be moved to the new room. They stated if a member of the management team was not in the facility and an emergency move needed to be made, they would contact the administrator before the resident was moved. Record review of the facility's POR binder revealed the following documents: 1. Under the tab labeled chart review was an undated list of residents (22) who had a recent room change, if they had a bed rail or enabler bar in place, a completed bed rail assessment, a consent, and a care plan for the bed rail. At the bottom of the page was the Director of Clinical Operations name. 2. Under the tab labeled visual audit was a resident room roster dated [DATE] with an x by the resident's name if they had a bed rail or enabler bar and the administrator's name/title was hand-written at the top. 3. Under the tab labeled Therapy/Nursing was a document dated [DATE] labeled Care Plan Item/Task Listing Report that listed residents with care plans for side rails. 4. Under the tab labeled Consent Order was an untitled, undated document with resident's name, if they had side rails, a bed rail assessment, a consent for the bed rail, and a care plan. Also under this tab was a document titled Siderail Enabler Assessment, dated [DATE] which listed residents with side rails. 5. Under the tab labeled Ad Hoc QAPI was an AD Hoc QAPI Meeting/Root Cause Analysis Agenda and Summary dated [DATE], indicated the Administrator, the DOR, the Medical Director, the Maintenance Director, the Social Worker had attended the meeting. The form indicated the facility would strive to ensure that the residents' environment was free of accident hazards, as possible, and each resident received adequate supervision in assistive devices to prevent accidents. 6. Under the tab labeled Documented Education was an in-service training done on [DATE] with 10 of 10 IDT managers; the IDT was educated on the process for ensuring that fall prevention/assistive mobility rails that were in place prior were transferred or remain in place after any room changes, the bed should be moved with the resident to ensure continuity of care associated with mobility rails and to notify the Administrator if a discrepancy related to mobility rails was identified. 7. Under the tab labeled Documented Education was an in-service training done on [DATE] with the Social Worker which indicated the social worker was educated on the requirement to communicate the need for side rails if applicable, on any resident for whom a bed is ordered to be provided by hospice, per the Hospice Plan of Care. 8. Under the labeled Documented Education was an in-service training done on [DATE] with 39 of 42 nursing staff (1 nursing staff was on medical leave and 2 nursing staff were PRN and had not worked in facility in past 30 days - which was noted next to their names) were in-serviced on the process for ensuring that fall prevention/assistive mobility rails that were in place prior are transferred or remain in place after any room change, the resident's bed should be moved with the resident to ensure continuity of care associated with mobility rails, and to notify the Administrator if a discrepancy related to mobility [NAME] was identified. Nursing staff were educated that room moves were conducted by the IDT team with the help of the nursing staff. In the event a room move was emergent, the Administrator/Designee would be notified. 9. Under the last tab that was unlabeled was an undated excel sheet with a list of residents who had recent room changes since [DATE], if they had bed rails/enabler bars, a bed rail assessment, a care plan for the bed rail, a consent for the bed rail, and a place for follow-up daily monitoring for 7 days and then further follow-up in five days. All residents on the list who had bed rails or enabler bars where follow-up on [DATE]. Also under this tab was an undated, untitled sheet that had resident's name, date of their room changes, and columns for day 1 through day 7 with the administrator's initials in the column for day 1 and day 2. Observation on [DATE] at 10:43 a.m. revealed Resident #13 was lying in a bariatric bed with ,d+[DATE] bed rails on both sides of the bed. Record review of Resident #13's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses which included morbid obesity and high blood pressure. Record review of Resident #13's electronic clinical record revealed a bed rail assessment was completed on [DATE]. Record review of Resident #13's electronic clinical record revealed a Physical Therapy note dated [DATE] by PTA P which indicated the resident demonstrated appropriate use of the bed rails. Observation on [DATE] at 10:36 a.m. revealed Resident #7 was lying in bed with ,d+[DATE] bed rails on both sides of the bed. Record review of Resident #7's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses which included morbid obesity and high blood pressure. Record review of Resident #7's electronic clinical record revealed a bed rail assessment was completed on [DATE]. Record review of Resident #7's electronic clinical record revealed a Physical Therapy note dated [DATE] by PTA P which indicated the resident demonstrated appropriate use of the bed rails. On [DATE] at 6:15 p.m. the facility's POR verification had been approved. On [DATE] at 6:29 p.m., the Administrator was informed the POR was validated and the immediacy was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal.