Every finding on record at Mission at Alpine Rehabilitation Center

Based on interview, and record review, for 10 of 32 residents sampled, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, the State Survey Agency was not notified of sexual relations between cognitively impaired residents, multiple resident elopements, injuries of unknown origin with some resulting in fractures, and a resident not secured in transportation vehicle. Resident identifiers: 2, 7, 11, 27, 31, 33, 36, 42, 47 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to report various forms of abuse. Notice of the IJ in Abuse was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/8/25 at 4:46 PM, the Administrator provided the following abatement plan for the removal of the Abuse IJ effective on 8/8/25 at 11:59 PM. The community would add sexual abuse to the revised Abuse Policy and Procedure, all staff would be educated by a LCSW (Licensed Clinical Social Worker) on resident intimacy and sexuality guidelines, the revised policy and the sexual intimacy capacity for consent assessment prior to the next shift worked. QAPI (Quality Assurance and Performance Improvement) will review the revised Abuse Policy and Procedure, all allegations and abuse packets will be reviewed by the QAPI Committee weekly for the next 3 months and any identified concerns will be addressed by said committee. However, the IJ could not be abated based on additional findings of neglect, specifically elopement. On 8/12/25 at 2:30 PM, IJ was again identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to report various forms of neglect. Notice of the IJ in neglect, specifically, elopement, was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/13/25 at 10:47 AM, the Administrator provided the following additional abatement plan for the removal of the IJ effective on 8/13/25 at 11:59 PM. All residents, with a history of elopement attempts will be supervised at all times when they are outside of the community. All residents with elopement risk assessments were reviewed and updated as necessary on 8/12/25. Any residents at high risk for elopement will have their care plans updated to reflect interventions to reduce the risk of elopement. The three doors that exit the community will be monitored by a staff member at all times until the egress doors are either secured by badge system or fence installation. Moving forward all allegations of mistreatment, abuse, neglect, exploitation, elopement or other reportable incidents, will be thoroughly investigated per the following: 1. Reporting Responsibilities; 2. Reporting Decision Tool; and 3. Incident Reportability Algorithm. Any incidents of elopement will be reviewed by the QAPI Committee on a monthly basis and recommendations will be implemented. On 8/14/25 while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 8/13/25 at 11:59 PM. Findings include: IMMEDIATE JEOPARDY INCIDENTS OF SEXUAL CONTACT 1. Resident 33 was admitted to the facility on [DATE] with diagnoses which included Parkinson's with dyskinesia, dementia, psychotic disorder with delusions due to non psychological conditions, and anxiety disorder. Resident 33’s medical record was reviewed from 8/4/25 through 8/20/25. Resident 33 had a BIMS (Brief Interview for Mental Status) completed on 6/14/25 which was 3 out of 15 which indicated severe cognitive impairment. Progress notes revealed the following: On 6/25/25 resident 33 was seen in another resident's room with a female resident. The nurse walked in and found them in close proximity. Quickly redirected and separated residents from each other. The resident was very receptive to redirection and followed the staff into his room. On 6/26/25 resident 33 was found sitting on a bed holding hands and kissing resident 31. On 7/28/25 resident 33 was found with his hand on resident 27’s shoulder/arm gently patting her. These incidents were not reported to the State Survey Agency (SSA). On 8/18/2025 at 1:55 PM, an interview was conducted with the Administrator (Admin). The Admin stated he did not report or do an investigation for the incidents with resident 33 because he thought they were consensual and didn’t need to be reported or investigated. 2. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia with mood disturbance, anxiety disorder, and mood disorder due to known physiological conditions. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment. Resident 31’s progress notes documented the following: On 6/25/25 at 9:03 AM, an Encounter Note documented that resident 31 was assessed using the St. Louis University Mental Status Examination (SLUMS) test and she scored 4 out of 30, suggesting dementia. The physician believed that a memory care unit was appropriate for her as far as her safety. Resident 31 was having episodes of agitation as well as crying periods because she did not know what was going on and did not understand why she was in the facility. On 6/25/25 at 7:18 PM, a Nursing Progress Note documented that resident 31 was removed from a male resident’s room and later that day she was found in another resident’s room with a male resident “in very close proximety [sic]”. On 6/26/25 at 5:19 PM, a Nursing Progress Note indicated, “Resident was found with a male resident in the residents room. A CNA [certified nursing assistant] walked in and found them sitting on the bed kissing. They were holding hands It appeared to be consensual. I talked privately with both residents and made sure they were both consenting and that is what they wanted to do. it was confirmed by both residents that they consented. I notified both families and they both gave their permission as long as the residents felt good about it. I tried to redirect them but they continued to be with each other. encouraged resident's to stay in public spaces. We will increase observation at this time.” On 6/26/25 at 9:16 PM, a Nursing Progress Note indicated, “CNA [name redacted] walked into male resident’s room to find him and [resident 31] both undressed. Male resident was sitting on his bed while [resident 31] was kneeling on floor by his groin. Both residents appeared happy and acting upon mutual consent. No signs of struggle. Both residents asked CNA to leave the room. CNA asked them to get dressed, and they complied. Both residents were interviewed and stated that they were not forced into anything, they enjoyed each other’s company and they both got undressed willingly. They both stated that they feel safe. Resident’s daughter [name redacted] notified of incident and she stated that her biggest desire was for her mom to be happy and safe. She stated that she felt her Mom was able to consent, and she had no concerns about the incident. She stated that her mom has been single for 20 years and it is good for her to have some companionship. administrator [name redacted] notified.” On 6/28/25 at 1:39 AM, a General Note documented that resident 33 was seen exiting resident 31’s room. Resident 31 was observed to be sleeping and not aware that resident 33 had been in her room. On 6/28/25 at 3:59 PM, a Nursing Progress Note documented that resident 31 was seen being affectionate with resident 33 by holding hands and kissing in private. On 7/8/25 at 6:45 AM, a Nursing Progress Note documented that resident 33 was found curled up in bed with resident 31 that morning. These incidents were not reported to the State Survey Agency. On 8/6/25 at 1:08 PM, the Admin was interviewed. The Admin stated sexual abuse was the intent to cause harm with resulting harm to a resident and the residents involved were consenting so it was not reported to the State. 3. A. Resident 11 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, cerebral infarction, aphasia, anxiety disorder, unspecified intellectual disabilities, and depression. B. Resident 49 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, anoxic brain damage, chronic viral hepatitis, delusional disorders, psychotic disorder, major depressive disorder, opioid abuse, anxiety disorder, unspecified mood disorder, and antisocial personality disorder. The resident was discharged from the facility on 5/29/25. On 3/26/25 at 9:13 AM, a complaint was called into the State Survey Agency (SSA) by an Adult Protective Services (APS) investigator. The APS investigator stated that they received a report that resident 11 was sexually assaulted by a fellow resident [resident 49]. The APS investigator reported that on 3/14/25 a CNA was checking on resident 49 and found him with his pants down on top of resident 11 and was attempting to initiate sexual contact. On 8/5/25, the facility abuse investigation documentation was reviewed. No documentation could be found of an investigation into the incident between resident 11 and resident 49 on 3/14/25. On 8/6/25 at 1:04 PM, an interview was conducted with the DON. The DON stated that she recalled the incident of resident 11 lying in resident 49’s bed. The DON stated that the Administrator conducted the abuse investigation. The DON stated that from what she recalled resident 11 was lying in resident 49’s bed but there were no signs of penetration. The DON stated that this incident of sexual activity was something that should have had an abuse investigation, and the SSA should have been informed within 2 hours of the incident. The DON stated that this incident should have also been reported to the police department within 2 hours of the incident and she did not believe it was ever reported to the police. On 8/6/25 at 2:38 PM, a follow-up interview with the DON. The DON stated that she discussed the incident with the Administrator and it was not reported to the SSA. Review of the facility Policy on Investigating Allegations of Resident Abuse, Actual Abuse and Neglect of a Resident documented that 1. In the event an incident that meets or has the potential to meet one of the definitions stated in the policy on abuse or neglect of a resident, the incident is reported to the Administrator and or designee. An investigation of the incident will be commenced promptly 2. Depending on the specifics of the incident, reporting to State agencies may occur and local law enforcement may be notified. It should be noted that the facility did not conduct an investigation into an allegation of sexual abuse or notify the State Survey Agency or local law enforcement. [Cross-refer F600] IMMEDIATE JEOPARDY ELOPEMENTS 4. Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of vascular dementia with agitation anxiety disorder, psychotic disorder with delusions, and depressive disorder. Resident 42’s medical record was reviewed between 8/4/25 and 8/20/25. On 3/12/25 at 5:25 PM, an incident report revealed that resident 42 was seen attempting to climb the fence at the facility. “Before Certified Nursing Assistant [CNA] could get to him, he hopped over.” Resident 42 was brought back into the facility and began kicking the front door, demanding to get out. Resident 42 was unable to give a description of the event. In the description of the event it stated that the CNAs caught up with the resident and walked him back to the facility without issue. Orders were received to send resident [42] out for an evaluation for possible UTI [urinary tract infection]. Emergency Medical Services [EMS] was contacted and the resident left the facility at 5:50 PM.” No injuries were noted as a result of the elopement. It should be noted that the elopement on 3/12/25 was not reported to the State Agency (SA) On 5/10/25 at 6:00 PM, an incident report revealed that resident 42 “stepped on wood beside fence to climb over fence” and was found outside alert and walking without difficulty. Resident 42 had a skin tear to his right forearm. The report stated that new orders were placed, the area was cleaned with wound cleanser and steri-strips were applied with monitoring for 7 days. There was no bleeding at the site. The resident stated, “I went over the fence.” Resident 42 was then assisted back into the facility. It should be noted that the elopement on 5/10/25 was not reported to the SA. On 8/12/25 at 8:37 AM, an interview was conducted with the Minimum Data Set Coordinator who stated if a resident eloped, she would report it to the administration, meaning the Admin and the DON. On 8/12/25 at 1:19 PM, an interview was conducted with the Admin who stated he did not report or investigate the incidents for resident 42 or report them to the state and they should have been investigated and reported to the State Survey agency. 5. Resident 36 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage with loss of consciousness, pain, generalized anxiety disorder, major depressive disorder, bipolar, and personal history of suicidal behaviors. Resident 36’s medical record was reviewed 8/4/25 through 8/20/25. Resident 36 had a BIMS completed on 7/31/25 and scored 4 out of 15 which indicated severe cognitive impairment. Resident 36 had a MOCA completed on 7/15/25 and scored 7 out of 30 which indicated severe cognitive impairment. On 11/19/24, resident 36’s elopement assessment documented that the resident had no history of wandering, could follow instructions, could communicate and had a medical diagnosis of cognitive impairment. Resident 36 scored low risk for elopement. On 1/24/25, resident 36’s quarterly elopement assessment documented that the resident had a history of elopement and had wandered off the grounds. The elopement assessment score was 35, which would indicate a high risk for elopement. Progress notes revealed the following: On 11/22/24 at 10:33 AM, a physician progress note documented, “ .This is my initial assessment. He is now currently blinded in both eyes due to his self-inflicted gunshot wound to his head…” On 12/14/24 at 7:00 PM, the note documented, “Doorbell to front door rang, nurse answered door and wife and resident were standing there. Wife stated she brought resident back and reported he had walked all the way home. Patient was wrapped in a blanket. Resident told nurse he broke through the fence because he had to get home. Resident stated he was mad because his wife wasn't answering the phone and he had to leave.” On 4/12/25 at 6:34 PM, the note documented, “Rsident ([sic] found outside after knocking down fence. resident walking down street cna saw resident and notified nurse.” The incident report dated 4/12/25 revealed “CNA over the radio said ‘2b is outside of the building’. Upon investigation, resident was walking towards state street and refused to turn around and walk the other way. Two CNA’s and myself, had to hold him and keep him from going any further where he could possibly harm himself especially with his partial blindness. After many attempts at redirection from many staff members, resident finally agreed to return when a member from the admin team came out to talk to him.” On 7/6/25 at 9:30 PM, the note documented, “Resident alert and oriented kicked fence out and eloped.Father and administration notified, 911 notified was told police offier [sic] was on his way back with resident.” On 7/7/25 at 5:35 PM, the note documented, “At 1640 [4:40 PM] CNA noted that [resident 36] was outside and wanted to make sure that we all could keep an eye on him as he has a history of trying to elope. He then began to try to take apart the fence. I asked what he what his plan is and why he was wanting to leave. He stated to go home and talk to his wife, i offered to help him contact his wife and other interventions. Myself and 3 other people attempted to intervene, and redirect, and attempted to tell him that it was unsafe for him and other residents, to have this fence broken, he continued and stated that he does not care that it is unsafe. Eventually he took the panels apart and stepped on the retaining wall. He then jumped down the wall…. He then walked directly into the road and myself and [Director of Rehab] had to take him by the arms so that he did not walk into traffic, I repeated that with his very limited vision this was very unsafe and you are putting yourself and us in danger. We were able redirect to walk on the sidewalk but he just kept repeating that he was walking home.” Note: The facility reported the 7/6/25 incident to the State Survey Agency. The incidents on 12/14/24 and 4/12/25 were not reported. On 8/12/25 at 1:19 PM, an interview was conducted with the Admin. The Admin stated the investigations were primarily done by talking with the nurses and looking into the events. The Admin stated they did a formal investigation on 7/6/25 for resident 36. The Admin stated he wasn’t totally aware of the elopement section of the reportable so because of that not being clear, he didn’t report them. The Admin stated because resident 36 was with a staff member they didn’t report the elopements. The Admin stated he did not report or investigate the incidents for resident 42 or report them to the state. The Admin stated that yes, these incidents should have been investigated and reported to the state survey agency. HARM INJURY OF UNKNOWN ORIGIN 6. Resident 2 was admitted to the facility on [DATE] with diagnoses which included Alzheimer’s disease, major depressive disorder, hypertension, and mood disorder due to known physiological condition. On 8/4/25 at 11:07 AM, an observation was conducted of resident 2 in the dining room doing an activity, she had a large purple bruise to her right eye. Resident 2's medical record was reviewed from 8/4/25 through 8/20/25. An admission MDS dated [DATE] indicated resident 2 had a BIMS score of 3. A BIMS score between 0 and 7 indicated severe cognitive impairment. An Incident Report dated 7/26/25 indicated, “Resident noted to have bruising and swelling to Rt eye. It further indicated, Resident stated that it occurred ‘a couple of days ago’ and that she ‘was not here when it happened’. Does state when asked about the bruising to right knee that she did fall. It further indicated, Notified Admin, Placed ice pack to rt eye, skin check performed- bruise to rt knee and scattered bruising to left forearm noted.” It further indicated that resident 2 was alert and Oriented to Person (It should be noted that there was no check mark next to Oriented to Situation, Place or Time). A Nursing Progress Note dated 7/26/25 at10:27 AM indicated, “Bruising noted to right eye as resident was walking down hall this morning. Resident stated that it happened a couple of days ago and that she wasn't here when it happened. Another nurse stated that the bruising was not there yesterday. Notified Admin and placed icepack to eye. Will notify other necessary parties.” On 8/6/25 at 2:11 PM, an interview was conducted with resident 2’s daughter. She stated the facility notified her that her mom had a fall and got a black eye. On 8/13/25 at 12:39 PM, an interview was conducted with the DON. The DON stated that if a resident could not tell them how a bruise of unknown origin occurred there would need to be an investigation completed. The DON further stated that if you cannot determine where the bruise came from then it should be reported to the State Agency. On 8/19/25 at 12:32 PM, an interview was conducted with the Admin. The Admin stated that the Interim DON was supposed to do the investigation into how resident 2 got a black eye. The Admin stated if we could not reasonably conclude that it was from a fall, it should have been reported to State. HARM INJURY IN TRANSPORTATION VEHICLE 7. Resident 7 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, type II diabetes, peripheral vascular disease, and chronic pain syndrome. Resident 7’s medical record was reviewed from 8/4/25 through 8/20/25. A progress note dated 2/11/25 revealed, “during transport to dialysis, resident reportedly fell out of his chair hitting his head and back. then transport pulledover [sic] and turned hazards on and got out of the van. grabbed chuck then put him back in his chair and buckled him back. Tookhim [sic] to his appointment then reported the incident to the nurses at the dialysis place. then when transport came back 15 minutes later, reported it to the nurses here. neuro checks initiated at 1600. first vital signs back to the facility after return was103 [sic], 100/64, 18, 95%, 96.5. no pain verbalized upon arrival.” A progress note dated 2/14/25 revealed, “The resident complained of pain in his head, neck, spine and back so I called the MD [medical doctor] and he ordered XRay of Skull, XRay of Neck, XRay of Cervical, thoracic and lumbar spine STAT [immediately].” … “The XRays came back and [provider] was sent the XRay results. He said there was no current acute problems. Everything looked fine. Continue treating with Tylenol for pain as needed.” A Facility Reported Incident (FRI) documented, “on 02/14/2025 at 10:45 am, the facility reported that on 02/12/2025 at 2:10 pm, [plant operations 2] who was taking resident 7 to a dr. appointment didn't properly secure front straps to the wheelchair and resident 7 picked his legs up and tipped backward. The Resident has a abrasion to back of head. Education given to [plant operations 2] and more training given.” On 8/18/2025 at 1:55 PM, the Admin stated he did report the incident with resident 7 falling over in the van but it was reported late. POTENTIAL FOR HARM ELOPEMENT 8. Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, type 2 diabetes mellitus, delirium due to known physiological condition, major depressive disorder, generalized anxiety disorder, chronic pancreatitis, essential hypertension, and cognitive communication deficit. Resident 47's medical record was reviewed from 8/4/25 through 8/20/25. An admission MDS assessment dated [DATE] indicated resident 47 had a BIMS score of 3. A BIMS score between 0 and 7 indicated severe cognitive impairment. It further indicated wandering behaviors were not exhibited. A Social Services Note dated 6/7/24 indicated, “…[Resident 47] is a high wander risk. He is often walking around the building and outside in the backyard. Staff is able to check on him frequently and provide activities to reduce risk of wandering. [Resident 47] has not left facility unattended.” A Nursing Progress Note dated 8/9/24 indicated, “Resident was found on state street in [City name redacted] by a staff member and brought back to the facility just as the nurse was looking for the resident. Resident was asked how he got out of the facility and the resident reports he exited the front door. He reports he does not remember who let him out…” A Nursing Progress Note dated 8/20/24 indicated, “resident attempted to elope and was found still on the facility premisis [sic] by a physical therapy personelle [sic] around 1805 [6:05 PM]. when asked how he got out he was not an accurate hisotrian [sic] and said he went through the front door but also said he jumped over the fence. upon further investigation, staff found an outside chair pushed up against the west fence and this is how we presume he got outside. Notified administration, ADON [Name redacted], and will continue checking his where abouts every hour. messaged management aboutgetting [sic] the outside chairs perminantely [sic] secured to the ground and kept away from the fences to prevent this from happening again in the future. Chairs are temporarily secured and unable to be moved at this time.” A Nursing Progress Note dated 10/2/24 indicated, “Resident was found 1.5 blocks from the facility walking towards the [Store name redacted] by the [City name redacted] police. Facility was called and a staff member went and picked resident up and brought him back to the facility…” On 8/19/25 at 12:25 PM, an interview was conducted with the Admin. The Admin stated the elopements on 8/9/24, 8/20/24, and 10/2/24 should have been reported to the State Survey Agency.

Based on observation, interview and record review it was determined, for 7 of 32 sampled residents, that the facility did not implement their written policies and procedures to prevent abuse, neglect, and investigate and report allegations. Specifically, the facility did not have written policies and procedures that defined sexual abuse, how to evaluate a resident's capacity to consent to a sexual relationship and elopements. These examples were cited at an Immediate Jeopardy level. Resident identifiers: 11, 27, 33, 31, 36, 42 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to implement policies and procedures to prevent various forms of abuse. Notice of the IJ in Abuse was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/8/25 at 4:46 PM, the Administrator provided the following abatement plan for the removal of the Abuse IJ effective on 8/8/25 at 11:59 PM. The community would add sexual abuse to the revised Abuse Policy and Procedure, all staff would be educated by a LCSW (Licensed Clinical Social Worker) on resident intimacy and sexuality guidelines, the revised policy and the sexual intimacy capacity for consent assessment prior to the next shift worked. QAPI (Quality Assurance and Performance Improvement) will review the revised Abuse Policy and Procedure, all allegations and abuse packets will be reviewed by the QAPI Committee weekly for the next 3 months and any identified concerns will be addressed by said committee. However, the IJ could not be abated based on additional findings of neglect, specifically elopement. On 8/12/25 at 2:30 PM, IJ was again identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to prevent various forms of neglect. Notice of the IJ in neglect, specifically, elopement, was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/13/25 at 10:47 AM, the Administrator provided the following additional abatement plan for the removal of the IJ effective on 8/13/25 at 11:59 PM. All residents, with a history of elopement attempts will be supervised at all times when they are outside of the community. All residents with elopement risk assessments were reviewed and updated as necessary on 8/12/25. Any residents at high risk for elopement will have their care plans updated to reflect interventions to reduce the risk of elopement. The three doors that exit the community will be monitored by a staff member at all times until the egress doors are either secured by badge system or fence installation. Moving forward all allegations of mistreatment, abuse, neglect, exploitation, elopement or other reportable incidents, will be thoroughly investigated per the following: 1. Reporting Responsibilities; 2. Reporting Decision Tool; and 3. Incident Reportability Algorithm. Any incidents of elopement will be reviewed by the QAPI Committee on a monthly basis and recommendations will be implemented. On 8/14/25 while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 8/13/25 at 11:59 PM. Findings include: IMMEDIATE JEOPARDY INCIDENTS OF SEXUAL CONTACT 1. Resident 33’s medical record was reviewed from 8/4/25 through 8/20/25. Resident 33 was admitted to the facility on [DATE] with diagnoses which included Parkinson's with dyskinesia, dementia, psychotic disorder with delusions due to non psychological conditions, and anxiety disorder. Resident 33 had a BIMS (Brief Interview for Mental Status) completed on 6/14/25 which was 3 out of 15 which indicated severe cognitive impairment. Resident 33 had a MOCA (Montreal Cognitive Assessment) completed on 7/19/24 which was 7 out of 30 which indicated severe cognitive impairment. Medicare Meeting notes on 6/11/25 documented resident 33’s confusion and cognition continued to fluctuate. A physician note dated 6/9/25 revealed resident 33 had severe cognitive impairment and was progressively declining. No documentation could be located in the medical record where resident 33 had been evaluated for the capacity to consent to sexual activity. Resident 33's progress notes were reviewed and revealed the following: On 4/16/25 resident 33 was found kissing resident 27 while lying on top of her. On 6/25/25 resident 33 was seen in another resident's room with a female resident. The nurse walked in and found them in close proximity. Quickly redirected and separated residents from each other. The resident was very receptive to redirection and followed the staff into his room. On 6/26/25 resident 33 was found sitting on a bed holding hands and kissing resident 31. On 6/26/25 at 6:08 PM CNA (Certified Nursing Assistant) walked into the resident's room to find him and a female resident both undressed. The resident was sitting on his bed while female resident 31 was kneeling on the floor by his groin. On 6/28/25 resident 33 was found holding hands and kissing resident 31. On 7/28/25 resident 33 was found with his hand on resident 27’s shoulder/arm gently patting her. A Facility Reported Incident (FRI) dated 4/16/25 documented that a CNA (Certified Nursing Assistant) noted that resident 27 had gone into resident 33’s room and laid down in his bed. The facility documented the following, she often liked to go to his room whether he was in or not and lay on his bed. This time he was found clothed laying in bed with her. There was no kissing or touching noted and resident 33’s denied kissing or touching. Both parties were noted to be calm and smiling. Immediately separate, investigate. Increase routine checks to 15 minutes. A FRI dated 6/26/25 documented the CNA noted resident 31 was observed in resident 33’s room. The facility documented the following, resident 33 was sitting on the bed and resident 31 was kneeling on the floor by his groin. Both had their clothes off, when the CNA entered both residents asked the CNA to leave the room. The CNA told them to get dressed which they did. Abuse was unsubstantiated. The residents were in their right to choose in this case. A FRI dated 6/28/25 documented that resident 33 was standing beside resident 27 who was lying in bed, he had his hand on her shoulder or arm and was gently patting her. The facility documented resident 33 was helped out of the room. Residents were redirected. Abuse inconclusive, there was no inappropriate touching. Given resident 33’s cognitive impairment and history to engage socially with others in a well meaning manner, it was reasonable to conclude that his actions were non-threatening and likely intended to be comforting or friendly in nature. A care plan problem of exhibits/at risk for behaviors such as being affectionate/intimate with some female residents, transferring and walking without assistance while weak, or unsteady on his feet related to parkinsonism, anxiety, delusional disorders, and dementia was initiated on 11/21/23. The interventions of when being affectionate towards another resident, he will receive consent prior to any affection and staff to intervene if needed was initiated on 6/26/25. And ensure resident finds his own room, redirect away from rooms that aren't his was initiated on 7/28/25. 2. Resident 27 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder, anxiety disorder, personality disorder, vascular dementia and psychosis. Resident 27’s medical record was reviewed between 8/4/25 and 8/20/25. On 7/9/24, an admission Minimum Data Set (MDS) assessment revealed a BIMS score of 0, indicating resident 27 had severe cognitive impairment. Resident 27 was evaluated for mood and was unable to provide a response to the questions being asked. A behavior assessment revealed resident 27 demonstrated wandering behaviors that disrupted the privacy of other residents. A review of resident 27’s care plan revealed, “The resident uses antidepressants, and anti-anxiety medications r/t [related to] anxiety, mood disorder, disrobing, and hypersexuality.” Interventions included: Administer psychotropic medications as ordered by physician. Monitor/document side effects and effectiveness Q-shift (every shift). Provide structured routine and activities to reduce idle time and overstimulation. Review in psychotropic committee at least quarterly. The goal was to be free from discomfort or adverse reactions to psychotropic therapy through the review date. This care area was initiated on 11/10/24. An assessment for the ability to consent to sexual activity could not be found in resident 27’s medical record. Resident 27’s progress notes were reviewed: On 4/16/25 at 11:20 PM, a nursing progress note revealed, “Nurse was notified by CNAs that resident from 6A was found in 18b’s bed and 18a was on top of 6a fully clothed. Resident 18a was witnessed kissing 6a. Resident 18a admitted to kissing 6a a couple of times. Residents were separated and 15 min [minute] checks for 72 hours were started. MD [medical doctor], ADMIN [administrator], DON [Director of Nursing] and family notified.” On 5/19/25 at 4:09 PM, a Social Services progress note revealed, “RA [Resident Advocate] called family regarding a possible discharge from facility due to recent incident. Family would prefer that resident remains in facility but is also willing to look into other options. Referrals sent to [facilities redacted].” It should be noted there was not a progress note in the medical record regarding the “recent incident” referred to in the 5/19/25 progress note. On 7/28/25 at 5:18 PM, a nursing progress note revealed, “It was reported today that on Saturday, July 28, 2025 a visitor for resident [redacted] in room [ROOM NUMBER]A walked into room [ROOM NUMBER]A to find resident 27/6A lying in a bed that wasn’t hers. Resident 18A/[redacted] was standing next to the bed with his hand on 6A/27’s shoulder/arm gently patting her. No other touching noted. Resident assessed for injuries or abnormal behavior, none noted. Resident redirected out of room. Staff to redirect resident away from rooms that aren’t hers. [Physician], administration, and family notified.” Incident reports were reviewed for resident 27: On 4/16/25 at 8:31 PM, the facility reported to the State Survey Agency that resident 27 and resident 33 were found together lying in resident 33’s bed. The report stated that resident 27 often would go into resident 33’s room, whether or not he was in the room, and lay on his bed. Both residents were clothed. The incident report stated there was no touching or kissing noted and resident 33 denied touching or kissing resident 27. The report stated both residents were calm and smiling. CNA 10 asked resident 27 to leave the room, and both residents peacefully separated. CNA 10 was interviewed by the administrator at an unknown date and time, and stated she witnessed resident 27 and resident 33 lying on resident 33’s bed cuddling with each other. CNA 10 stated both residents were fully clothed, and she did not observe any inappropriate touching or kissing. CNA 10 stated both residents looked comfortable and content. CNA 10 asked resident 27 to leave the room, which she did. Resident 33 stated that resident 27 was a friend and comforted him. Both residents were poor historians and unable to fully recount what happened. Resident 27 was put on 15 minute checks. Responsible parties and families were notified. Abuse was not verified due to lack of inappropriate touching as witnessed or confirmed by the residents. The investigation stated both residents were comfortable and seeking to comfort each other, and were easily redirected. The report stated no harm was intended by either resident and both residents were at baseline. The intervention created as a result of this incident was to immediately separate, investigate, increase routine checks to 15 minutes, and keep resident 27 in the dining room when she leaves her room. On 5/13/25 at 11:20 PM, the facility reported to the State Survey Agency that resident 27 had walked into resident 49’s room after going to bed in her own room, and then was found in resident 49’s bed. Resident 49 was leaning next to her on the bed. The report stated that resident 49 was leaning close to her face, but was not touching or kissing resident 27. The report stated residents were being helped to bed during rounds. Interviews were conducted by the administrator with resident 49’s roommate and CNA 5. Resident 49’s roommate stated that resident 27 opened the door and entered the room, walked toward him, and then went over to resident 49 and laid down in resident 49’s bed. Resident 49 was already in bed and started to lean over resident 27 when CNA 5 walked into the room. The report stated that resident 49 had his pants down and was leaning close to resident 27’s head. Resident 27 was looking at resident 49 peacefully. The report stated there was no touching or kissing that took place. CNA 5 redirected resident 27 out of the room. Resident 49 denied touching or kissing resident 27. Resident 49’s roommate confirmed there was no touching or kissing. Abuse was not verified because there was no touching or kissing. The report stated resident 49 may have removed some of his clothing because it was hot. Resident 49 was known to have his pants down in his room occasionally. The report stated resident 49 did not force resident 27 into his bed or into his room, and resident 27 laid down intentionally and was calm. Neither resident had a change in their baseline behavior. The intervention created as a result of this incident was to monitor both residents and to discharge on e of the residents. On 7/28/25 at 3:43 PM, the facility reported an incident to the State Survey Agency that occurred on 7/26/25 between resident 27 and resident 33. A brief investigation was conducted with inconclusive results. The administrator determined there was no inappropriate touching. The investigation stated that resident 33 enjoys socializing with other residents and is often seen as a peace maker among the residents. Resident 33 left the situation willingly, and there was no evidence that anything other than one resident comforting another was occurring. The administrator concluded that because resident 33 has cognitive impairment and a history of engaging socially with others in a well-meaning manner, a reasonable conclusion would be that his actions were non-threatening and likely friendly in nature. The administrator stated no negative impact was observed or reported with resident 27. Both residents were acting at baseline after the incident occurred. An intervention of showing resident 33 to his room after dinner was put into place. Resident 27’s family member was interviewed and stated she had walked into her mother’s room and observed resident 33 standing next to resident 27 with his hand on her shoulder and arm. Resident 27’s family member stated she had not seen any inappropriate touching, but she had walked resident 33 out of the room and he left without hesitation. Resident 33 did not remember the incident and resident 27 was unable to say anything about the incident either. Neither resident showed any signs of distress. On 8/6/25 at 11:08, an interview was conducted with CNA 1 who stated she believed the medical director conducted assessments on the residents to determine their capacity to consent to sexual activity. 3. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia with mood disturbance, anxiety disorder, and mood disorder due to known physiological conditions. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment. Resident 31’s progress notes documented the following: a. On 6/25/25 at 9:03 AM, an Encounter Note documented that resident 31 was assessed using the St. Louis University Mental Status Examination (SLUMS) test and she scored 4 out of 30, suggesting dementia. The physician believed that a memory care unit was appropriate for her as far as her safety. Resident 31 was having episodes of agitation as well as crying periods because she did not know what was going on and did not understand why she was in the facility. b. On 6/25/25 at 7:18 PM, a Nursing Progress Note documented that resident 31 was removed from a male resident’s room and later that day she was found in another resident’s room with a male resident “in very close proximety [sic]”. c. On 6/26/25 at 5:19 PM, a Nursing Progress Note indicated, “Resident was found with a male resident in the residents room. A CNA walked in and found them sitting on the bed kissing. They were holding hands It appeared to be consensual. I talked privately with both residents and made sure they were both consenting and that is what they wanted to do. it was confirmed by both residents that they consented. I notified both families and they both gave their permission as long as the residents felt good about it. I tried to redirect them but they continued to be with each other. encouraged resident's to stay in public spaces. We will increase observation at this time.” d. On 6/26/25 at 9:16 PM, a Nursing Progress Note indicated, “CNA [name redacted] walked into male resident’s room to find him and [resident 31] both undressed. Male resident was sitting on his bed while [resident 31] was kneeling on floor by his groin. Both residents appeared happy and acting upon mutual consent. No signs of struggle. Both residents asked CNA to leave the room. CNA asked them to get dressed, and they complied. Both residents were interviewed and stated that they were not forced into anything, they enjoyed each other’s company and they both got undressed willingly. They both stated that they feel safe. Resident’s daughter [name redacted] notified of incident and she stated that her biggest desire was for her mom to be happy and safe. She stated that she felt her Mom was able to consent, and she had no concerns about the incident. She stated that her mom has been single for 20 years and it is good for her to have some companionship. administrator [name redacted] notified.” e. On 6/28/25 at 1:39 AM, a General Note documented that resident 33 was seen exiting resident 31’s room. Resident 31 was observed to be sleeping and not aware that resident 33 had been in her room. f. On 6/28/25 at 3:59 PM, a Nursing Progress Note documented that resident 31 was seen being affectionate with resident 33 by holding hands and kissing in private. g. On 7/8/25 at 6:45 AM, a Nursing Progress Note documented that resident 33 was found curled up in bed with resident 31 that morning. No documentation could be located in the medical record where resident 31 had been evaluated for the capacity to consent to sexual activity. 4. A. Resident 11 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, cerebral infarction, aphasia, anxiety disorder, unspecified intellectual disabilities, and depression. On 3/26/25 at 9:13 AM, a complaint was called into the State Survey Agency (SSA) by an Adult Protective Services (APS) investigator. The APS investigator stated that they received a report that resident 11 was sexually assaulted by a fellow resident [resident 49]. The APS investigator reported that on 3/14/25 a CNA was checking on resident 49 and found him with his pants down on top of resident 11 and was attempting to initiate sexual contact. On 8/5/25, the facility abuse investigation documentation was reviewed. No documentation could be found of an investigation into the incident between resident 11 and resident 49 on 3/14/25. On 8/5/25, Resident #11's medical records were reviewed. On 3/9/25, resident 11’s admission MDS assessment documented that a BIMS was not conducted due to the resident being rarely/never understood. The assessment documented that the resident 11 had short-term memory (STM) and long-term memory (LTM) deficits. The assessment documented that resident 11 was not able to recall the current season, the name and faces of staff, and if they were in a nursing home or hospital. The assessment documented that the cognition skills for daily decision making was moderately impaired. The assessment documented that resident 11 had behavioral symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming and disruptive sounds and the behavior that occurred 1-3 days. Resident 11’s progress notes documented the following: a. On 3/6/25 at 10:30, the note documented, “Resident is pleasant and alert x 1[self]. She has a tbi [traumatic brain injury] and roams around. She has a short attention span & aphasia from stroke. no s/s [signs and symptoms] of pain. She is ambulatory without assistance. She has a good appetite.” b. On 3/15/25 at 10:10, the Nursing Progress Note documented, ”This nurse notified [name omitted], sister of resident, as she was the first one to answer the phone. Discussed with [name omitted] the encounter between resident and male resident the previous day. Sister confirmed she knew about encounter. Sister expressed that resident had encounters of that nature in previous setting. Family was not concerned about resident or encounter. MD [Medical Doctor] will see resident on next visit day. Family would like referral to OB/GYN [obstetrician/gynecologist] for possible birth control and/or ablation if preferred.” On 9/17/24, resident 11’s PASRR Level II documented a motor vehicle accident at age 9 which resulted in a TBI and stroke. Family reports an emotional age equivalent of nine, but she does present as younger with some items (i.e. wandering and getting lost in her own neighborhood), and older with others.… She did attempt to work at Deseret Industries for a time, but she did not do well in this setting and ended up being impregnated by another employee Following her TBI, [Resident 11] has been unable to independently manage hygiene tasks. ‘You have to stay on top of it all the time, or she won’t do it at all.’ [Resident 11] has no concept of money, how to manage it, count change, etc. Because of this, family has always managed her finances. [Resident 11] cannot shop alone, and requires supervision for this ADL [Activities of Daily Living] Safety awareness is quite poor, and [Resident 11] would be considered highly exploitable.… Informed decision making is impaired, as is her ability to learn and apply new information Following her TBI, she is no longer able to recognize when she is full. Because of this, she will often eat to the point of vomiting. She is also noted to sneak food in her bra (i.e. cookies and bread), and will add inappropriate food to daily meals (i.e. putting non salad items in a salad). [Resident 11] is often attention seeking and will claim others have raped her. When upset, [Resident 11] will ‘throw tantrums,’ yell, scream, hit, scratch, and throw items at others. She also takes items which do not belong to her, and will wander from the home and become lost. For this reason, she is currently in a memory care unit in the nursing home setting. Family report [Resident 11] is having conflicts and physical altercations with other residents, and that she is taking other resident’s belongings (other residents are also taking her belongings). If she feels left out of an activity (i.e. missing a visit from Santa Clause, not getting flowers for Mother’s day, etc.), she will often yell and scream.” The assessment determined that resident 11 required “Specialized Services” for an intellectual disability. No documentation could be found to demonstrate that resident 11 had been evaluated for the capacity to consent to sexual activity. B. Resident 49 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, anoxic brain damage, chronic viral hepatitis, delusional disorders, psychotic disorder, major depressive disorder, opioid abuse, anxiety disorder, unspecified mood disorder, and antisocial personality disorder. The resident was discharged from the facility on 5/29/25. Resident 49’s medical records were reviewed. On 3/7/25, resident 49’s Quarterly MDS assessment documented a BIMS score of 3/15, which would indicate severe cognitive impairment. The assessment documented that resident 49 had difficulty focusing attention, being easily distractible or had difficulty keeping track of what was said. On 8/16/22, resident 49’s PASRR Level II documented that the resident had an anoxic brain injury/TBI that resulted from a heroin overdose that required resuscitation. The assessment documented that resident 49 had poor short term memory as a result of the anoxic brain injury. “He is very impulsive with no insight into his medical conditions and needs. He currently requires extensive assistance with all ADLs including dressing, grooming, toileting, bathing and medication management. The assessment documented that resident 49 was referred for a PASRR Level II due to a history of antisocial personality disorder, depression and anxiety. “Pt [patient] reports that he has struggled with poor mood and anxiety since the TBI. Prior to the TBI he had significant substance use concerns but does not recall episodes of significant depression/anxiety prior to the TBI. History is limited d/t [due to] pt’s inability to recall past or recent events. Pt does have an extensive legal history with past assaults and prison/jail time d/t assault and drug use/possession.” The assessment documented under current psychiatric functioning when resident 49 was asked about his mood he stated, “I need something…I’m emotionally disturbed.” The assessment documented that resident 49 may benefit from medication management, neurological testing and ongoing psychiatric care. No documentation could be found to demonstrate that resident 49 had been evaluated for the capacity to consent to sexual activity. On 8/05/25 at 1:11 PM, a telephone interview was conducted with the APS investigator who was the complainant. The APS investigator stated that she had a report of a sexual abuse incident between resident 11 and resident 49 from a staff member at the facility. The APS investigator stated she investigated and found that both residents were cognitively impaired. The APS investigator stated that her biggest concern was that they did not separate the residents after the incident occurred and they were still located across the hallway from each other when she went to the facility. The APS investigator stated that the Admin reported that resident 11 was very vocal when she liked something and could follow directions and that was their rationale for the incident being consensual. The APS investigator stated that resident 11’s guardian acknowledged that both resident 11 and resident 49 were cognitively impaired, but were under the impression that resident 49 had been moved away from resident 11 for safety. On 8/6/25 at 1:04 PM, an interview was conducted with the DON. The DON stated that resident 11 was able to understand questions and could respond with “good, good”. The DON stated that resident 11 could respond to questions with yes/no answers, and she had both STM and LTM deficits. The DON stated that resident 11 had verbal outburst, would clap her hands aggressively, yell, and curse. The DON stated that resident 11 would say “[NAME] mad, [NAME] mad, mad” and she would know to ask her to show her what was bothering her. The DON stated that resident 11’s developmental level would be contained in the PASRR. The DON stated that she recalled the incident of resident 11 lying in resident 49’s bed. The DON stated that the Admin conducted the abuse investigation. The DON stated that from what she recalled resident 11 was lying in resident 49’s bed but there were no signs of penetration. The DON stated that this incident of sexual activity was something that should have had an abuse investigation, and the State Survey Agency (SSA) should have been informed within 2 hours of the incident. The DON stated that this incident should have also been reported to the police department within 2 hours of the incident and she did not believe it was ever reported to the police. The DON stated that resident 49 was oriented to person and had episodes of confusion. The DON stated that resident 49 had both STM and LTM deficits. The DON stated that resident 49 would not be able to problem solve, reason or understand risks. “He was impulsive and don’t believe he would think of those things.” The DON stated that the criteria for determining a resident’s capacity to consent to sexual activity was based on their BIMS score and consultation with the provider. The DON replied “no” when asked if resident 11 had the capacity to consent to sexual activity. The DON stated they determined that resident 11 lacked the capacity to consent to sexual activity after discussing it with the provider. The DON stated that they did not have any documentation of the capacity to consent assessment for resident 11. On 8/6/25 at 2:38 PM, a follow-up interview with the DON. The DON stated that she reviewed resident 11 and resident 49’s MDS assessments and determined that both residents had the same cognitive level. It should be noted that resident 49’s BIMS score of 3 determined a severe cognitive impairment and resident 11 did not have a BIMS assessment completed. The DON stated that resident 11 was able to determine if she wanted to do something or not and could say yes or no. The DON stated that she discussed the incident with the Administrator and it was not reported to the State Survey Agency (SSA). The DON stated that the decision to not report the incident to the SSA was based on the resident’s having the same cognitive level and ability to consent. The DON stated that the ability to consent was based on day to day interactions with the residents. On 8/7/25 at 9:25 AM, a telephone interview was conducted with CNA 6. CNA 6 stated that on 3/14/25, when they came on shift the resident 11 was in the dining room in an activity and resident 49 was in his room. CNA 6 stated that during dinner service, after 4:00 PM, she realized that they had not seen either resident for approximately 10 minutes. CNA 6 stated that she entered resident 49’s room with CNA 5 and CNA 11. CNA 6 stated that when they entered the room resident 11 was lying on the bed and resident 49 was lying on top of her. CNA 6 stated that resident 49 had his pants down and resident 11’s underwear was down exposing her genitals. CNA 6 stated that from her viewpoint she could see both residents genitals and could see resident 49 actively trying to penetrate resident 11’s vagina with his penis. CNA 6 stated that she believed no penetration occurred but there was skin to skin contact. CNA 6 stated that resident 11 was not talking to them and appeared to not be aware that they were talking to her. CNA 6 stated that resident 11’s communication was limited due to her TBI but she would repeat phrases, could say yes or no, nod head yes or no, and give a thumbs up. CNA 6 stat[TRUNCATED]

Based on interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents. Specifically, for 6 out of 32 sampled residents, three residents with cognitive impairment eloped from the facility, this was at an immediate jeopardy level for two of these residents. A resident was not secured in a facility van and suffered a head injury, this was at a harm level. Two residents experienced falls with no interventions put into place and one resident had injuries of unknown origin. Resident identifiers: 7, 11, 12, 36, 42 and 47. NOTICE On 8/12/25 at 2:30 PM, IJ was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to ensure that each resident received adequate supervision to prevent accidents, specifically elopement. Notice of the IJ was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/13/25 at 10:47 AM, the Administrator provided the following additional abatement plan for the removal of the IJ effective on 8/13/25 at 11:59 PM. All residents, with a history of elopement attempts will be supervised at all times when they are outside of the community. All residents with elopement risk assessments were reviewed and updated as necessary on 8/12/25. Any residents at high risk for elopement will have their care plans updated to reflect interventions to reduce the risk of elopement. The three doors that exit the community will be monitored by a staff member at all times until the egress doors are either secured by badge system or fence installation. Moving forward all allegations of mistreatment, abuse, neglect, exploitation, elopement or other reportable incidents, will be thoroughly investigated per the following: 1. Reporting Responsibilities; 2. Reporting Decision Tool; and 3. Incident Reportability Algorithm. Any incidents of elopement will be reviewed by the QAPI Committee on a monthly basis and recommendations will be implemented. On 8/14/25 while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 8/13/25 at 11:59 PM. IMMEDIATE JEOPARDY ELOPEMENTS 1. Resident 36 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage with loss of consciousness, pain, generalized anxiety disorder, major depressive disorder, bipolar, and personal history of suicidal behaviors. On 8/5/25 from 9:00 AM until approximately 10:30 AM, an observation was made of the west door. A walkie talkie on the nurses cart was observed to be alerting that the west door was alarming. No staff were observed to look at the door or go out the door to look for residents. Resident 36’s medical record was reviewed 8/4/25 through 8/20/25. Resident 36 had a BIMS (Brief Interview for Mental Status) completed on 7/31/25 which was 4 out of 15 which indicated severe cognitive impairment. Resident 36 had a MOCA (Montreal Cognitive Assessment) completed on 7/15/25 which was 7 out of 30 which indicated severe cognitive impairment. On 11/19/24, resident 36’s elopement assessment documented that the resident had no history of wandering, could follow instructions, could communicate and had a medical diagnosis of cognitive impairment. Resident 36 scored low risk for elopement. On 1/24/25, resident 36’s quarterly elopement assessment documented that the resident had a history of elopement and had wandered off the grounds. The elopement assessment score was 35, which would indicate a high risk for elopement. Progress notes revealed the following: a. On 11/22/24 at 10:33 AM, a physician progress note documented, “ .This is my initial assessment. He is now currently blinded in both eyes due to his self-inflicted gunshot wound to his head…” b. On 12/9/24 at 6:00 PM, the note documented, “resident attempted to elope by climbing a tree. he was on the fence saying he wanted to leave and be put in ‘jail instead of stay here.’ the staff got him down, but he is refusing to come inside. we got a prn [as needed] order from [provider] for ativan, but resident is refusing to take it.” c. On 12/14/24 at 7:00 PM, the note documented, “Doorbell to front door rang, nurse answered door and wife and resident were standing there. Wife stated she brought resident back and reported he had walked all the way home. Patient was wrapped in a blanket. Resident told nurse he broke through the fence because he had to get home. Resident stated he was mad because his wife wasn't answering the phone and he had to leave.” c. On 12/15/24 at 5:33 PM, the note documented, “Resident was trying to break down the fence in the backyard to ‘get out of this place’. he was unsuccessful. staff tried to talk to him and get him to come back inside but he refused. staff stayed with him and called his wife [name redacted], she came down and wasable [sic] to calm him down and get him to come inside. Resident then apologized to staff for his behavior. currently in a pleasant mood and stated that he won't try to break out of the building tonight. His wife said she will come visit him again tomorrow. Administrator [name omitted] notified.” d. On 1/25/25 at 11:46 AM, the note documented, “resident escalated and was shoving the fence so hard that it took five staff to hold the fence latch. family were called and they tried redirecting him with no success. [Medical Doctor] was called and after he tried redirecting him with no success he ordered haldol 5mg [miligram] IM [Intramuscular injection] injection. this was given in the left gluteal muscle. he is now in his room in a recliner with an aid by his side.” e. On 1/26/25 at 7:08 PM, the note documented, “Pt [patient] was calm in the a.m [morning] took all meds willingly including Ativan. By late afternoon pt became very agitated insisting he was leaving and went outside and was climbing over the fence. 2 cna's [Certified Nursing Assistant] were able to assist him down. pt made several attempts over a 2 hr period when validation and redirecting weren't effective, IM Haldol 0.5mg given with results after an hour pt finally came back inside and is resting in his bed at this time. Report given to noc [night] nurse on incident.” f. On 4/12/25 at 6:34 PM, the note documented, “Rsident [sic] found outside after knocking down fence. resident walking down street cna saw resident and notified nurse.” g. On 5/30/25 at 5:30 PM, the note documented, “Resident was found outside down the street a little way after apparently escaping through the fence after trying to break the fence down.staff was with him and trying to get him to come back when he broke through it. Resident reported he was trying to go home and that is why he was doing that. I was told that he was trying to go home so I asked him why he was trying to get home. He just said he was tired of being here. I tried calling his wife but she didn't answer. I notified the Dr. and administration. We took his vitals and they were within normal limits.” h. On 7/6/25 at 9:30 PM, the note documented, “Resident alert and oriented kicked fence out and eloped.Father and administration notified, 911 notified was told police offier [sic] was on his way back with resident.” i. On 7/7/25 at 5:35 PM, the note documented, “At 1640 [4:40 PM] CNA [Certified Nurse Assistant] noted that [resident 36] was outside and wanted to make sure that we all could keep an eye on him as he has a history of trying to elope. He then began to try to take apart the fence. I asked what he what his plan is and why he was wanting to leave. He stated to go home and talk to his wife, i offered to help him contact his wife and other interventions. Myself and 3 other people attempted to intervene, and redirect, and attempted to tell him that it was unsafe for him and other residents, to have this fence broken, he continued and stated that he does not care that it is unsafe. Eventually he took the panels apart and stepped on the retaining wall. He then jumped down the wall…. He then walked directly into the road and myself and [Director of Rehab] had to take him by the arms so that he did not walk into traffic, I repeated that with his very limited vision this was very unsafe and you are putting yourself and us in danger. We were able redirect to walk on the sidewalk but he just kept repeating that he was walking home.” Note: The facility only reported the 7/7/25 incident to the State Survey Agency. On 12/25/24, a care plan for risk for elopement related to impaired cognition due to traumatic subdural hemorrhage was initiated. The interventions identified on the care plan included: allow resident to verbalize feelings, initiated on 7/6/25; answer call light promptly, initiated on 12/15/24; anticipate resident's need and ensure needs are met, initiated on 7/7/25; check on resident every 15 minutes, initiated on 4/13/25; distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, initiated on 4/13/25; educate all staff on resident's elopement risk and specific behaviors/triggers such as family unavailable for phone calls, initiated on 4/12/25; Memory care unit, initiated on 5/30/25; monitor for signs and symptoms of pain or discomfort, 12/15/24; orient and reorient on an ongoing basis, initiated on 3/20/25; and re-educate resident regarding safety and risk of leaving, initiated on 12/15/24. On 8/11/25 at 12:45 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that when a resident was missing from the facility they attempted to locate them. RN 4 stated that resident 36 was found further down the street and they had to call 911, at his father’s prompting, to get the resident back to the facility. RN 4 stated that the aide reported seeing resident 36 last at 8:30 PM, and they identified he was missing at 9:00 PM. RN 4 stated that resident 36, “breaks the fence” and “usually he's just down the street a little ways”. RN 4 stated that resident 36 had approximately 3 elopements where he had exited the facility. RN 4 stated that resident 36’s room was located next to an exit door to the locked courtyard and that the resident could go into the courtyard at any time. RN 4 stated that when resident 36 eloped they just went and found him and made sure he came back to the facility. RN 4 stated that she was not aware that staff had to step in front of him to prevent him from going into traffic. RN 4 stated that interventions to prevent elopement were to “keep a close eye on him, talk to him a lot so he doesn't want to leave.” RN 4 stated that usually when resident 36 gets upset, he wants to leave. RN 4 stated that resident 36 was going through a divorce so he got upset. On 8/12/25 at 1:19 PM, an interview was conducted with the Administrator (Admin). The Admin stated the investigations were primarily done by talking with the nurses and looking into the events. The Admin stated they did a formal investigation on 7/6/25 for resident 36. The Admin stated he wasn’t totally aware of the elopement section of the reportable so because of that not being clear, he didn’t report them. The Admin stated because resident 36 was with a staff member they didn’t report the elopements. The Admin stated he did not report or investigate the incidents for resident 42 or report them to the state. The Admin stated that yes, these incidents should have been investigated and reported to the state survey agency. 2. Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of vascular dementia with agitation anxiety disorder, psychotic disorder with delusions, and depressive disorder. Resident 42’s medical records were reviewed between 8/4/25 and 8/20/25. Resident 42 had a BIMS completed on 3/2/25 which was 3 out of 15, which indicated severe cognitive impairment. Resident 42 had a MOCA completed on 12/13/24 which was 13 out of 30, which indicated moderate cognitive impairment. An elopement assessment dated [DATE] revealed that resident 42 had no history of wandering and was considered a low risk for elopement. An admission Elopement assessment dated [DATE] categorized resident 42 as low risk, with no history of wandering and had not wandered since admission to the facility. No other elopement assessments were found in resident 42’s medical records. Resident 42’s care plan included, “Elopement: The resident is an elopement risk r/t [related to] vascular dementia, history of wandering/getting lost.” Approaches to the care area included: Complete wander risk assessment on admission and at least quarterly. Wander risk is: (specify: High, moderate, low) Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (none listed) Identify pattern of wandering: is it purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Orient and reorient on an ongoing basis. Place resident near nurses station to monitor. The goal for this care area was that the resident would not leave the facility unattended through the review date. Initiated 2/26/25. A review of resident 42’s progress notes revealed, on 3/12/15 at 5:29 PM,“CNA asked for help outside, as resident had jumped the fence out back. CNAs caught up with resident and escorted him inside. He is now kicking the front door and demanding to get out. Called guardian to make her aware - no answer, left vm [voice mail]. Spoke with DON - said go ahead and send him out. Called for EMS [emergency medical services].” An incident report dated 3/12/25 revealed, “Resident was seen attempting to climb the fence. Before CNA could get him, he hopped over. Once back in the facility, resident began kicking the front door, demanding out.“ The resident left the facility at 5:25 PM. The CNA’s caught up with the resident and were able to walk him back into the facility without issue. Orders were received to send the resident out to evaluate for possible UTI (urinary tract infection). Staff called EMS and the resident left the facility at 5:50 PM. An incident report dated 5/10/25 revealed, “Resident stepped on wood beside fence to climb over fence found outside alert and walking without difficulty. Skin tear to right forearm. New orders placed. Area cleaned with wound cleanser. Steri-strip applied with monitor for 7 days. No bleeding at site.” The resident stated, “I went over the fence.” It should be noted that no progress note was found regarding the incident on 5/10/25. No documentation could be found to indicate that resident 42's elopements were investigated and reported to the State Survey agency. On 8/4/25, at 7:15 AM, an observation was made of west outside door alarming frequently about every 5 minutes. During that time, there was nobody observed entering or exiting the west door, nor was there anyone observed to be near the west door. On 8/4/25 at 8:58 AM, an interview was conducted with RN 6 who was in the west hallway, regarding the alarm. RN 6 stated the alarm was to alert staff when a resident entered or exited the west door. At approximately 9:20 AM, the west door alarm stopped alarming completely and was not heard the remainder of the day. On 8/5/25 at 8:00 AM, a resident was observed exiting the west door and west outside door was heard. Shortly thereafter, the resident was observed re-entering the door, but there was no alarm when the door was opened. On 8/11/25 at 10:00 AM, west outside door was observed to be alarming, then again at 10:02 AM, again at 10:04 AM, again at 10:05 AM, again at 10:06 AM, again at 10:07 AM, again at 10:08 AM, Five doors were visualized, 2 in the dining room, 1 on the west hallway, 1 on the east hallway, and the door to the foyer and main entrance. No staff were near any of the doors, or looking at any of the doors to see if someone was entering or exiting. None of the doors opened during this time. All staff made no signs of noticing the alarm. Again at 10:10 AM, west outside door was heard with no staff response. On 8/12/25 at 8:37 AM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated resident 36 and resident 42 had eloped. The MDSC stated that when an elopement occurred, staff would get on the radio and let other staff know, follow the resident and notify the administration, and get the police involved if it was necessary. For resident 36, she stated they have reinforced the fence so he was unable to disassemble it and cannot push the panels through and they are very selective about who they admit to the facility. She stated all the staff know who have the tendencies to wander and keep an eye out for them and where they are. They look outside, and look for residents who are pacing. She stated they monitor any residents who can ambulate and can go outside on their own. She stated 15 minute checks were done for 72 hours and then the resident was re-assessed depending on the circumstance. If the provider needed to get involved, or labs needed to be drawn, they determined what needs to be done next. Elopements were documented in the risk management and in the progress notes. They would also be documented in the physician notes. The west door alarms when anyone goes out, and continues to alarm until someone clears it. Someone was required to go outside and see who went outside. When staff unlock the front door they are supposed to stand there until the person enters or exits and make sure the door was completely closed and locked before they leave. Staff in-services are provided depending on what happens during the month. They also do huddles for what happens in the week and focus on occurrences and remind staff about what things need to be focused on. Residents are assessed for wandering and elopement on admission. If she witnesses a resident elopes she would follow the resident and request another resident to come and help. She would notify the other staff and administration. The MDSC stated that if she was notified that there was an elopement, she would take the role of making sure the residents at the facility remained calm and cared for while the others were taking care of the elopement. She stated she did not know what a code [NAME] was, but could get back to me on that. She stated the IDT (Interdisciplinary) team updated the care plan, and that she was the primary person as the MDS coordinator. She reports elopements to the administration, meaning the DON and the administrator. FALLS: Resident 42's progress notes and incident reports revealed the following: On 3/19/25 at 2:25 PM, a nursing progress note revealed, “nurse called into the dining room and was found that resident was on the floor. It was reported that he hit his head. Neuro checks were initiated immediately. Vital signs within normal limits except for blood pressure being low. Pushed 500 ml [milliliters] oral fluids. He has no complaints of pain. Has been restless today and trying to stand over and over. Has sat himself on the floor several times before this fall.An incident report dated 3/19/25 at 12:30 PM, described the incident documented in the progress note. Action taken: neuro checks, vital signs, physician and POA [power of attorney] notified. No injuries were observed at time of incident. The resident was described as being confused.Resident 42’s care plan was not updated after the fall on 3/19/25. On 8/5/25 at 7: 05 PM, a nursing progress note revealed, “Resident stood up from chair in dining room and fell. Staff called for nurse, resident did not hit his head. Obrain [sic] vitals, resident was hypotensive. Assessed for injuries-none found. Resident appeared drowsy but was responsive to verbal commands. Helped resident get up and assessed gait and steadyness [sic]. Resident was taken to his room to lay down in bed. Guardian notified.”Resident 42’s care plan was not updated after the fall on 8/5/25. On 8/10/25 at 3:42 PM, a nursing progress note revealed, “Staff was notified that resident was trying to step up onto window ledge in dining and lost his balance and fell. Unable to say if he hit his head. Assessed for injuries with none noted. Vitals taken and baseline for resident. Neuros started. Hospice, DON [Director of Nursing], and Admin [Administrator] notified.”Resident 42’s care plan was not updated after the fall on 8/10/25. On 8/14/25 at 11:43 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4 who stated resident 42 was a high fall risk. LPN 4 stated most of the precautions in place had come from the hospice company caring for resident 42, such as the fall mat next to his bed, ensuring his room is clear of fall hazards. LPN 4 stated resident 42’s blood pressure medications had been discontinued and his blood pressure had improved. LPN 4 stated staff help resident 42 walk to and from meals, and help him sit down and stand up. LPN 4 stated resident 42 was at risk for dehydration so his fluid intake was monitored. On 8/20/25 at 1:39 PM, an interview was conducted with the Director of Nursing (DON) who stated interventions should be in the care plan related to the falls on 8/5/25 and 8/10/25. The DON stated the staff try to intervene with resident 42 as much as he will allow them to. The DON stated that resident 42 will swing at staff if he does not want assistance, and would also pinch staff. The DON stated staff make sure resident 42 does not need anything. The DON stated sometimes resident 42 was ambulatory and sometimes he would eat by himself. The DON stated that to prevent falls for resident 42 right now staff were addressing his needs, assisting with toileting, addressing pain, monitoring agitation, keeping his bed in the lowest position, and prompting him to attend activities. The DON stated staff were tag-teaming resident 42 in the dining room to intervene quickly. The DON stated at the end of the alert charting assessment period, the IDT would meet and talk about what interventions should be for the recent fall, then the interventions are discussed in a staff huddle so all staff are aware of the new intervention. The DON stated the DON IT (Director of Nursing In Training) was going to investigate resident 42’s recent falls and put interventions into the care plan, they may just not have been put in yet. HARM 3. Resident 7 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, type II diabetes, peripheral vascular disease, and chronic pain syndrome. Resident 7’s medical record was reviewed from 8/4/25 through 8/20/25. A Facility Reported Incident (FRI) documented, “on 02/14/2025 at 10:45 am, the facility reported that on 02/12/2025 at 2:10 pm, [Plant Operations 2] who was taking resident 7 to a dr. appointment didn't properly secure front straps to the wheelchair and resident 7 picked his legs up and tipped backward. The Resident has a abrasion to back of head. Education given to [Plant Operations 2] and more training given.” A progress note dated 2/11/25 revealed, “during transport to dialysis, resident reportedly fell out of his chair hitting his head and back. then transport pulledover [sic] and turned hazards on and got out of the van. grabbed chuck then put him back in his chair and buckled him back. Tookhim [sic] to his appointment then reported the incident to the nurses at the dialysis place. then when transport came back 15minutes later, reported it to the nurses here. neuro checks initiated at 1600. first vital signs back to the facility after return was103 [sic], 100/64, 18, 95%, 96.5. no pain verbalized upon arrival.” A progress note dated 2/14/25 revealed, “The resident complained of pain in his head, neck, spine and back so I called the MD [medical doctor] and he ordered XRay of Skull, XRay of Neck, XRay of Cervical, thoracic and lumbar spine STAT [immediately].” … “The XRays came back and {provider] was sent the XRay results. He said there was no current acute problems. Everything looked fine. Continue treating with Tylenol for pain as needed.” A quarterly Minimum Data Set (MDS) dated [DATE] documented resident 7 was a partial assist with mobility and used a wheelchair and walker for mobility. On 8/4/25 at 9:00 AM, an interview was conducted with resident 7. Resident 7 stated that he had been in an accident in the facility van about 9 months ago. Resident 7 stated that Plant Operations 2 forgot to buckle his wheelchair into place and when the van moved forward resident 7 fell backward, his feet went up into the air and he hit his head on the ramp. Resident 7 stated he got a sore on the top of his head but he did not remember if there was pain or if he had an x-ray completed. Resident 7 stated it was an accident and it never happened again. On 8/14/2025 at 10:25 AM, an interview was conducted with Plant Operations (PO) 2. The PO 2 stated he was no longer an employee at the facility but he did remember the incident with resident 7. PO 2 stated he had transported resident 7 to dialysis and had forgotten to secure the wheelchair after he put it in the van. PO 2 stated he was in charge of transporting the residents to medical appointments and that the facility did do verbal education on how to secure the wheelchairs in the vans but there was no demonstration. PO 2 stated there were these anchors in the floor and you would lock the tires with the brakes, then you would put the anchors from the floor onto the wheelchair and tighten them and then you would put a seatbelt across the resident. PO 2 stated there were 2 anchors in front and 2 anchors in the back and the lap belt would go under the arm rests and over the resident. PO 2 stated you did not anchor to the tires because they could roll but you would anchor to a secure spot that you could find on the wheelchair. PO 2 stated the residents were facing forward in the van so he could see their face in the mirror. PO 2 stated when he first started working at the facility he did not hook the front anchors and that was when resident 7 rolled and hit his head. PO 2 when he started to drive he looked in his rearview mirror and saw resident 7's feet in the air. PO 2 stated after it happened he pulled over to the side of the road and got resident 7 sat back up. PO 2 stated that resident 7 had a sore on the top of his head but he seemed ok. PO 2 stated he got resident 7 buckled in and took him to dialysis. PO 2 stated he told the dialysis staff to watch resident 7 and then he told the nurse at the facility what had happened when PO 2 returned. PO 2 stated he did not call anyone to come have resident 7 assessed since it was not that big of an injury. PO 2 stated the facility does training that if a resident falls at the facility we are not supposed to move them in case they have hurt their head or have a spinal injury but that did not count when we are in the van. PO 2 stated after the incident we did another training on how to secure the wheelchairs properly. This time they taught me that I needed to secure all 4 points, not just some of them. I can't remember if they taught me that the first time was too long ago. PO 2 stated it was an accident. On 8/14/2025 at 8:42 AM, an interview was conducted with PO 1. PO 1 stated his job was to drive residents to their appointments. PO 1 stated that they had a van that they put the chair in and they had a straps, 2 in the front and 2 in the back, to tie it down. PO 1 stated the residents were usually facing forward when they ride in the van. PO 1 stated resident 7 usually sits up front in the passenger set of the van with a seatbelt. PO 1 stated they did train him on how to secure wheelchairs into the transport van before he started to do it. On 8/18/2025 at 10:05 AM, an interview was conducted with the DON. The DON stated the process for transportation was before they drove any residents they received education on how to put the residents into the van, how to lock them down, how the locking mechanisms and the seatbelts work and all of those things. The DON stated she could not be sure but she believed PO 2 had received the information. On 8/18/2025 at 2:16 PM, an interview was conducted with the Admin. The Admin stated they educated PO 2 prior to him transporting resident 7 but they do not have any documentation of it. The Admin stated they did more education after the incident and went out to the van and demonstrated how to secure a resident the correct way. The Admin stated that it should not have happened but it did. [NAME] stated the transporters were all educated on how to transport the residents. The Admin stated if there was an accident the staff are supposed to call for assistance and get the resident evaluated. A document titled, Facility Driver Orientation Checklist” was provided by the facility on 8/6/25. The checklist was not filled out or signed by the PO 2. A document titled, “Safe Transport of Residents” with a date of 2/18/25 was signed by PO 2. Please note this document was signed after the incident occurred with resident 7. POTENTIAL FOR HARM 4. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included alcohol dependence with Korsakoff Syndrome, alcohol-induced persisting amnesic disorder, mild dementia with agitation, major depressive disorder, psychotic disorder with delusions, altered mental status, and seizures. On 8/19/25 at 11:27 AM, an observation was made of resident 12 in his room. Resident 12 was laying on a mattress on the floor next to his bed with his limbs hanging over the edges. No staff were observed in his room or in the hallway. After staff were notified of resident 12’s position by surveyor, a Certified Nurse Assistant (CNA) was observed to go into his room at 11:31 AM. Resident 12's medical record was reviewed from 8/4/25 through 8/20/25. An Annual MDS dated [DATE] indicated a BIMS could not be conducted because the resident was rarely/never understood. It further indicated a short and long-term memory problem and Cognitive Skills for Daily Decision Making was Severely impaired. It further indicated resident 12 had impairments to both sides of his upper and lower extremities, required substantial/maximal assistance to roll left and right in bed, was dependent to transfer from bed to chair, and was dependent on staff to use his manual wheelchair. A Nursing Progress Note dated 5/2/25 at 2:19 PM indicated, “resident rolled unto [sic] fall mat next to bed. no injuries noted. denies pain at this time. smiling and saying ‘i love you’ over and over. assisted him back into bed with a three person transfer. is resting comfortably in bed”. An Alert Charting document dated 5/10/25 at 1:00 AM indicated, “resident found in between bed and wall. resident did not sustain any injuries. resident was helped back into bed and neuros were initiated. Interventions to ensure brakes are initiated and ensure proper body positioning.” An Incident Report dated 7/3/25 at 10:00 PM indicated, “Resident found by cna lying between mattress and wall”. A Nursing Progress Note dated 7/9/25 at 2:14 PM indicated, “Resident found by cna lying betweenof [sic] beds and wall mattresassisted [sic] to bed,[sic] , neuro == xhecks [sic] started , appropriate administration notifed [sic], [medical doctor name redacted] notified assured wheels to bed are locked properly”. A Nursing Progress Note dated 7/14/25 at 11:14 AM indicated, “Resident fouond [sic] lying on flo[TRUNCATED]

Based on observation, interview and record review the facility did not ensure, 9 of 32 sampled residents, were free from abuse and neglect. Specifically, multiple residents with cognitive impairment were identified to have sexual contact and were not assessed for capacity to consent to a sexual relationship. In addition, 2 residents eloped from the facility and were returned to the facility without the staff's knowledge. These examples were cited at an Immediate Jeopardy level. Resident identifiers: 11, 21, 25, 27, 31, 33, 36, 42 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to prevent various forms of abuse. Notice of the IJ in Abuse was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/8/25 at 4:46 PM, the Administrator provided the following abatement plan for the removal of the Abuse IJ effective on 8/8/25 at 11:59 PM. The community would add sexual abuse to the revised Abuse Policy and Procedure, all staff would be educated by a LCSW (Licensed Clinical Social Worker) on resident intimacy and sexuality guidelines, the revised policy and the sexual intimacy capacity for consent assessment prior to the next shift worked. QAPI (Quality Assurance and Performance Improvement) will review the revised Abuse Policy and Procedure, all allegations and abuse packets will be reviewed by the QAPI Committee weekly for the next 3 months and any identified concerns will be addressed by said committee. However, the IJ could not be abated based on additional findings of neglect, specifically elopement. On 8/12/25 at 2:30 PM, IJ was again identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to prevent various forms of neglect. Notice of the IJ in neglect, specifically, elopement, was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/13/25 at 10:47 AM, the Administrator provided the following additional abatement plan for the removal of the IJ effective on 8/13/25 at 11:59 PM. All residents, with a history of elopement attempts will be supervised at all times when they are outside of the community. All residents with elopement risk assessments were reviewed and updated as necessary on 8/12/25. Any residents at high risk for elopement will have their care plans updated to reflect interventions to reduce the risk of elopement. The three doors that exit the community will be monitored by a staff member at all times until the egress doors are either secured by badge system or fence installation. Moving forward all allegations of mistreatment, abuse, neglect, exploitation, elopement or other reportable incidents, will be thoroughly investigated per the following: 1. Reporting Responsibilities; 2. Reporting Decision Tool; and 3. Incident Reportability Algorithm. Any incidents of elopement will be reviewed by the QAPI Committee on a monthly basis and recommendations will be implemented. On 8/14/25 while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 8/13/25 at 11:59 PM. Findings include: IMMEDIATE JEOPARDY INCIDENTS OF SEXUAL CONTACT 1. Resident 33 was admitted to the facility on [DATE] with diagnoses which included Parkinson's with dyskinesia, dementia, psychotic disorder with delusions due to non psychological conditions, and anxiety disorder. Resident 33 had a BIMS completed on 6/14/25 which was 3 out of 15 which indicated severe cognitive impairment. Resident 33 had a MOCA (Montreal Cognitive Assessment) completed on 7/19/24 which was 7 out of 30 which indicated severe cognitive impairment. Medicare Meeting notes on 6/11/25 documented resident 33’s confusion and cognition continues to fluctuate. A physician note dated 6/9/25 revealed resident 33 had severe cognitive impairment and was progressively declining. No documentation could be located in the medical record where resident 33 had been evaluated for the capacity to consent to sexual activity. Resident 33's progress notes were reviewed and revealed the following: On 4/16/25 resident 33 was found kissing resident 27 while lying on top of her. On 6/25/25 resident 33 was seen in another resident's room with a female resident. The nurse walked in and found them in close proximity. Quickly redirected and separated residents from each other. The resident was very receptive to redirection and followed the staff into his room. On 6/26/25 resident 33 was found sitting on a bed holding hands and kissing resident 31. On 6/26/25 at 6:08 PM CNA (Certified Nursing Assistant) walked into the resident's room to find him and a female resident both undressed. The resident was sitting on his bed while female resident 31 was kneeling on the floor by his groin. On 6/28/25 resident 33 was found holding hands and kissing resident 31. On 7/28/25 resident 33 was found with his hand on resident 27’s shoulder/arm gently patting her. A Facility Reported Incident (FRI) dated 4/16/25 documented that a CNA noted that resident 27 had gone into resident 33’s room and laid down in his bed. The facility documented the following, she often likes to go to his room whether he was in or not and lay on his bed. This time he was found clothed laying in bed with her. There was no kissing or touching noted and resident 33’s denied kissing or touching. Both parties were noted to be calm and smiling. Immediately separate, investigate. Increase routine checks to 15 minutes. A FRI dated 6/26/25 documented the CNA noted resident 31 was observed in resident 33’s room. The facility documented the following, resident 33 was sitting on the bed and resident 31 was kneeling on the floor by his groin. Both had their clothes off, when the CNA entered both residents asked the CNA to leave the room. The CNA told them to get dressed which they did. Abuse was unsubstantiated. The residents were in their right to choose in this case. A FRI dated 6/28/25 documented that resident 33 was standing beside resident 27 who was lying in bed, he had his hand on her shoulder or arm and was gently patting her. The facility documented resident 33 was helped out of the room. Residents were redirected. Abuse inconclusive, there was no inappropriate touching. Given resident 33’s cognitive impairment and history to engage socially with others in a well meaning manner, it was reasonable to conclude that his actions were non-threatening and likely intended to be comforting or friendly in nature. A care plan problem of exhibits/at risk for behaviors such as being affectionate/intimate with some female residents, transferring and walking without assistance while weak, or unsteady on his feet related to parkinsonism, anxiety, delusional disorders, and dementia was initiated on 11/21/23. The interventions of when being affectionate towards another resident, he will receive consent prior to any affection and staff to intervene if needed was initiated on 6/26/25. And ensure resident finds his own room, redirect away from rooms that aren't his was initiated on 7/28/25. On 8/6/25 at 10:59 AM, an interview was conducted with Registered Nurse (RN) 1 and 2. RN 1 stated resident 33 was mostly independent with care and needed partial assistance with showering. RN 1 stated that resident 33 did not have any behaviors. RN 2 stated resident 33 liked to spend time with resident 31 before she passed away, they were in a relationship. RN 1 stated administration had told them it was a consensual relationship. RN 1 stated resident 33 was oriented to person and could talk in full sentences but sometimes had a hard time getting the right words to come out. RN 2 stated resident 33 had been seen holding hands with resident 27 along with having the relationship with resident 31 before she passed. RN1 stated it would determine on the day whether resident 33 would be able to give consent himself or determine if a partner could give consent in a sexual relationship based on his cognitive ability. RN 2 stated it depended on the day whether resident 33 was completely with it. On 8/6/25 at 11:58 AM, an interview was conducted with CNA 3. CNA 3 stated resident 33 required limited assistance and that he did have sexual tendencies. CNA 3 stated that resident 33 would get excited when he saw a girl, he liked holding their hands and stuff. CNA 3 stated that sometimes resident 27 wandered into his room. CNA 3 stated that she had not seen anything happen between them. CNA 3 stated resident 33 was oriented to familiar faces but not where he was or the date and time. CNA 3 stated that resident 33 would not be able to determine if the resident he was in a sexual relationship with could or could not give consent. CNA 3 stated that resident 27 will go with whoever will ask her to go with her and she can not give consent at all. 2. Resident 27 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder, anxiety disorder, personality disorder, vascular dementia and psychosis. On 08/04/25 at 7:51 AM, resident 25 opened the door to his room, 10B and said he needed some help. The staff went in, resident 25 stated, “I have someone in my bed.” Resident 27 was laying in bed 10A. No other resident was in bed with her. The resident whose bed resident 27 was in was not in the room. Resident 27 was escorted out of the room by staff. Resident 25 stated, “she always comes in my room, she goes wherever she wants to go.” Resident 27's medical records were reviewed between 8/4/25 and 8/20/25. On 7/9/24, an admission assessment revealed a BIMS score of 0, indicating resident 27 had severe cognitive impairment. Resident 27 was evaluated for mood and was unable to provide a response to the questions being asked. A behavior assessment revealed resident 27 demonstrated wandering behaviors that disrupted the privacy of other residents. Resident 27’s care plan revealed, “[Resident 27] exhibits alteration in thought process manifested by cognitive impairment r/t [related to] dementia; needs reminders/prompts/cues to choose activities; has depression/anxiety/psychotic disorder; has other behaviors at times.” Interventions included, “Redirect resident away from rooms that aren't hers.” No documentation could be located in the medical record where resident 27 had been evaluated for the capacity to consent to sexual activity. On 4/16/25 at 11:20 PM, a progress note revealed that the nurse on duty was notified by a CNA that resident 27 was found in resident 33’s bed and resident 33 was on top of resident 27 fully clothed. Resident 33 was witnessed kissing resident 27. Resident 33 admitted to kissing resident 33 a couple of times. Residents 27 and 33 were separated and put on 15 minute checks for 72 hours. The facility physician, the administrator, the Director of Nursing and families were notified. An “Incident Report Form” submitted to the State Survey Agency by the facility on 4/16/25 stated that resident 27 “likes to go to his room whether he is in or not and lay on his bed. This time he was found clothed laying in bed with her.” The report stated, “there was no kissing or touching noted and resident 33 denied kissing or touching. Both parties were noted to be calm and smiling.” Both parties were peacefully separated. The administrator interviewed the CNA, on an unknown date, who witnessed the residents. The CNA stated both residents were fully clothed and there was no inappropriate touching or kissing. The CNA also stated both residents looked comfortable and neither resident expressed discontent. In this case, abuse was not verified because the facility determined that both residents were comfortable and seeking to comfort each other and were easily redirected. The report also stated no harm was intended by either resident. A Nurse Practitioner’s progress note dated 4/22/25 revealed, “Chief complaint: Dementia and behaviors, Interval History: She appears to be at her baseline today. Has severe dementia and cognitive impairments. Her mood this morning is a [sic] very pleasant. She has to be redirected continually throughout the day doesn’t understand boundaries with other residents and the rooms.” On 5/13/25, an “Incident Report Form” was submitted to the State Survey Agency by the facility reporting that resident 27 walked into resident 49’s room after going to bed in her room. Resident 27 was found laying in resident 49’s bed. Resident 49 was leaning next to her on the bed. Resident 49 was leaning close to her face, but no kissing or other touching was noted. Both residents were placed on 15 minute checks. The report stated resident 27 would be referred to another facility. It should be noted that there was no progress note in the resident's medical record regarding the incident on 5/13/25. The administrator interviewed a CNA and resident 49’s roommate at an unknown date and time. They CNA told the administrator that resident 49 had his pants down and was leaning close to resident 27’s head. Resident 27 was resting peacefully. There was no touching or kissing noted. The CNA redirected resident 27 out of the room. Resident 49 denied touching or kissing resident 27. Resident 49’s roommate also denied observing any touching or kissing. On 7/28/25, an “Incident Report Form” was submitted to the State Survey Agency by the facility reporting that on 7/26/25, a visitor entered a resident room to find resident 27 laying in a bed that was not hers. Resident 33 was found standing next to resident 27 with his hand on her shoulder, gently patting her. No other touching was noted. Neither resident was able to give a description. Resident 27 was assessed for injuries and abnormal behavior. None were noted. The residents were redirected out of the room. The incident report stated staff were to redirect resident 27 out of rooms that were not hers. No injuries were observed at the time of the incident. The physician, administration and family were notified. On 8/6/25 at 11:08 AM, an interview was conducted with CNA 1 who stated she had witnessed resident 27 and resident 49 in resident 49’s room on 5/13/25. CNA 1 stated she walked into resident 49’s room to check on him and found resident 27 asleep in his bed. Resident 49 had taken off his pants and his shirt and was in the process of taking off his socks. Resident 49 only had his brief on. CNA 1 stated that she walked over, aroused resident 27 and directed her out of resident 49’s room. CNA 1 stated resident 27 did not respond to resident 49 being undressed next to the bed. CNA 1 also stated she did not believe resident 49 could get up on the bed with resident 27. 3. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia with mood disturbance, anxiety disorder, and mood disorder due to known physiological conditions. An admission MDS assessment dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment. Resident 31’s progress notes documented the following: a. On 6/19/25 at 5:49 PM, a Nursing Progress Note documented that resident 31’s daughter called and stated the resident’s confusion was getting worse. b. On 6/25/25 at 9:03 AM, an Encounter Note documented that resident 31 was assessed using the St. Louis University Mental Status Examination (SLUMS) test and she scored 4 out of 30, suggesting dementia. The physician believed that a memory care unit was appropriate for her as far as her safety. Resident 31 was having episodes of agitation as well as crying periods because she did not know what was going on and did not understand why she was in the facility. c. On 6/25/25 at 12:06 PM, a Nursing Progress Note documented that resident 31 had been more sad and confused than usual and that she had been crying more, getting more confused and accusing staff of lying to her. d. On 6/25/25 at 7:18 PM, a Nursing Progress Note documented that resident 31 was removed from a male resident’s room and later that day she was found in another resident’s room with a male resident “in very close proximety [sic]”. e. On 6/26/25 at 5:19 PM, a Nursing Progress Note indicated, “Resident was found with a male resident in the residents room. A CNA walked in and found them sitting on the bed kissing. They were holding hands It appeared to be consensual. I talked privately with both residents and made sure they were both consenting and that is what they wanted to do. it was confirmed by both residents that they consented. I notified both families and they both gave their permission as long as the residents felt good about it. I tried to redirect them but they continued to be with each other. encouraged resident's to stay in public spaces. We will increase observation at this time.” f. On 6/26/25 at 9:16 PM, a Nursing Progress Note indicated, “CNA [name redacted] walked into male resident’s room to find him and [resident 31] both undressed. Male resident was sitting on his bed while [resident 31] was kneeling on floor by his groin. Both residents appeared happy and acting upon mutual consent. No signs of struggle. Both residents asked CNA to leave the room. CNA asked them to get dressed, and they complied. Both residents were interviewed and stated that they were not forced into anything, they enjoyed each other’s company and they both got undressed willingly. They both stated that they feel safe. Resident’s daughter [name redacted] notified of incident and she stated that her biggest desire was for her mom to be happy and safe. She stated that she felt her Mom was able to consent, and she had no concerns about the incident. She stated that her mom has been single for 20 years and it is good for her to have some companionship. administrator [name redacted] notified.” g. On 6/28/25 at 1:39 AM, a General Note documented that resident 33 was seen exiting resident 31’s room. Resident 31 was observed to be sleeping and not aware that resident 33 had been in her room. h. On 6/28/25 at 3:59 PM, a Nursing Progress Note documented that resident 31 was seen being affectionate with resident 33 by holding hands and kissing in private. i. On 7/8/25 at 6:45 AM, a Nursing Progress Note documented that resident 33 was found curled up in bed with resident 31 that morning. A care plan Focus for resident 31 was revised on 6/26/25 to include, “Resident exhibits behaviors such as wandering, rejecting cares, tearfulness, being affectionate/intimate with some male residents r/t Alzheimer's dementia.”; and a Goal of “The resident will have fewer episodes of behaviors by review date.” Interventions initiated on 6/26/25 included: a. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; b. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed; and c. When being affectionate towards another resident, he will receive consent prior to any affection. Staff to intervene if needed. No documentation could be located in the medical record where resident 31 had been evaluated for the capacity to consent to sexual activity. On 8/6/25 at 12:00 PM, a telephone interview was conducted with CNA 2. CNA 2 stated she was passing out snacks down the hall and knocked on resident 33’s door three times and then opened the door and she saw resident 33 sitting on his bed completely naked and resident 31 was completely naked and it looked like she was giving him oral sex. CNA 2 stated she closed the door and went and told the nurse immediately. CNA 2 stated resident 31’s head was down in his private area and when she opened the door resident 31’s head looked up, resident 31’s back was facing the CNA. CNA 2 stated resident 33 was facing the CNA. CNA 2 stated resident 33 was pretty forgetful when we asked him about the incident and had no idea what we were talking about. CNA 2 stated resident 31 was more with it than resident 33 but was more confused about the situation. CNA 2 stated resident 31 could perform all activities of daily living on her own but needed reminders. CNA 2 stated both of their families stated resident 31 and 33 could hang out with each other and be in rooms together. CNA 2 stated that there were no other actions taken or interventions put into place after this incident. 4. A. Resident 11 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury (TBI), cerebral infarction, aphasia, anxiety disorder, unspecified intellectual disabilities, and depression. On 8/4/25 at 7:34 AM, an observation was made of resident 11 walking down the hallway. Resident 11 was asked how she was doing, and resident 11 responded with “fuck you”. On 8/4/25 at 8:06 AM, resident 11 approached the licensor in the dining room. Resident 11 mumbled “micky mad” and demonstrated slapping her hands together. Resident 11 was asked if she was okay and she replied “yes”. On 3/26/25 at 9:13 AM, a complaint was called into the State Survey Agency (SSA) by an Adult Protective Services (APS) investigator. The APS investigator stated that they received a report that resident 11 was sexually assaulted by a fellow resident [resident 49]. The APS investigator reported that on 3/14/25 a CNA was checking on resident 49 and found him with his pants down on top of resident 11 and was attempting to initiate sexual contact. The APS investigator went to the facility on 3/24/25 and interviewed resident 11 and resident 49, and determined that both residents did not have the cognitive ability to consent to sexual activity. The APS investigator reported that the Director of Nursing (DON) had no knowledge of the incident but that the facility Admin was aware of it. The APS investigator reported that she asked the Admin what the plan was to keep resident 11 safe and why the resident’s rooms were still directly across from each other. The APS investigator reported that the Admin had stated that the sexual activity was consensual, but did not provide a clear response for how that determination was made. The APS investigator reported that the Admin had determined that the incident was consensual because resident 11 did not yell or push and had a history of this behavior. The APS investigator reported they felt like the Admin was trying to hide the fact it had occurred. The APS investigator reported that the concern was that there was no plan to keep the residents separated. The APS investigator reported that she spoke with resident 11’s family representative and they had been told that resident 49 had been moved away from resident 11. The APS investigator reported that on 3/24/25 when she was at the facility she went from resident 11’s room to resident 49’s room and no staff was present watching the residents. It should be noted that the APS investigator indicated in the report that resident 11’s room was directly across the hall from resident 49’s room. The APS investigator reported that the Admin stated that the safety plan included 1:1 activities, increased supervision and monitoring, and the separation of the rooms. On 8/5/25, the facility abuse investigation documentation was reviewed. No documentation could be found of an investigation into the incident between resident 11 and resident 49 on 3/14/25. On 5/27/25 at 3:30 PM, the facility abuse investigations documented an incident between resident 11 and resident 49. The facility critical incident report form documented that the Activities Coordinator (AC) was the staff who witnessed the incident. The description of the incident documented, [Resident 49] and [Resident 11] were facing each other holding hands when [Resident 49] reached around and grabbed her [Resident 11] bum. They were separated by rec therapy staff. The incident occurred in the dining room where activities were happening. The report documented that the actions taken were 15-minute checks were conducted on [Resident 49] and he was discharged from the facility. On 8/5/25, Resident #11's medical records were reviewed. On 3/9/25, resident 11’s admission MDS assessment documented that a BIMS was not conducted due to the resident being rarely/never understood. The assessment documented that the resident 11 had short term memory (STM) and long term memory (LTM) deficits. The assessment documented that resident 11 was not able to recall the current season, the name and faces of staff, and if they were in a nursing home or hospital. The assessment documented that the cognition skills for daily decision making was moderately impaired. The assessment documented that resident 11 had behavioral symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming and disruptive sounds and the behavior that occurred 1-3 days. Resident 11’s progress notes documented the following: a. On 3/6/25 at 10:30, the note documented, “Resident is pleasant and alert x 1[self]. She has a tbi and roams around. She has a short attention span & aphasia from stroke. no s/s [signs and symptoms] of pain. She is ambulatory without assistance. She has a good appetite.” b. On 3/15/25 at 10:10, the Nursing Progress Note documented, ”This nurse notified [name omitted], sister of resident, as she was the first one to answer the phone. Discussed with [name omitted] the encounter between resident and male resident the previous day. Sister confirmed she knew about encounter. Sister expressed that resident had encounters of that nature in previous setting. Family was not concerned about resident or encounter. MD [Medical Doctor] will see resident on next visit day. Family would like referral to OB/GYN [obstetrician/gynecologist] for possible birth control and/or ablation if preferred.” c. On 3/15/25 at 10:14 AM, the Nursing Progress Note documented, “resident keeps going over to sit by a male resident and holding his hand. even after redirection she goes back.” d. On 3/31/25 at 1:01 PM, the Social Services Note documented, “[Resident 11] is new to the facility. [Resident 11] transferred from another skilled nursing facility. [Resident 11] has adjusted well to facility. [Resident 11] does have the occasional behaviors such as screaming and crying. This usually occurs when she needs something fixed and moved in her room. Staff is able to quickly assess the situation and provide a solution and comfort to [Resident 11]. [Resident 11] does also have sexual behaviors that are monitored by staff. [Resident 11] enjoys spending time in her room and participating in activities. [Resident 11] does need assistance with ADLs [activities of daily living], staff will assist with ADLs and [Resident 11] is cooperative and does well by pointing to what she needs. [Resident 11] family participated in recent IDT and is grateful for care she receives and wishes for [Resident 11] to remain long term in facility. e. On 4/4/25 at 1:08 PM, the Nursing Progress Note documented, “resident has been fine all morning up until about 20 minutes ago. I heard [Resident 11] yelling very loudly and out of control. As I walked up to try to console her she was very agitated yelling and screaming offensive language. I tried to offer her some meds, some snacks and even a change of scenery. I called the MD and got an order prn med and offered it to her and she took It. Within an hour later she was acting better and she was not yelling as much. Vital signs were within normal limits.” f. On 4/6/25 7:53 PM, the Nursing Progress Note documented, “Pt had another total meltdown swearing, screaming at everyone vulgar languge [sic] jumping at everyone in a threatening manner. Pt grabbed a pt [patient] box of playing cards [NAME] [sic] throgh [sic] it acrossed [sic] the room. Ativan given x2 some relief with second dose. Pt redirected by the nurse taken outside several times and given chocolate to calm pt. Pt had outbursts for over 2 hrs. Pt finally taken to her room and laid on her bed to calm down. Pt offered fluids since pt was exhauted [sic] after eratic [sic] behaviors. Able to get pt down to diner [sic] once pt calmed down. Will cont [continue] to monitor pt behaviors.” g. On 4/8/25 at 3:09 PM, the Nursing Progress Note documented, “This afternoon [Resident 11] became upset, and agitated. Yelling what sounded like ‘f*ck you, men. F*ck me. Mad mad.’ While putting up her middle finger. Staff walked with her out of the dining room into the hallway and outside for a walk. She became calmer and she we attempted to see what she was upset about, but with her limited vocabulary we were unable to specifically identify why she was reacting this way at this time.” h. On 4/9/25 at 5:55 PM, the Nursing Progress Note documented, “resident became upset and started to shout and clap hands and saying ‘fuck you!’. charged at a male resident but a CNA directed her in another direction. she was able to be redirected after the third attempt. she went to her room and was drinking water.” i. On 5/27/25 at 5:51 PM, the Nursing Progress Note documented, “It was reported to this nurse that another resident was touching all over this resident and making this resident visibly uncomfortable. A few minutes later, resident was witnessed attempting to grab on to [sic] this resident's hand and then her shirt tail as she walked away. Separated residents and started this resident on q15min [every 15 minute] checks”. j. On 7/7/25 at 9:39 AM, the Nursing Progress Note documented, “Resident became very upset since another resident was in her room. [Resident 11] started screaming and cussing at other resident. Was able to get other resident out and redirect and reassure [Resident 11] who eventually calmed down. Separated the two resident as much as possible during the day.” On 3/14/25 at 2:30 PM, resident 11 had an incident report that documented, It was reported to nurse by CNA that she saw resident in other male resident's room [resident 49]. [Resident 49] was last at about 4:10pm. The had their pants off and were laying on top of each other. There was no penetration. When CNA walked in the room she told resident to pull her pants up. She did and [resident 49] got off her. There was no struggle. Normally if resident did not want something she yells and screams and hits. There was none of this. The immediate action taken documented, Resident was educated on interaction and that it was not okay. Resident was encouraged to be in day room with other residents and participating in activities. Staff to redirect resident away from other resident's room if necessary. It should be noted that the report documented that resident 49 was last seen at 4:10 PM and this timestamp was after the timestamp that the incident report was documented. On 3/24/25, resident 11 had a care plan initiated for “Resident exhibits/at risk for behaviors such as aggression, agitation, hypersexuality/affection at times, yelling profanities repeatedly, sitting herself on the ground or floors, digging around in the dirt of the flower beds/pulling leaves and branches off of plants in courtyard, and at times getting dirt on her clothing several times daily r/t [related to] history of hypersexuality in group settings, anxiety, depression, history of TBI, intellectual disabilities,

Based on interview and record review, the facility in response to allegations of abuse, neglect, or mistreatment did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 9 out of 32 sampled residents, allegations of sexual abuse, elopements, injuries of unknown origins and fractures were not investigated or the allegations were not investigated thoroughly. Resident identifiers: 2, 11, 27, 31, 33, 36, 42, 47 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to investigate various forms of abuse. Notice of the IJ in Abuse was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/8/25 at 4:46 PM, the Administrator provided the following abatement plan for the removal of the Abuse IJ effective on 8/8/25 at 11:59 PM. The community would add sexual abuse to the revised Abuse Policy and Procedure, all staff would be educated by a LCSW (Licensed Clinical Social Worker) on resident intimacy and sexuality guidelines, the revised policy and the sexual intimacy capacity for consent assessment prior to the next shift worked. QAPI (Quality Assurance and Performance Improvement) will review the revised Abuse Policy and Procedure, all allegations and abuse packets will be reviewed by the QAPI Committee weekly for the next 3 months and any identified concerns will be addressed by said committee. However, the IJ could not be abated based on additional findings of neglect, specifically elopement. On 8/12/25 at 2:30 PM, IJ was again identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to investigate various forms of neglect. Notice of the IJ in neglect, specifically, elopement, was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/13/25 at 10:47 AM, the Administrator provided the following additional abatement plan for the removal of the IJ effective on 8/13/25 at 11:59 PM. All residents, with a history of elopement attempts will be supervised at all times when they are outside of the community. All residents with elopement risk assessments were reviewed and updated as necessary on 8/12/25. Any residents at high risk for elopement will have their care plans updated to reflect interventions to reduce the risk of elopement. The three doors that exit the community will be monitored by a staff member at all times until the egress doors are either secured by badge system or fence installation. Moving forward all allegations of mistreatment, abuse, neglect, exploitation, elopement or other reportable incidents, will be thoroughly investigated per the following: 1. Reporting Responsibilities; 2. Reporting Decision Tool; and 3. Incident Reportability Algorithm. Any incidents of elopement will be reviewed by the QAPI Committee on a monthly basis and recommendations will be implemented. On 8/14/25 while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 8/13/25 at 11:59 PM. Findings include: IMMEDIATE JEOPARDY INCIDENTS OF SEXUAL CONTACT 1.Resident 33 was admitted to the facility on [DATE] with diagnoses which included Parkinson's with dyskinesia, dementia, psychotic disorder with delusions due to non psychological conditions, and anxiety disorder. Resident 33’s medical record was reviewed from 8/4/25 through 8/20/25. Resident 33 had a BIMS (Brief Interview for Mental Status) completed on 6/14/25 which was 3 out of 15 which indicated severe cognitive impairment. Progress notes revealed the following: On 6/25/25 resident 33 was seen in another resident's room with a female resident. The nurse walked in and found them in close proximity. Quickly redirected and separated residents from each other. The resident was very receptive to redirection and followed the staff into his room. On 6/26/25 resident 33 was found sitting on a bed holding hands and kissing resident 31. On 7/28/25 resident 33 was found with his hand on resident 27’s shoulder/arm gently patting her. No investigation documentation for these incidents was provided by the facility. On 8/18/2025 at 1:55 PM, an interview was conducted with the Administrator (Admin). The Admin stated he did not report or do an investigation for the incidents with resident 33 because he thought they were consensual and didn’t need to be reported or investigated. 2. Resident 27 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder, anxiety disorder, personality disorder, vascular dementia and psychosis. Resident 27’s medical records were reviewed between 8/4/25 and 8/20/25. On 7/9/24, an admission Minimum Data Set (MDS) revealed a BIMS score of 0, indicating resident 27 had severe cognitive impairment. Resident 27 was evaluated for mood and was unable to provide a response to the questions being asked. A behavior assessment revealed resident 27 demonstrated wandering behaviors that disrupted the privacy of other residents. Resident 27’s care plan revealed, “[Resident 27] exhibits alteration in thought process manifested by cognitive impairment r/t [related to] dementia; needs reminders/prompts/cues to choose activities; has depression/anxiety/psychotic disorder; has other behaviors at times.” Interventions included, “Redirect resident away from rooms that aren't hers.” On 4/16/25 at 8:31 PM, the facility reported to the State Survey Agency that resident 27 and resident 33 were found together lying in resident 33’s bed. The report stated that resident 27 often would go into resident 33’s room, whether or not he was in the room, and lay on his bed. Both residents were clothed. The incident report stated there was no touching or kissing noted and resident 33 denied touching or kissing resident 27. The report stated both residents were calm and smiling. Certified Nursing Assistant (CNA) 10 asked resident 27 to leave the room, and both residents were peacefully separated. The Admin interviewed CNA 10 on an unknown date and time, who stated she witnessed resident 27 and resident 33 lying on resident 33’s bed cuddling with each other. CNA 10 stated both residents were fully clothed, and she did not observe any inappropriate touching or kissing. CNA 10 stated both residents looked comfortable and content. CNA 10 asked resident 27 to leave the room, which she did. Resident 33 stated that resident 27 was a friend and comforted him. Both residents were poor historians and unable to fully recount what happened. Resident 27 was put on 15 minute checks. Responsible parties and families were notified. Abuse was not verified due to lack of inappropriate touching as witnessed or confirmed by the residents. The investigation stated both residents were comfortable and seeking to comfort each other, and were easily redirected. The report stated no harm was intended by either resident and both residents were at baseline. The intervention created as a result of this incident was to immediately separate, investigate, increase routine checks to 15 minutes, and keep resident 27 in the dining room when she leaves her room. On 5/13/25 at 11:20 PM, the facility reported to the State Survey Agency that resident 27 had walked into resident 49’s room after going to bed in her own room, and then was found in resident 49’s bed. Resident 49 was leaning next to her on the bed. The report stated that resident 49 was leaning close to her face, but was not touching or kissing resident 27. The report stated residents were being helped to bed during rounds. Interviews were conducted by the ADMIN with resident 49’s roommate and CNA 5. Resident 33’s roommate stated that resident 27 opened the door and entered the room, walked toward him, and then went over to resident 49 and laid down in resident 49’s bed. Resident 49 was already in bed and started to lean over resident 27 when CNA 5 walked into the room. The report stated that resident 49 had his pants down and was leaning close to resident 27’s head. Resident 27 was looking at resident 49 peacefully. The report stated there was no touching or kissing that took place. CNA 5 redirected resident 27 out of the room. Resident 49 denied touching or kissing resident 27. Resident 49’s roommate confirmed there was no touching or kissing. Abuse was not verified because there was no touching or kissing. The report stated resident 49 may have removed some of his clothing because it was hot. Resident 49 was known to have his pants down in his room occasionally. The report stated resident 49 did not force resident 27 into his bed or into his room, and resident 27 laid down intentionally and was calm. Neither resident had a change in their baseline behavior. The intervention created as a result of this incident was to monitor both residents and to discharge on e of the residents. On 7/28/25 at 3:43 PM, the facility reported to the State Survey Agency that an incident had occurred on 7/26/25 between resident 27 and resident 33 which included a brief investigation that had inconclusive results. The administrator determined there was no inappropriate touching. The investigation stated that resident 33 enjoyed socializing with other residents and was often seen as a peace maker among the residents. Resident 33 left the situation willingly, and there was no evidence that anything other than one resident comforting another was occurring. The administrator concluded that because resident 33 has cognitive impairment and a history of engaging socially with others in a well-meaning manner, a reasonable conclusion would be that his actions were non-threatening and likely friendly in nature. The administrator stated no negative impact was observed or reported with resident 27. Both residents were acting at baseline after the incident occurred. An intervention of showing resident 33 to his room after dinner was put into place. Resident 27’s family member was interviewed and stated she had walked into her mother’s room and observed resident 33 standing next to resident 27 with his hand on her shoulder and arm. Resident 27’s family member stated she had not seen any inappropriate touching, but she had walked resident 33 out of the room and he left without hesitation. Resident 33 did not remember the incident and resident 27 was unable to say anything about the incident either. Neither resident showed any signs of distress. 3. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia with mood disturbance, anxiety disorder, and mood disorder due to known physiological conditions. An admission MDS assessment dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment. Resident 31’s progress notes documented the following: On 6/25/25 at 9:03 AM, an Encounter Note documented that resident 31 was assessed using the St. Louis University Mental Status Examination (SLUMS) test and she scored 4 out of 30, suggesting dementia. The physician believed that a memory care unit was appropriate for her as far as her safety. Resident 31 was having episodes of agitation as well as crying periods because she did not know what was going on and did not understand why she was in the facility. On 6/25/25 at 7:18 PM, a Nursing Progress Note documented that resident 31 was removed from a male resident’s room and later that day she was found in another resident’s room with a male resident “in very close proximety [sic]”. On 6/26/25 at 5:19 PM, a Nursing Progress Note indicated, “Resident was found with a male resident in the residents room. A CNA walked in and found them sitting on the bed kissing. They were holding hands It appeared to be consensual. I talked privately with both residents and made sure they were both consenting and that is what they wanted to do. it was confirmed by both residents that they consented. I notified both families and they both gave their permission as long as the residents felt good about it. I tried to redirect them but they continued to be with each other. encouraged resident's to stay in public spaces. We will increase observation at this time.” On 6/26/25 at 9:16 PM, a Nursing Progress Note indicated, “CNA [name redacted] walked into male resident’s room to find him and [resident 31] both undressed. Male resident was sitting on his bed while [resident 31] was kneeling on floor by his groin. Both residents appeared happy and acting upon mutual consent. No signs of struggle. Both residents asked CNA to leave the room. CNA asked them to get dressed, and they complied. Both residents were interviewed and stated that they were not forced into anything, they enjoyed each other’s company and they both got undressed willingly. They both stated that they feel safe. Resident’s daughter [name redacted] notified of incident and she stated that her biggest desire was for her mom to be happy and safe. She stated that she felt her Mom was able to consent, and she had no concerns about the incident. She stated that her mom has been single for 20 years and it is good for her to have some companionship. administrator [name redacted] notified.” On 6/28/25 at 1:39 AM, a General Note documented that resident 33 was seen exiting resident 31’s room. Resident 31 was observed to be sleeping and not aware that resident 33 had been in her room. On 6/28/25 at 3:59 PM, a Nursing Progress Note documented that resident 31 was seen being affectionate with resident 33 by holding hands and kissing in private. On 7/8/25 at 6:45 AM, a Nursing Progress Note documented that resident 33 was found curled up in bed with resident 31 that morning. These incidents were not reported to the State Survey Agency. On 8/6/25 at 1:08 PM, the Administrator (Admin) was interviewed. The Admin stated sexual abuse was the intent to cause harm with resulting harm to a resident and the residents involved were consenting so it was not reported to the State and was not investigated. 4. A. Resident 11 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, cerebral infarction, aphasia, anxiety disorder, unspecified intellectual disabilities, and depression. B. Resident 49 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, anoxic brain damage, chronic viral hepatitis, delusional disorders, psychotic disorder, major depressive disorder, opioid abuse, anxiety disorder, unspecified mood disorder, and antisocial personality disorder. The resident was discharged from the facility on 5/29/25. On 3/26/25 at 9:13 AM, a complaint was called into the State Survey Agency (SSA) by an Adult Protective Services (APS) investigator. The APS investigator stated that they received a report that resident 11 was sexually assaulted by a fellow resident [resident 49]. The APS investigator reported that on 3/14/25 a Certified Nurse Assistant (CNA) was checking on resident 49 and found him with his pants down on top of resident 11 and was attempting to initiate sexual contact. On 8/5/25, the facility abuse investigation documentation was reviewed. No documentation could be found of an investigation into the incident between resident 11 and resident 49 on 3/14/25. On 8/6/25 at 1:04 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she recalled the incident of resident 11 lying in resident 49’s bed. The DON stated that the Administrator conducted the abuse investigation. The DON stated that from what she recalled resident 11 was lying in resident 49’s bed but there were no signs of penetration. The DON stated that this incident of sexual activity was something that should have had an abuse investigation. On 8/6/25 at 1:08 PM, the Administrator (Admin) was interviewed. The Admin stated around 3/12/25 resident 49 was found on top of resident 11 in bed pulling his pants down and trying to undress her. The Admin stated prior to that resident 49 had tried to pull resident 11 into his room multiple times, rubbed her shoulder and tried to hold her hand. The Admin stated resident 49 gravitated towards resident 11 and their rooms were across the hall from each other. The Admin stated the incident was reported to him that night and the next day the Admin followed up with staff to determine how to keep the residents safe. The Admin stated he did not know what happened to keep them safe. The Admin stated there was no investigation into the incident. [Cross-refer F600] IMMEDIATE JEOPARDY ELOPEMENT 5. Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of vascular dementia with agitation anxiety disorder, psychotic disorder with delusions, and depressive disorder. An admission MDS assessment dated [DATE] revealed a BIMS score of 3, indicating significant cognitive impairment. Resident 42’s care plan included, “Elopement: The resident is an elopement risk r/t vascular dementia, history of wandering/getting lost.” On 3/12/25 at 5:25 PM, an incident report revealed that resident 42 was seen attempting to climb the fence at the facility. “Before Certified Nursing Assistant [CNA] could get to him, he hopped over.” Resident 42 was brought back into the facility and began kicking the front door, demanding to get out. Resident 42 was unable to give a description of the event. In the description of the event it stated that the CNAs caught up with the resident and walked him back to the facility without issue. Orders were received to send resident [42] out for an evaluation for possible UTI (urinary tract infection). Emergency Medical Services (EMS) was contacted and the resident left the facility at 5:50 PM. No injuries were noted as a result of the elopement. On 3/12/25 at 5:29 PM, a progress note revealed, “CNA asked for help outside, as resident had jumped the fence out back. CNAs caught up with resident and escorted him inside. He is now kicking the front door and demanding to get out. Called guardian to make her aware-no answer, left vm [voice mail], spoke with DON [Director of Nursing]-said go ahead and send him out. Called EMS.” It should be noted that this incident was not reported to the State Agency. There was no investigation into the resident’s elopement. On 5/10/25 at 6:00 PM, an incident report revealed that resident 42 “stepped on wood beside fence to climb over fence” and was found outside alert and walking without difficulty. Resident 42 had a skin tear to his right forearm. The note states that new orders were placed, the area was cleaned with wound cleaner and steri-strips were applied with monitoring for 7 days. There was no bleeding at the site. The resident stated, “I went over the fence.” Resident 42 was then assisted back into the facility. It should be noted there was no progress note in the resident medical record regarding this incident, no report to the state agency, and no investigation related to how the resident was able to the resident’s elopement. On 8/12/25 at 1:19 PM, an interview was conducted with the Administrator (ADMIN) who stated investigations were primarily completed by talking with the nurses and looking into the events. The ADMIN stated he did not report or investigate the incidents for resident 42 or report them to the stated and they should have been investigated and reported to the State Survey agency. 6. Resident 36 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage with loss of consciousness, pain, generalized anxiety disorder, major depressive disorder, bipolar, and personal history of suicidal behaviors. Resident 36’s medical record was reviewed 8/4/25 through 8/20/25. Resident 36 had a BIMS (Brief Interview for Mental Status) completed on 7/31/25 which was 4 out of 15 which indicated severe cognitive impairment. Resident 36 had a MOCA (Montreal Cognitive Assessment) completed on 7/15/25 which was 7 out of 30 which indicated severe cognitive impairment. On 11/19/24, resident 36’s elopement assessment documented that the resident had no history of wandering, could follow instructions, could communicate and had a medical diagnosis of cognitive impairment. Resident 36 scored low risk for elopement. On 1/24/25, resident 36’s quarterly elopement assessment documented that the resident had a history of elopement and had wandered off the grounds. The elopement assessment score was 35, which would indicate a high risk for elopement. Progress notes revealed the following: On 11/22/24 at 10:33 AM, a physician progress note documented, “ .This is my initial assessment. He is now currently blinded in both eyes due to his self-inflicted gunshot wound to his head…” On 12/14/24 at 7:00 PM, the note documented, “Doorbell to front door rang, nurse answered door and wife and resident were standing there. Wife stated she brought resident back and reported he had walked all the way home. Patient was wrapped in a blanket. Resident told nurse he broke through the fence because he had to get home. Resident stated he was mad because his wife wasn't answering the phone and he had to leave.” On 4/12/25 at 6:34 PM, the note documented, “Rsident ([sic] found outside after knocking down fence. resident walking down street cna saw resident and notified nurse.” The incident report dated 4/12/25 revealed “CNA over the radio said ‘2b is outside of the building’. Upon investigation, resident was walking towards state street and refused to turn around and walk the other way. Two CNA’s and myself, had to hold him and keep him from going any further where he could possibly harm himself especially with his partial blindness. After many attempts at redirection from many staff members, resident finally agreed to return when a member from the admin team came out to talk to him.” On 7/6/25 at 9:30 PM, the note documented, “Resident alert and oriented kicked fence out and eloped.Father and administration notified, 911 notified was told police offier [sic] was on his way back with resident.” On 7/7/25 at 5:35 PM, the note documented, “At 1640 [4:40 PM] CNA noted that [resident 36] was outside and wanted to make sure that we all could keep an eye on him as he has a history of trying to elope. He then began to try to take apart the fence. I asked what he what his plan is and why he was wanting to leave. He stated to go home and talk to his wife, i offered to help him contact his wife and other interventions. Myself and 3 other people attempted to intervene, and redirect, and attempted to tell him that it was unsafe for him and other residents, to have this fence broken, he continued and stated that he does not care that it is unsafe. Eventually he took the panels apart and stepped on the retaining wall. He then jumped down the wall…. He then walked directly into the road and myself and [Director of Rehab] had to take him by the arms so that he did not walk into traffic, I repeated that with his very limited vision this was very unsafe and you are putting yourself and us in danger. We were able redirect to walk on the sidewalk but he just kept repeating that he was walking home.” Note: The facility reported the 7/6/25 incident to the State Survey Agency. The incidents on 12/14/24 and 4/12/25 were not reported. On 8/11/25 at 12:45 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that when a resident was missing from the facility they attempted to locate them. RN 4 stated that resident 36 was found further down the street and they had to call 911, at his father’s prompting, to get the resident back to the facility. RN 4 stated that the aide reported seeing resident 36 last at 8:30 PM, and they identified he was missing at 9:00 PM. RN 4 stated that resident 36, “breaks the fence” and “usually he's just down the street a little ways”. RN 4 stated that resident 36 had approximately 3 elopements where he had exited the facility. RN 4 stated that resident 36’s room was located next to an exit door to the locked courtyard and that the resident could go into the courtyard at any time. RN 4 stated that when resident 36 eloped they just went and found him and made sure he came back to the facility. RN 4 stated that she was not aware that staff had to step in front of him to prevent him from going into traffic. 7. Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, type 2 diabetes mellitus, delirium due to known physiological condition, major depressive disorder, generalized anxiety disorder, chronic pancreatitis, essential hypertension, and cognitive communication deficit. Resident 47's medical record was reviewed from 8/4/25 through 8/20/25. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated resident 47 had a BIMS score of 3. A BIMS score between 0 and 7 indicated severe cognitive impairment. It further indicated wandering behaviors were not exhibited. A Social Services Note dated 6/7/24 indicated, “…[Resident 47] is a high wander risk. He is often walking around the building and outside in the backyard. Staff is able to check on him frequently and provide activities to reduce risk of wandering. [Resident 47] has not left facility unattended.” A Nursing Progress Note dated 8/9/24 indicated, “Resident was found on state street in [City name redacted] by a staff member and brought back to the facility just as the nurse was looking for the resident. Resident was asked how he got out of the facility and the resident reports he exited the front door. He reports he does not remember who let him out…” A Nursing Progress Note dated 8/20/24 indicated, “resident attempted to elope and was found still on the facility premisis [sic] by a physical therapy personelle [sic] around 1805 [6:05 PM]. when asked how he got out he was not an accurate hisotrian [sic] and said he went through the front door but also said he jumped over the fence. upon further investigation, staff found an outside chair pushed up against the west fence and this is how we presume he got outside. Notified administration, ADON [Name redacted], and will continue checking his where abouts every hour. messaged management aboutgetting [sic] the outside chairs perminantely [sic] secured to the ground and kept away from the fences to prevent this from happening again in the future. Chairs are temporarily secured and unable to be moved at this time.” A Nursing Progress Note dated 10/2/24 indicated, “Resident was found 1.5 blocks from the facility walking towards the [Store name redacted] by the [City name redacted] police. Facility was called and a staff member went and picked resident up and brought him back to the facility…” On 8/19/25 at 12:25 PM, an interview was conducted with the Administrator (Admin). The Admin stated the elopements on 8/9/24, 8/20/24, and 10/2/24 should have been reported to State and investigated. POTENTIAL FOR HARM INJURY OF UNKNOWN ORIGIN 8. Resident 2 was admitted to the facility on [DATE] with diagnoses which included Alzheimer’s disease, major depressive disorder, hypertension, and mood disorder due to known physiological condition. On 8/4/25 at 11:07 AM, an observation was conducted of resident 2 in the dining room doing an activity, she had a large purple bruise to her right eye. Resident 2's medical record was reviewed from 8/4/25 through 8/20/25. An admission MDS dated [DATE] indicated resident 2 had a BIMS score of 3. A BIMS score between 0 and 7 indicated severe cognitive impairment. An Incident Report dated 7/26/25 indicated, “Resident noted to have bruising and swelling to Rt eye. It further indicated, Resident stated that it occurred ‘a couple of days ago’ and that she ‘was not here when it happened’. Does state when asked about the bruising to right knee that she did fall. It further indicated, Notified Admin, Placed ice pack to rt eye, skin check performed- bruise to rt knee and scattered bruising to left forearm noted.” It further indicated that resident 2 was alert and Oriented to Person (It should be noted that there was no check mark next to Oriented to Situation, Place or Time). A Nursing Progress Note dated 7/26/25 at10:27 AM indicated, “Bruising noted to right eye as resident was walking down hall this morning. Resident stated that it happened a couple of days ago and that she wasn't here when it happened. Another nurse stated that the bruising was not there yesterday. Notified Admin and placed icepack to eye. Will notify other necessary parties.” On 8/6/25 at 2:11 PM, an interview was conducted with resident 2’s daughter. She stated the facility notified her that her mom had a fall and got a black eye. On 8/13/25 at 12:39 PM, an interview was conducted with the DON. The DON stated that if a resident could not tell them how a bruise of unknown origin occurred there would need to be an investigation completed. The DON further stated that if you cannot determine where the bruise came from they it should be reported to the State Agency. On 8/19/25 at 12:32 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the Interim DON was supposed to do the investigation into how resident 2 got a black eye. The ADM stated if we could not reasonably conclude that it was from a fall, it should have been reported to State. It should be noted that no investigation documentation was provided. On 8/12/25 at 1:19 PM, an interview was conducted with the administrator (Admin). The Admin stated the investigations were primarily done by talking with the nurses and looking into the events. The Admin stated they did a formal investigation on 7/6/25 for resident 36. The Admin stated he wasn’t totally aware of the elopement section of the reportable so because of that not being clear, he didn’t report them. The Admin stated because resident 36 was with a staff member they didn’t report the elopements. The Admin stated he did not report or investigate the incidents for resident 42 or report them to the state. The Admin stated that yes, these incidents should have been investigated and reported to the state survey agency.

Based on interview and record review it was determined that the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents were identified to be in Immediate Jeopardy and/or have experienced harm. Resident identifiers: 7,11, 12, 25, 27, 33, 31, 36, 42, 47, and 49.1. Based on interview and record review, it was determined for 7 out of 32 sampled residents that the facility did not ensure that each resident had the right to be free from abuse and neglect. Specifically, residents were not assessed for the capacity to consent to a sexual relationship. This was cited at an immediate jeopardy level. In addition, two residents without capacity were able to elope from the facility. This was cited at an immediate jeopardy level. Resident identifiers: 11, 25, 27, 33, 31, 36, 42 and 49. (Cross refer to F600) 2. Based on observation, interview, and record review, it was determined for 6 of 32 sampled residents that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, three residents with cognitive impairment eloped from the facility, a resident was not secured in a facility van and suffered an injury, two residents experienced falls with no interventions put into place and one resident had injuries of unknown origin. Resident identifiers: 7, 11, 12, 36, 42 and 47. (Cross refer to F689) 3. Based on interview, and record review, for 9 of 32 residents sampled, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, sexual relations between cognitively impaired residents, multiple resident elopements, injuries of unknown origin resulting in fractures and the State Survey Agency was not notified. This was determined to have occurred at an Immediate Jeopardy level. Resident identifiers: 2, 7, 11, 33, 31, 36, 42, 47 and 49. [Cross-refer F609] 4. Based on interview and record review, the facility in response to allegations of abuse, neglect, or mistreatment did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 7 out of 32 sampled residents, allegations of sexual abuse, elopements, injuries of unknown origins and fractures were not investigated or the allegations were not investigated thoroughly. This was determined to have occurred at an Immediate Jeopardy level. Resident identifiers: 11, 27, 33, 31, 36, 42 and 49. [Cross-refer F610] 5. Based on interview, observation, and record review it was determined that the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The facility did not develop and implement policies addressing how they would use a systematic approach to determine underlying causes of problems impacting larger systems; how they would develop corrective actions that would be designed to effect change at the system level to prevent quality of car, quality of life, or safety problems; and how the facility would monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. Specifically multiple residents were identified to be in Immediate Jeopardy and /or have experienced harm. In addition, multiple deficiencies from recertification and complaint surveys had not been corrected. Resident identifiers: 11, 27, 31, 33, 36, 42, and 49. [Cross-refer F867]

Based on interview, observation, and record review it was determined that the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. Specifically, multiple residents were identified to be in Immediate Jeopardy (IJ) related to abuse and elopements and the facility did not develop and implement policies to address the underlying cause of the problems or identify how corrective actions were taken and monitored. Resident identifiers: 11, 27, 31, 33, 36, 42, and 49.Findings included:1. A. Resident 11 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury (TBI), cerebral infarction, aphasia, anxiety disorder, unspecified intellectual disabilities, and depression.B. Resident 49 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, anoxic brain damage, chronic viral hepatitis, delusional disorders, psychotic disorder, major depressive disorder, opioid abuse, anxiety disorder, unspecified mood disorder, and antisocial personality disorder. The resident was discharged from the facility on 5/29/25.On 3/26/25 at 9:13 AM, a complaint was called into the State Survey Agency (SSA) by an Adult Protective Services (APS) investigator. The APS investigator stated that they received a report that resident 11 was sexually assaulted by a fellow resident [resident 49]. The APS investigator reported that on 3/14/25 a Certified Nurse Assistant (CNA) was checking on resident 49 and found him with his pants down on top of resident 11 and was attempting to initiate sexual contact. On 8/5/25, the facility abuse investigation documentation was reviewed. No documentation could be found of an investigation into the incident between resident 11 and resident 49 on 3/14/25. On 8/6/25 at 1:08 PM, the Administrator (Admin) was interviewed. The Admin stated there were some investigations regarding resident-to-resident interactions but he was unable to remember what they were. The Admin stated that resident 49 was found on top of resident 11 in bed pulling his pants down and trying to undress her. The Admin stated prior to that resident 49 had tried to pull resident 11 into his room multiple times, rubbed her shoulder, and tried to hold her hand. The Admin stated resident 49 gravitated towards resident 11 and their rooms were across the hall from each other. The Admin confirmed there was no investigation into the incidents.On 8/19/25 at 11:54 AM, a follow-up interview was conducted with the Admin. The Admin stated that the Quality Assurance and Performance Improvement (QAPI) team met once a month and included all department heads and the Medical Director. The Admin stated that examples of topics for QAPI review included dry wall repairs, concrete hazards in the courtyard, and dementia care. The Admin stated that he completed a performance improvement plan for dementia training. The Admin stated that they identified the need for dementia training one year ago. The Admin stated that system changes over the last year included more dementia training. The Admin stated that sometimes they documented the staff training and sometimes they did not. The Admin stated that they discussed these items in QAPI but he was not sure how they measured the effectiveness of the training. The Admin stated that staff were provided education on abuse, fall hazards, and accidents annually. The Admin stated that they did not identify the non-compliance related to abuse and elopements in QAPI prior to the survey. The Admin stated that they did discuss resident-to-resident altercations and elopements but he did not make a formal performance improvement plan for those areas. 2. Resident 33 was admitted to the facility on [DATE] with diagnoses which included Parkinson's with dyskinesia, dementia, psychotic disorder with delusions due to non-psychological conditions, and anxiety disorder.Progress notes revealed the following:a. On 4/16/25 resident 33 was found kissing resident 27 while lying on top of her.b. On 6/25/25 resident 33 was seen in another resident's room with a female resident. The nurse walked in and found them in close proximity. Quickly redirected and separated residents from each other. The resident was very receptive to redirection and followed the staff into his room.c. On 6/26/25 resident 33 was found sitting on a bed holding hands and kissing resident 31. d. On 6/26/25 at 6:08 PM CNA (Certified Nursing Assistant) walked into the resident 33's room to find him and a female resident both undressed. The resident was sitting on his bed while female resident 31 was kneeling on the floor by his groin.On 8/6/25 at 12:10 PM, an interview was conducted with the Director of Nursing in Training (DON IT). The DON IT stated that since she had been in management resident 31 and resident 33 had expressed a desire to engage in sexual activity. The DON IT stated she could not recall when it had started. The DON IT stated she called a family member for resident 33 when he was found naked in one of their rooms. And to her knowledge, resident 33 was at the edge of the bed and resident 31 was kneeling on the floor and they were naked and the CNA came in and broke it up. The DON IT stated she told resident 33's family member about the incident and the placement of the residents and physical contact wasn't necessarily witnessed. The DON IT stated that in the report that she received, no physical contact had occurred. The DON IT stated it may have looked like oral sex but that may have been because they were in that position and were unclothed. The DON IT stated that when the family member was told about the incident he laughed and said something like good for you dad. The family member said he just wanted his dad to be happy.3. Resident 27 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder, anxiety disorder, personality disorder, vascular dementia, and psychosis.Resident 27's medical records were reviewed between 8/4/25 and 8/20/25.On 4/16/25 at 11:20 PM, a progress note revealed that the nurse on duty was notified by a CNA that resident 27 was found in resident 33's bed and resident 33 was on top of resident 27 fully clothed. Resident 33 was witnessed kissing resident 27. Resident 33 admitted to kissing resident 33 a couple of times. Residents 27 and 33 were separated and put on 15 minute checks for 72 hours. The facility physician, the administrator, the Director of Nursing and families were notified. On 5/13/25, the incident report form documented that the administrator interviewed a CNA and resident 49's roommate at an unknown date and time. The CNA told the administrator that resident 49 had his pants down and was leaning close to resident 27's head. Resident 27 was resting peacefully. There was no touching or kissing noted. The CNA redirected resident 27 out of the room. Resident 49 denied touching or kissing resident 27. Resident 49's roommate also denied observing any touching or kissing. 4. Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of vascular dementia with agitation, anxiety disorder, psychotic disorder with delusions, and depressive disorder. Resident 42's medical records were reviewed between 8/4/25 and 8/20/25.A review of resident 42's progress notes revealed, on 3/12/25 at 5:29 PM, CNA asked for help outside, as resident had jumped the fence out back. CNAs caught up with resident and escorted him inside. He is now kicking the front door and demanding to get out. Called guardian to make her aware - no answer, left vm [voice mail]. Spoke with DON - said go ahead and send him out. Called for EMS [emergency medical services].An incident report dated 5/10/25 revealed, Resident stepped on wood beside fence to climb over fence found outside alert and walking without difficulty. Skin tear to right forearm. New orders placed. Area cleaned with wound cleanser. Steri-strip applied with monitor for 7 days. No bleeding at site. The resident stated, I went over the fence.5. Resident 36 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage with loss of consciousness, pain, generalized anxiety disorder, major depressive disorder, bipolar, and personal history of suicidal behaviors. Resident 36's medical record was reviewed 8/4/25 through 8/20/25.Progress notes revealed the following:a. On 12/14/24 at 7:00 PM, the note documented, Doorbell to front door rang, nurse answered door and wife and resident were standing there. Wife stated she brought resident back and reported he had walked all the way home. Patient was wrapped in a blanket. Resident told nurse he broke through the fence because he had to get home. Resident stated he was mad because his wife wasn't answering the phone and he had to leave.b. On 4/12/25 at 6:34 PM, the note documented, Rsident ([sic] found outside after knocking down fence. resident walking down street cna saw resident and notified nurse.c. On 5/30/25 at 5:30 PM, the note documented, Resident was found outside down the street a little way after apparently escaping through the fence after trying to break the fence down.staff was with him and trying to get him to come back when he broke through it. Resident reported he was trying to go home and that is why he was doing that. I was told that he was trying to go home so I asked him why he was trying to get home. He just said he was tired of being here. I tried calling his wife but she didn't answer. I notified the Dr. and administration. We took his vitals and they were within normal limits.d. On 7/6/25 at 9:30 PM, the note documented, Resident alert and oriented kicked fence out and eloped.Father and administration notified, 911 notified was told police offier [sic] was on his way back with resident.e. On 7/7/25 at 5:35 PM, the note documented, At 1640 [4:40 PM] CNA noted that [resident 36] was outside and wanted to make sure that we all could keep an eye on him as he has a history of trying to elope. He then began to try to take apart the fence. I asked what he what his plan is and why he was wanting to leave. He stated to go home and talk to his wife, i offered to help him contact his wife and other interventions. Myself and 3 other people attempted to intervene, and redirect, and attempted to tell him that it was unsafe for him and other residents, to have this fence broken, he continued and stated that he does not care that it is unsafe. Eventually he took the panels apart and stepped on the retaining wall. He then jumped down the wall. He then walked directly into the road and myself and [Director of Rehab] had to take him by the arms so that he did not walk into traffic, I repeated that with his very limited vision this was very unsafe and you are putting yourself and us in danger. We were able redirect to walk on the sidewalk but he just kept repeating that he was walking home. On 8/12/25 at 9:59 AM, the Director of Nursing (DON) stated that the facility did not have a policy and procedure for elopements. The DON stated that they assessed the residents for elopement risk upon admission and quarterly thereafter.On 8/12/25 at 1:19 PM, an interview was conducted with the Admin. The Admin stated the investigations were primarily done by talking with the nurses and looking into the events. The Admin stated they did a formal investigation on 7/6/25 for resident 36. The Admin stated he wasn't totally aware of the elopement section of the reportable so because of that not being clear, he did not report them. The Admin stated because resident 36 was with a staff member they didn't report the elopements. The Admin stated he did not report or investigate the incidents for resident 42 or report them to the state. The Admin stated that yes, these incidents should have been investigated and reported to the state survey agency.[Cross-refer F600 and F689]

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and dry food storage room were open to the air, some walls were in disrepair, several tiles were cracked throughout the kitchen and bugs were found in the freezer. Findings include: 1.On 8/4/25 at 6:59 AM, an initial walkthrough of the kitchen was conducted. In the walk-in freezer, a box of frozen green beans was open to air, a box of cubed carrots was open to air, a bag of breaded chicken was not dated and a bag of frozen fried rice was not dated. There were cracked tiles outside of the walk-in freezer and walk-in refrigerator. In the dry storage room, a large, plastic bag of white powder was found on the bottom shelf, and was open to air. The bag was also not labeled. There were several cracked tiles in the dish room and the wall under the dish machine was in disrepair. The paint was chipped on the wall next to the steam table. An interview was conducted with [NAME] 2, who stated the white powder in the plastic bag was powdered milk.On 8/19/25 at 11:48 AM, a second walkthrough of the kitchen was conducted. A box of chicken gyros were open to air, a box of dinner rolls was open to air, a box of California vegetable blend was open to air. Tiles throughout the kitchen and dish room that were cracked, the paint was chipped on the wall next to the steam table, and the wall under the dish machine was in disrepair. On 8/20/25 at approximately 1:30 PM, an observation was made of the freezer in the dining room. There were dead bugs in the freezer. An interview was immediately conducted with [NAME] 1. [NAME] 1 stated he was not sure how often the refrigerator and freezer were cleaned. [NAME] 1 stated there should not be bugs in the freezer.On 8/19/25 at 12:07 PM, an interview was conducted with the Dietary Manager (DM) who stated that a kitchen remodel was anticipated as soon as the facility could find a kitchen trailer for them to move into during the remodel. The DM stated administration was aware of the cracked tiles and the need for the update. The DM stated staff would get in a hurry and forget to seal up food items in the freezer after obtaining what they needed. The DM stated leaving food open to air in the freezer could result in freezer burn and reduced food quality. On 8/19/25 at 1:54 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated she conducted a kitchen audit once per month that included looking at regulatory requirements such as cleanliness, and food was labeled and dated properly.

Based on interview and record review it was determined that the facility did not develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program. Specifically, the facility did not identify and prioritize problems related to resident abuse and elopements and corrective actions were not identified, monitored, or evaluated for effectiveness. The facility was found to be in non-compliance with F600, F607, F609, F610, and F689 at an Immediate Jeopardy level, indicating substandard quality of care. Resident identifiers: 7, 11, 12, 27, 31, 33, 36, 42, 47, and 49.Findings included:On 8/19/25 at 11:54 AM, an interview was conducted with the Administrator (Admin). The Admin stated that the QAPI team met once a month and included all department heads and the Medical Director. The Admin stated that examples of topics for QAPI review included dry wall repairs, concrete hazards in the courtyard, and dementia care. The Admin stated that he completed a performance improvement plan for dementia training. The Admin stated that they identified the need for dementia training one year ago. The Admin stated that system changes over the last year included more dementia training. The Admin stated that an in-service on dementia was being completed once a month. The monitoring for the plan was conducted by the Assistant Director of Nursing (ADON) and they discussed upcoming training. The Admin stated that prior to the current ADON's participation, he and the previous ADON did the training. The Admin stated that sometimes they documented the staff training and sometimes they did not. The Admin stated that they needed to be better about having the staff sign the attendance sheets for the education. The Admin stated that if a staff member did not sign the education attendance form, they were provided education during staff huddles. The Admin stated that huddle education was conducted for a few weeks and the Director of Nursing and ADON would determine that it was finished. The Admin stated that they discussed these items in QAPI but he was not sure how they measured the effectiveness. The Admin stated that staff were provided education annually on abuse, fall hazards, and accidents. The Admin stated that they did not identify the non-compliance related to abuse and elopements in QAPI prior to survey. The Admin stated that they did discuss resident-to-resident altercations and elopements but he did not make a formal performance improvement plan for those areas.

Based on interview and record review, the facility did not have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. Specifically, the facility did not have a hospital transfer agreement. Findings included: On 8/7/24 at 2:03 PM, a hospital transfer agreement was provided from the Administrator. The transfer agreement was observed to be void of any facility information, hospital information or signatures. On 8/7/25 at 3:00 PM, an interview was conducted with the Administrator (Admin). The Admin stated that the facility just had a verbal agreement with the local hospitals that if the facility would send a face sheet, medication list and allergy list with the resident then it would be fine for the resident to go to that hospital. On 8/20/25 at 10:00 AM, a follow up interview was conducted with the Admin. The Admin stated the facility did not have a signed transfer agreement with the local hospitals.

Based on interview and observation, the facility did not care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, during the lunch meal, residents were served on Styrofoam plates and provided beverages in Styrofoam cups. Resident identifier: 18 and 41.Findings included: On 8/12/25 at 12:25 PM, an observation was made of the residents being served on small Styrofoam plates and cups in the dining room for the lunch time meal. On 8/12/25 at 12:26 PM, an observation was made of resident 41 served lunch in a Styrofoam bowl. On 8/12/25 at 12:30 PM, an observation was made of resident 18, who was legally blind, being served lunch in a Styrofoam bowl and juice in a Styrofoam cup. On 8/12/25 at 1:01 PM, an interview was conducted with CNA (Certified Nursing Assistant) 1. CNA 1 stated the sandwiches that were served today were cut up into pieces and served to the residents and they were not usually measured. CNA 1 stated they just used the tongs and gave them food in the Styrofoam bowls. On 8/12/25 at 1:10 PM, an interview was conducted with NA (Nursing Assistant) 6. NA 6 stated the sandwich that was served was half of a ham sandwich and it could be served as bite sized or pureed. NA 6 stated the residents received milk or juice. NA 6 stated the residents did not receive anything else for lunch today and that lunch was usually always served in Styrofoam plates, bowls and cups. On 8/18/2025 at 11:58 AM, an observation was made of NA 7 passing lunch. NA 7 stated lunch was cottage cheese in a plastic cup with fruit on the bottom and a muffin wrapped in saran wrap. NA 7 stated that the residents could have milk and juice if they wanted it. NA 7 stated she did not know how big the cups were that held the cottage cheese. NA 7 stated the milk and juice were served in Styrofoam cups. On 8/5/25 at 12:20 PM, an observation was made of pizza being served in the dining room. Residents were being served one slice of pizza on a Styrofoam plate. Residents were then offered a beverage in a red plastic cup. At 12:52, an observation was made of 2 CNAs pushing a serving cart down the East hallway. The CNA served up slice of pizza on a Styrofoam plate and provided it to residents. The residents were offered water or lemonade in a red plastic cup. On 8/11/25 at 12:38 PM, an observation was made of the lunch meal, which consisted of 1 piece of vegetarian quiche on a Styrofoam plate, with a plastic fork, and a beverage of choice served with a Styrofoam cup. Some residents had brought their personal mugs to the dining room for the meal. On 8/12/25 at 12:32 PM, an observation was made of the lunch meal. Resident 18 was observed to be sitting at a table with a blanket over her head and over her lap. Resident 18 asked for half of a sandwich. The CNA serving the meal told resident 18 it was already half of a sandwich and served some cut sandwich pieces into a Styrofoam bowl, and poured some ice water and left. After the CNA left, resident 18 asked for a clothing protector, but there were no staff members around that could hear her to provide one to her. On 8/5/25 at 1:00 PM, an interview was conducted with CNA 1 who stated the lunch meal on 8/5/25 was not a special meal, but that sometimes the residents had pizza for lunch. When CNA 1 was asked why Styrofoam plates were being used, she replied that they were always used during the lunch time meal. On 8/12/25 at 1:03 PM, an interview was conducted with the Dietary Manager (DM) who stated the light meal during the lunch hour was frequently called a snack, and it had been served using Styrofoam plates and cups for years.

Based on interviews and facility policy review, the facility failed to conduct mandatory training for all staff on the facility's quality assurance and performance improvement (QAPI) program. This deficient practice affected all residents who currently resided in the facility.Findings included:A facility policy titled, 2025 QAPI Plan, revised in July 2025, revealed, It is our mission to provide an Individual Quality Life Experience through Extraordinary service. A Promise delivered. The QAPI program will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice, and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action. The policy did not address sexual abuse, sexual abuse training, or elopement training on the facility's QAPI program.On 8/6/25 at 11:58 AM, an interview was conducted with Nursing Assistant (NA) 6. NA 6 stated they did education at the facility. NA 6 stated they just went over things that needed to be fixed. Usually the teaching was done during the in-service or the daily huddle that they had with everyone. NA 6 wasn't sure what the QAPI meetings were about or if there was education that went over that stuff. On 8/18/25 at 1:25 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated she didn't know what QAPI was. On 8/19/25 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was no specific staff training on what was covered in the QAPI meetings.On 8/19/25 at 1:00 PM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated she did not know what QAPI was but they did get trainings at work. On 8/19/25 at 1:33 PM, an interview was conducted with RN 2. RN 2 stated they did get education at work but he was unsure what QAPI was.During an interview on 8/19/25 at 9:15 AM, the Administrator stated there had not been any staff training on QAPI. The Administrator stated that he had sent over the facility in-services to the survey team.The in-services provided by the facility were reviewed on 8/19/25 and an in-service on the focus of QAPI was not noted.

Based on observation, interview, and record review, it was determined for 2 of 32 sampled residents, that the facility went over 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Specifically, a resident was provided late breakfasts and another resident experienced weight loss with no nourishing evening snack documented. Resident identifiers: 12 and 25.Findings included:1. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included alcohol dependence with Korsakoff Syndrome, alcohol-induced persisting amnesic disorder, mild dementia with agitation, major depressive disorder, psychotic disorder with delusions, altered mental status, and seizures. The posted dining schedule was Breakfast from 8:30 - 11:00 AM; Snack from 12:15 - 1:30 PM; Dinner from 4:00 - 5:00 PM; and Night Cap at 7:00 PM. On 8/13/25 at 10:35 AM an observation of resident 12 was made in his room. Resident 12 was laying in bed, awake and smiled and laughed in response to questions. At 11:07 AM, an observation and interview was conducted with Licensed Practical Nurse (LPN) 4. Resident 12 was observed in his room, laying in bed, awake. LPN 4 stated she was not sure if he had eaten breakfast yet. At 11:51 AM, LPN 4 stated he had not eaten breakfast yet because the CNA's (Certified Nurse Assistant) could not wake him up this morning, but the kitchen was making him something to eat. On 8/14/25 at 9:47 AM, an observation of resident 12 was conducted. Resident 12 was being brought out of his room via wheelchair with two CNA's. One of the CNA's was overheard to ask resident 12 if he was ready for breakfast. Resident 12 was then observed to be brought into the dining room and assisted to eat breakfast. At 9:48 AM, an interview was conducted with CNA 9. CNA 9 and another staff member were standing outside of resident 12's room with a breakfast tray and bathing supplies. CNA 9 stated they were going to be taking his breakfast into him now. Resident 12's medical record was reviewed 8/4/25 through 8/20/25. An Annual Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) could not be conducted because the resident was rarely/never understood. It further indicated a short and long-term memory problem and Cognitive Skills for Daily Decision Making was severely impaired. It further indicated resident 12 was dependent on staff to eat, had impairments to both sides of his upper and lower extremities, required substantial/maximal assistance to roll left and right in bed, was dependent to transfer from bed to chair, and was dependent on staff to use his manual wheelchair. A physician's order dated 8/12/25 indicated resident had a Puree textured diet. A Meal Task document dated 8/19/25 indicated resident 12 had breakfast at 9:00 AM on 8/13/25, breakfast and lunch at 1:56 PM on 8/14/25, and breakfast at 11:20 AM on 8/18/25. It should be noted that there was no documentation of a night snack being provided. A care plan problem indicated, The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] Korsakoff syndrome, dementia, agitation, restlessness, psychotic disorder with delusions, muscle weakness, altered mental status. It was initiated on 6/18/24 and revised on 8/4/25. An approach dated 6/18/24 and revised on 8/4/25 included, EATING: The resident is usually able to eat with dependent assistance. On 8/14/25 at 10:13 AM, an interview was conducted with CNA 1. CNA 1 stated resident 12 needed full assistance for eating. CNA 1 stated he did not get breakfast on 8/13/24 because a meal ticket did not print out for him. CNA 1 stated they usually get him up at about 9:30 AM to feed him breakfast. CNA 1 stated they would get him up when she was done getting everyone else up and out to breakfast and then she would have to wait for someone else to be free because he required a 2-person assist. CNA 1 stated she feeds resident 12 when she can sit down and feed him. CNA 1 stated resident 12 was awake at about 8:30 AM this morning. On 8/14/25 at 10:30 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated resident 12 could not feed himself and could not verbalize if was hungry. RN 5 stated resident 12 tended to get agitated but would calm down after he ate. On 8/19/25 at 1:11 PM, an interview was conducted with CNA 1. CNA 1 reviewed the Meal Task document and stated the times that were listed on the document were not accurate and did not reflect the times the resident ate because she waited until the end of her shift to document. On 8/19/25 at 1:29 PM, an interview was conducted with the Dietary Manager (DM). The DM stated she did not know what happened but resident 12 missed breakfast on 8/13/25 because when she cut the meal cards, his card disappeared somehow. The DM stated it was her expectation that the CNA would notify her if their resident did not get a meal. The DM stated the CNAs passed out the snacks. The DM stated if a resident missed the 7:00 PM snack, the resident could ask for snacks and that there were sandwiches in the fridge. The DM stated she could not answer what should be done about residents who missed the 7:00 PM snack and could not say if they were hungry or not. On 8/20/25 at 9:42 AM, an interview was conducted with the Director of Nursing (DON). The DON stated residents who needed assistance to eat should eat by 9:00 AM. On 8/20/25 at 11:36 AM, an interview was conducted with RN 2. RN 2 stated there was a snack provided at 7:00 PM every day but he did not think the snacks were documented. RN 2 stated there was no continental breakfasts served and breakfast was the first meal offered at about 8:30 AM. On 8/20/25 at 1:10 PM, an interview was conducted with [NAME] 1. [NAME] 1 stated he filled the fridge with sandwiches, yogurt, cottage cheese, pudding, and string cheese for the 7:00 PM snack. [NAME] 1 stated there were no pureed sandwiches for residents on a puree diet, but they could have cottage cheese and pudding. On 8/20/25 at 1:14 PM, a telephone interview was conducted with the Registered Dietician (RD). The RD stated there were 5 meals served per day that included a continental breakfast, breakfast, lunch snack, dinner, and a night snack. The RD stated the continental breakfast was not being served because residents could go to the dining room and request breakfast items anytime before breakfast. The RD stated she was unsure where snack intakes were documented but the nurses and CNAs paid attention to that. The RD stated residents were able to get eggs, toast, cereal or yogurt for the continental breakfast. It should be noted that if resident 12 received dinner when it was scheduled to be served at 4:00 PM, there would have been approximately 17 hours between dinner and breakfast, which was observed to be served at approximately 10:00 AM on 8/14/25 and 8/18/25. 2. Resident 25 was admitted to the facility on [DATE] with diagnoses which included fracture of right humerus, type 2 diabetes mellitus, difficulty in walking, major depressive disorder, Alzheimer's disease, history of transient ischemic attack and cerebral infarction, and chronic kidney disease stage 3. On 8/4/25 at 8:22 AM, an observation was conducted of resident 25. Resident 25 was observed to walk to the dining room. At 8:49 AM, resident 25 left the dining room before being served breakfast. At 8:59 AM, staff walked with resident 25 back into dining room. At 9:06 AM, resident 25 had his breakfast sitting in front of him, he was not eating or drinking. At 9:49 AM, resident 25 continued looking around the room, he had not eaten his breakfast that was in front of him. Resident 25 then stood up and left the dining room, staff was observed to bring him his walker. Resident 25's medical record was reviewed from 8/4/25 through 8/20/25. A Weight Summary indicated:a. 6/12/25 155.4 Lbs (pounds)b. 6/16/25 153.2 Lbsc. 7/6/25 150.3 Lbsd. 7/11/25 151.4 Lbse. 7/17/25 145.8 Lbsf. 8/6/25 143 Lbsg. 8/8/25 143 Lbsh. 8/14/25 141.4 Lbs A Skin and Weight Review dated 8/5/25 indicated his Most Recent Weight was 143 Lbs on 8/8/25 and 148.8 Lbs on 7/23/25 that his Change in Weight was Stable and 2% loss in 7 days. It further indicated an Average Percentage of Meal Intake was 51-75%. It further indicated the Average Percentage of Supplement Intake was 0-25% and an Average Percentage of Snack Intake was 26-50%. It further indicated his Level of Eating Assistance was Independent, Set Up Only, and Cueing. It further indicated, Restorative shakes were started on the 7/9. Mirtazapine started on 7/11 to promote appetite. New orders to start Med Pass 60ML [milliliters] BID [twice daily] to assist with weight gain. Pain appears to be well managed. Resident continues having confusion r/t [related to] progression of disease. Staff continues to encourage oral intake and monitor weekly. A Meal Task document dated 7/22/25 through 8/20/25 indicated:a. Dinner was documented at 4:31 PM on 7/22/25 and breakfast was documented at 9:56 AM on 7/23/25, which was an approximately 17.5-hour span.b. Dinner was documented at 4:58 PM on 7/25/25 and breakfast was documented at 9:00 AM on 7/26/25, which was an approximately 16-hour span.c. Dinner was documented at 4:57 PM on 7/26/25 and breakfast was documented at 11:18 AM on 7/27/25, which was an approximately 18-hour span.d. Dinner was documented at 6:00 PM on 8/3/25 and breakfast was documented at 11:35 AM on 8/4/25, which was an approximately 17.5-hour span. It should be noted that there were multiple examples that documented a span of more than 14 hours between dinner and breakfast being served on the Meal Task document. It should be noted that there was no documentation of a night snack being provided. The Care Plan initiated on 6/17/25 and revised on 7/15/25 revealed a Problem of The resident has a potential nutritional problem r/t [related to] type 2 diabetes, HLD [hyperlipidemia], HTN [hypertension], CKD [chronic kidney disease] stage 3, Alzheimer's disease, MDD [major depressive disorder], atherosclerotic heart disease. The goal was resident would not have significant weight loss. The Approaches included: a. Monitor intake and provide alternative options if intake is low. Date Initiated: 06/18/2025 Revision on: 07/15/2025;b. Provide and serve diet as ordered. Date Initiated: 06/17/2025;c. Provide diet to maintain weight and strength. Date Initiated: 06/18/2025 Revision on: 07/15/2025;d. Provide resident with required level of assistance for eating/drinking while allowing as much independence as possible Date Initiated: 06/18/2025; ande. Restorative shake Date Initiated: 06/18/2025. Another Care Plan dated 6/17/25 and revised on 7/15/25 revealed a Problem of The resident is at risk for impaired skin integrity r/t recent surgery, incontinence, altered mobility, impaired cognition. An approach included, Monitor nutritional status. Serve diet as ordered, monitor intake and record. On 8/19/25 at 1:11 PM, an interview was conducted with CNA 1. CNA 1 reviewed the Meal Task document and stated the times that were listed on the document are not accurate and did not reflect the times the resident ate because she waited until the end of her shift to document. On 8/19/25 at 1:29 PM, an interview was conducted with the DM. The DM stated the CNAs passed out the snacks. The DM stated if a resident missed the 7:00 PM snack, the resident could ask for snacks and that there were sandwiches in the fridge. The DM stated she could not answer what should be done about residents who missed the 7:00 PM snack and could not say if they were hungry or not. On 8/20/25 at 11:36 AM, an interview was conducted with RN 2. RN 2 stated there was a snack provided at 7:00 PM every day but he did not think the snacks were documented. RN 2 stated there was no continental breakfasts served and breakfast was the first meal offered at about 8:30 AM. On 8/20/25 at 1:14 PM, a telephone interview was conducted with the RD. The RD stated there were 5 meals served per day that included a continental breakfast, breakfast, lunch snack, dinner, and a night snack. The RD stated she was unsure where snack intakes were documented but the nurses and CNAs paid attention to that. The RD stated residents were able to get eggs, toast, cereal or yogurt for the continental breakfast. The RD stated there was a concern for resident 25's weight loss. The RD stated she received reports that he was not eating well and that the DM kept a close eye on the residents. On 8/11/25 at 1:10 PM, an interview was conducted with the Dietary Manager (DM) who stated a snack was served at 7:00 PM in the dining room and then in the hallways. The DM stated snack items were sandwiches, fruit, yogurt, applesauce, pudding, cheese sticks, fruit, cookies, crackers, chips, milk and punch. The DM stated residents could choose 2 items initially and then after everyone had been served, they could have additional snack items if they desired more. On 8/20/25 at 11:59 AM, an interview was conducted with the DM. The DM was asked how she ensured that the residents were not going longer than 14 hours between meal times. The DM stated she did not know the answer to that question. The DM stated that hall trays at breakfast time went out at 9:00 AM. The DM stated she had discussed the meal schedule with the Registered Dietitian and was assured she was in compliance with the regulation. The DM stated she was not at the facility in the evening when the snacks were passed to monitor. The DM stated she did not know where resident snacks were being documented or how much they were consuming. The DM looked in the medical record and could not locate where documentation would be for snacks. The DM stated the staff were not looking at resident orders when providing snacks, they were just asking the residents what they wanted for a snack and giving it to them. It should be noted that if a resident required assistance with meals or eats in their room receives their dinner meal at 5:00 PM after the dining room was served, and the breakfast cart left the kitchen at 9:00 AM the following morning, the span of time was 16 hours which was beyond the 14 hour requirement. Although snacks were offered at 7:00 PM, they were not being documented and therefore cannot be considered for nutritional adequacy.

Based on interview and record review, it was determined for 4 out of 32 sampled residents, that the facility did not ensure that residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms. Specifically, a resident was being given risperidone for over affectionate behaviors when the resident was not exhibiting those behaviors, residents were not being monitored while on psychotropic medications, there was no follow-up when medications were ineffective, and a resident was provided anti-anxiety medication on an as needed basis for longer than 14 days without justification. Resident identifiers: 24, 25, 27, 40, and 41.Findings included: 1. Resident 27 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder, anxiety disorder, personality disorder, vascular dementia and psychosis. On 8/04/25 at 7:51 AM, resident 25 opened the door to his room [ROOM NUMBER]B and said he needed some help, staff were right there and went in. Resident 25 stated, I have someone in my bed. Resident 27 was laying in bed 10A. No other residents were in bed with her, and resident whose bed 10A belonged to was not in the room. Resident 27 was escorted out of the room by staff. Resident 25 stated, she always comes in my room, she goes wherever she wants to go. On 8/4/25 at 8:39 AM, resident 27 was observed wandering around the dining room while residents were being served breakfast. On 8/05/2025 at 9:07 AM, resident 27 walked into room [ROOM NUMBER], then walked out and went into room [ROOM NUMBER]A ,and then walked back out. No staff were in west hallway. On 8/05/2025 at 1:22 PM, an observation was made of resident 27 taking a pair of socks off of the cart of clean clothing that were being put away. Resident 27 was intercepted by a nurse that was walking down the hallway and the socks were taken away. Resident 27's medical records were reviewed between 8/4/25 and 8/20/25. On 7/9/24, an admission Minimum Data Set (MDS) assessment revealed a BIMS (Brief Interview for Mental Status) score of 0, indicating resident 27 had severe cognitive impairment. Resident 27 was evaluated for mood and was unable to provide a response to the questions being asked. A behavior assessment revealed resident 27 demonstrated wandering behaviors that disrupted the privacy of other residents. Resident 27's physician orders included: a. Cimetidine Oral tablet, give 400 mg (milligrams) by mouth two times a day for Hypersexuality. b. Clonazepam Oral tablet, 0.5 mg by mouth two times a day related to anxiety disorder due to known physiological condition. c. Depakote Oral tablet delayed release, 125 mg, give 1 tablet by mouth two times a day for hypersexuality. d. Risperdal oral tablet 0.5 mg, give 0.5 mg by mouth two times a day for behaviors related to other frontotemporal neurocognitive disorder; unspecified psychosis not due to a substance or known physiological condition. e. Anti-depressant monitoring days and evenings: Behavior: disrobing/hypersexuality. f. Anti-anxiety monitoring: Behavior: anxiousness. A review of resident 27 Anti-depressant monitoring in the Treatment Administration Record (TAR) (including hypersexual behavior) revealed: a. May: for all monitoring from 5/1/25 through 5/31/25, no behaviors were documented and no non-pharmacological interventions were provided. It should be noted that there were 5 DAYS that had no documentation. b. June: for all monitoring from 6/1/25 through 6/30/25, no behaviors were documented and no non-pharmacological interventions were provided. It should be noted that there were 2 DAYS that had no documentation, and 2 EVENINGS that had no documentation. In the POC (Point of Care) documentation for July and August, a 30 day look-back period, behavior monitoring included: 7/7/25 at 1:51 PM - entering another resident's room 7/13/25 at 9:59 PM - entering another resident's room 7/14/25 at 2:14 AM - disrobing in public 7/16/25 at 7:59 PM - repetitive motion and entering another resident's room 7/17/25 at 9:59 PM - hitting others, expressing frustration or anger to others, entering other resident's room 7/19/25 at 9:59 PM - entering other resident's room 7/20/25 at 7:47 PM - entering other resident's room 7/25/25 at 3:24 AM - entering other resident's room 7/26/25 at 1:59 PM - entering other resident's room 7/29/25 at 4:59 PM -entering other resident's room 7/30/25 at 1:25 PM - entering other resident's room 8/3/25 at 2:31 AM - entering other resident's room A review of resident 27's care plan revealed, The resident uses antidepressants, and anti-anxiety medications r/t [related to] anxiety, mood disorder, disrobing, and hypersexuality. Interventions included: a. Administer psychotropic medications as ordered by physician. Monitor/document side effects and effectiveness Q-shift (every shift). b. Provide structured routine and activities to reduce idle time and overstimulation. c. Review in psychotropic committee at least quarterly. The goal was to be free from discomfort or adverse reactions to psychotropic therapy through the review date. This care area was initiated on 11/10/24. A review of resident 27's progress notes revealed for the months of February, March, and April no documentation of hypersexual behavior was found in resident 27's progress notes. Progress notes in May and June revealed: On 5/16/25 at 10:55 AM, a provider progress note revealed, Chief complaint: Over affectionate Behavior, Interval History: She struggles with over affectionate behaviors. Currently on Paxil 60 mg daily. Will add Risperidone 0.5 mg bid [two times daily]. Staff continues to watch her very closely. Discussed the case with [physician] today.Medications: Depakote Oral Tablet Delayed Release 125 MG: 1 tablet by mouth two times a day, Give 1 tablet by mouth two times a day for hypersexuality Take 125 mg PO [by mouth] BID [twice daily] daily for hypersexuality. Status: ACTIVE start date: 5/1/25.Assessment/Plan: Over Affectionate behavior currently on Paxil I will add risperidone 0.5 milligrams bid. On 5/16/26 at 3:15 PM, a nursing progress note revealed, nurse practitioner [name redacted] in to see resident today and ordered to put her on Risperdal for her increase in behaviors including sexual behaviors. 0 5 mg BID. On 6/26/25 a Psychotropic Medication Review progress note revealed, Interval History: The patient is discussed today in psychotropic meeting she's been doing a little better lately with less affectionate activities given the recent medication changes will not make any new changes today.There are no other new reported problems per staff. On 8/20/25 at 9:16 AM, an interview was conducted with the Director of Nursing in Training (DON IT) who stated she had never observed resident 27 initiate any sexual behavior toward other residents. The DON IT stated resident 27 never sought out other residents, nor was she the instigator of that kind of behavior. The DON IT stated resident 27 was calm, wandered around, smiled, and giggled occasionally. The DON IT stated the most resident 27 would ever do would be to tap staff on the shoulder. On 8/20/25 at 9:28 AM, an interview was conducted with the MDS coordinator who stated resident 27 was very affectionate and would rub the backs of male and female residents alike. The MDS coordinator stated resident 27 liked to give hugs, up until the time that she left the facility. The MDS coordinator stated resident 27 did not seek out anyone in particular. The MDS coordinator stated to her knowledge, resident 27 was not kissing anyone. On 8/20/25 at 9:32 AM, an interview was conducted with the Resident Advocate (RA) who stated resident 27 did not initiate any of the incidents she was involved with in the facility. The RA stated resident 27 was not overly friendly with anyone, she did not seek out anyone, and did not exhibit any inappropriate behaviors with any residents. On 8/20/25 at 9:58 AM, an interview was conducted with the Director of Nursing (DON) who stated resident 27 was very friendly and would like to take your hand and walk with you. The DON stated resident 27 would rub the back of everyone. The DON stated resident 27's family told the facility she used to seek out and had a lot of men. The DON stated resident 27 had not done that while at the facility. The DON stated resident 27 was drawn to men and loved attention from men. The DON stated resident 27's care plan included using redirection, meaningful activities, and a busy book to prevent resident 27 from wandering into other resident rooms. The DON stated resident 27's behavior was not an all the time thing. The DON stated she would consider a chemical restraint to be a medication to hinder a resident's quality of life. The DON stated the justification used for Risperdal being used was based on the providers, pharmacist and behavior studies in this population. The DON also stated it was her belief that resident 27 being started on risperidone was related to several of the incidents involving resident 27 and different males in the building. 2. Resident 24 was admitted to the facility on [DATE] with diagnoses which included vascular dementia, bipolar disorder, borderline personality disorder, post-traumatic stress disorder, suicidal ideation, hypertension, and type 2 diabetes mellitus. Resident 24's medical records were reviewed. Resident 24's physician orders revealed the following: a. Citalopram Hydrobromide Oral Tablet, Give 40 mg by mouth in the morning for depression related to Bipolar Disorder. The order was initiated on 7/25/25. b. Prazosin HCl (Hydrochloride) Oral Capsule 1 mg, Give 3 capsule by mouth at bedtime related to Post-Traumatic Stress Disorder. The order was initiated on 5/26/25. c. Quetiapine Fumarate Oral Tablet 200 mg, Give 600 mg by mouth at bedtime related to Bipolar Disorder. The order was initiated on 5/26/25. d. Depakote Oral Tablet Delayed Release 125 mg, Give 1 tablet by mouth in the morning related to Bipolar Disorder. The order was initiated on 5/26/25. e. Depakote Tablet Delayed Release 250 mg, Give 3 tablets by mouth at bedtime related to Bipolar Disorder. The order was initiated on 5/26/25. Resident 24's July 2025 Medication Administration Record (MAR) revealed the following: a. Monitoring for anti-depressant behaviors and non-pharmacologic interventions did not have documentation on the 7/3/25 PM dose; 7/10/25 AM dose; 7/18/25 AM dose; 7/19/25 AM dose; 7/20/25 PM dose; and 7/21/25 AM dose. b. Monitoring for anti-psychotic behaviors and non-pharmacologic interventions did not have documentation on the 7/3/25 PM dose; 7/10/25 AM dose; 7/18/25 AM dose; 7/19/25 AM dose; 7/20/25 PM dose; and 7/21/25 AM dose. c. Monitoring for mood stabilizer behaviors and non-pharmacologic interventions did not have documentation on the 7/3/25 PM dose; 7/10/25 AM dose; 7/18/25 AM dose; 7/19/25 AM dose; 7/20/25 PM dose; and 7/21/25 AM dose. On 8/18/25 at 9:55 AM, an interview was conducted with the DON. The DON stated that if there were holes on the MAR it meant that the nurse did not mark it. The DON stated that it should be marked to ensure that it was completed. 3. Resident 41 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, dementia, anxiety disorder, mild cognitive impairment, neurocognitive disorder with Lewy Bodies, and psychotic disorder with hallucinations. Resident 41's medical records were reviewed. Resident 41's physician orders revealed the following: a. Clonazepam Oral Tablet Disintegrating 0.25 mg, Give 0.25 mg by mouth three times a day for anxiety. The order was initiated on 6/10/25. b. Lorazepam Oral Tablet 0.5 milligram (mg), Give 1 tablet by mouth every 12 hours as needed (PRN) for anxiety. The order was initiated on 7/24/25. c. Nuplazid Oral Tablet, Give 34 mg by mouth in the morning related to Parkinson's Disease. The order was initiated on 5/26/25 and was discontinued on 8/14/25. d. Quetiapine Oral Tablet, Give 25 mg by mouth at bedtime related to psychotic disorder with hallucinations. The order was initiated on 5/27/25 and discontinued on 8/4/25. e. Quetiapine Oral Tablet, Give 25 mg by mouth two times a day related to psychotic disorder with hallucinations. The order was initiated on 8/4/25. Resident 41's August 2025 MAR revealed the following: a. Monitoring for anti-anxiety behaviors and non-pharmacologic interventions did not have documentation on 8/6/25, 8/7/25, 8/8/25. b. Monitoring for anti-psychotic behaviors and non-pharmacologic interventions did not have documentation on 8/6/25, 8/7/25, 8/8/25. c. Monitoring for hypnotic behaviors and hours of sleep did not have documentation on 8/6/25, 8/7/25, 8/8/25. d. The Lorazepam 0.5 mg PRN was documented as administered on 8/1/25 and on 8/19/25. On 8/20/25 at 10:23 AM, an interview was conducted with the DON. The DON stated that she would look for the physician rationale to extend the PRN Ativan past 14 days with a duration of use. No additional information was provided by the DON for the extended use of the Ativan past 14 days. 4. Resident 40 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of dementia, type II diabetes mellitus, hypertension, psychotic disorder with delusions and hallucinations, anxiety disorder, insomnia, schizophrenia, and major depressive disorder. Resident 40's medical records were reviewed. Resident 40's physician orders revealed the following: a. Celexa Tablet 10 mg, Give 10 mg by mouth in the morning for depression/anxiety related to Mood Disorder. The order was initiated on 5/26/25. b. Lorazepam Oral Tablet 0.5 mg, Give 0.5 mg by mouth every 6 hours as needed for restlessness related to Anxiety Disorder. The order was initiated on 4/28/25, discontinued on 7/7/25, and reinstated on 7/7/25. c. Lorazepam Tablet 0.5 mg, Give 1 tablet by mouth one time a day related to Anxiety Disorder. The order was initiated on 3/15/23. d. Quetiapine Fumarate Tablet 50 mg, Give 1.5 tablets by mouth at bedtime related to Schizophrenia. The order was initiated on 5/26/25. Resident 40's July 2025 MAR revealed the following: a. Monitoring for anti-anxiety behavior episodes and non-pharmacologic interventions did not have documentation on the 7/3/25 PM dose, 7/6/25 PM dose, and 7/18/25 AM dose. b. Monitoring for anti-depressant behaviors and non-pharmacologic interventions did not have documentation on the 7/3/25 PM dose, 7/6/25 PM dose, and 7/18/25 AM dose. c. Monitoring for anti-psychotic behaviors with ASE and non-pharmacologic interventions did not have documentation on the 7/3/25 PM dose, 7/6/25 PM dose, and 7/18/25 AM dose. d. Monitoring for behaviors of touching, pinching, grabbing others inappropriately and non-pharmacologic interventions did not have documentation on the 7/3/25 PM dose, 7/6/25 PM dose, and 7/18/25 AM dose. e. Monitoring for hours of sleep and non-pharmacologic interventions did not have documentation on the 7/3/25 PM dose, 7/6/25 PM dose, and 7/18/25 AM dose. f. The scheduled dose of Lorazepam 0.5 mg daily was not documented as administered on 7/13/25, 7/20/25, and 7/23/25. g. The Lorazepam 0.5 mg every 6 hours as needed was documented as administered on 7/4/25 and 7/6/25. On 8/19/25 at 10:19 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that no documentation in the MAR would mean that it was not administered or completed. RN 2 stated that it should be documented in the administration details why the medication was not administered. RN 2 stated that the scheduled Lorazepam looked like it was not administered. On 8/19/25 at 11:09 AM, an interview was conducted with the DON. The DON stated that holes in MAR meant that the medication was not given. The DON stated that they had been going over PRN orders in psychotropic meetings and rationales with the duration of use was documented there. On 8/19/25 at 3:00 PM, a follow-up interview was conducted with the DON. The DON stated that she had no additional information or documentation of the rationale for extended use of the Lorazepam with the duration of use.

Based on observation, interview, and record review, it was determined that for 3 of 32 sampled residents, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan must describe the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Specifically, care plans were not updated when there was a change in the resident's condition and therefore were not reflective of the services required for the residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident identifiers: 12, 42, and 47.Findings included:1. Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of vascular dementia with agitation anxiety disorder, psychotic disorder with delusions, depressive disorder, lumbar spondylolysis, and polyneuropathy. Resident 42’s medical records were reviewed between 8/4/25 and 8/20/25. Resident 42's care plan initiated on 2/26/25 documented that the resident was at risk for falls related to medication use, dementia history of falls, poor cognition, and unsteady gait. Interventions in place included keeping his bed in low and locked position, encouraging resident to wait for assistance, wearing well fitting shoes, and increased supervision by facility staff. Resident 42’s progress notes and incident reports revealed the following: On 3/19/25 at 2:25 PM, a nursing progress note revealed, “nurse called into the dining room and was found that resident was on the floor. It was reported that he hit his head. Has been restless today and trying to stand over and over. Has sat himself on the floor several times before this fall. Resident 42’s care plan was not updated after the fall on 3/19/25. On 8/5/25 at 7: 05 PM, a nursing progress note revealed, “Resident stood up from chair in dining room and fell. Staff called for nurse, resident did not hit his head. Resident 42’s care plan was not updated after the fall on 8/5/25. On 8/10/25 at 3:42 PM, a nursing progress note revealed, “Staff was notified that resident was trying to step up onto window ledge in dining and lost his balance and fell. Unable to say if he hit his head. Resident 42’s care plan was not updated after the fall on 8/10/25. On 8/14/25 at 11:43 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4 who stated resident 42 was a high fall risk. LPN 4 stated most of the precautions in place had come from the hospice company caring for resident 42, such as the fall mat next to his bed, ensuring his room was clear of fall hazards. On 8/20/25 at 1:39 PM, an interview was conducted with the Director of Nursing (DON) who stated interventions should be in the care plan related to the falls on 8/5/25 and 8/10/25. The DON stated that to prevent falls for resident 42 right now staff were addressing his needs, assisting with toileting, addressing pain, monitoring agitation, keeping his bed in the lowest position, and prompting him to attend activities. The DON stated staff were tag-teaming resident 42 in the dining room to intervene quickly. The DON stated at the end of the alert charting assessment period, the IDT (interdisciplinary team) met and talked about what interventions should be for the recent fall, then the interventions were discussed in a staff huddle so all staff are aware of the new intervention. The DON stated the DON IT (Director of Nursing In Training) was going to investigate resident 42’s recent falls and put interventions into the care plan and they may just not have been put in yet. 2. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included alcohol dependence with Korsakoff Syndrome, alcohol-induced persisting amnesic disorder, mild dementia with agitation, major depressive disorder, psychotic disorder with delusions, altered mental status, and seizures. On 8/19/25 at 11:27 AM, an observation was made of resident 12 in his room. Resident 12 was laying on a mattress on the floor next to his bed with his limbs hanging over the edges. No staff were observed in his room or in the hallway. After staff were notified of resident 12’s position by surveyor, a CNA was observed to go into his room at 11:31 AM. Resident 12's medical record was reviewed from 8/4/25 through 8/20/25. An Annual Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) assessment could not be conducted because the resident was rarely/never understood. It further indicated a short and long-term memory problem and Cognitive Skills for Daily Decision Making was Severely impaired. It further indicated resident 12 had impairments to both sides of his upper and lower extremities, required substantial/maximal assistance to roll left and right in bed, was dependent to transfer from bed to chair, and was dependent on staff to use his manual wheelchair. A Nursing Progress Note dated 5/2/25 at 2:19 PM indicated, “resident rolled unto [sic] fall mat next to bed. no injuries noted. denies pain at this time. smiling and saying ‘i love you’ over and over. assisted him back into bed with a three person transfer. is resting comfortably in bed”. An Alert Charting document dated 5/10/25 at 1:00 AM indicated, “resident found in between bed and wall. resident did not sustain any injuries. resident was helped back into bed and neuros were initiated. Interventions to ensure brakes are initiated and ensure proper body positioning.” An Incident Report dated 7/3/25 at 10:00 PM indicated, “Resident found by cna lying between mattress and wall”. A Nursing Progress Note dated 7/9/25 at 2:14 PM indicated, “Resident found by cna lying betweenof [sic] beds and wall mattresassisted [sic] to bed,[sic] , neuro == xhecks [sic] started , appropriate administration notifed [sic], [medical doctor name redacted] notified assured wheels to bed are locked properly”. A Nursing Progress Note dated 7/14/25 at 11:14 AM indicated, “Resident fouond [sic] lying on floor slipped out of recliner no change in status, neuro checks normmal [sic], no signs of pain or discomfort. No injury noted”. A Nursing Progress Note dated 8/3/25 at 4:13 PM indicated, “CNA reported that she found resident laying on floor beside bed. Fall mat was not placed beside bed at this time. Assessed for injuries and none present at this time. Vitals taken and neuros started. Hoyer lift used to assist into WC [wheelchair]…” A Nursing Progress Note dated 8/7/25 at 5:03 AM indicated, “CNA staff were doing rounds and found resident on the floor; staff contacted nurse and nurse came in and assessed resident & initiated neuro checks per protocol (unwitnessed fall) vital signs were within normal limits…”. A Nursing Progress Note dated 8/13/25 at 8:53 AM indicated, “Resident found on floor mat next to bed. Assessed resident. No injuries noted. Took VS [vital signs], which were within normal limits. Notified DON [Director of Nursing] and MD [Medical Doctor]. Family declined to be notified of falls. Neuro checks initiated.”. The Care Plan Report indicated, “The resident is at risk for falls r/t history of falls, dependent for transfers, hx [history] of alcohol use, seizures, side effects of medications. Date Initiated: 08/10/2024 Revision on: 08/13/2025”. The Goal indicated, “The resident will not sustain serious injury through the review date. Date Initiated: 06/18/2024 Revision on: 07/10/2025…” Interventions included: a. Ensure proper body positioning. Date Initiated: 05/10/2025 It should be noted that this intervention was initially initiated on the care plan as of 11/28/24. b. Instruct resident to change positions slowly. Date Initiated: 07/03/2025 c. Ensure body positioning is adjusted frequently while in recliner. Date Initiated: 07/13/2025 It should be noted that this intervention was initially initiated on the care plan as of 5/29/25. d. Increase checks on resident while in bed to ensure proper body positioning and bed locked and in lowest position Date Initiated: 08/03/2025 It should be noted that this intervention was initially initiated on the care plan as of 11/7/24 and 12/18/24. It should be noted that there were no new interventions implemented on the falls care plan for the falls on 5/2/25, 5/10/25, 7/3/25, 7/9/25, 7/14/25, 8/3/25, 8/7/25, or 8/13/25. On 8/18/25 at 12:45 PM, an interview was conducted with the DON. The DON stated that after each fall, the fall interventions were reviewed and a new intervention should be put into the care plan. On 8/5/25 at 9:10 AM, an observation was made of resident 12 in the dining room. He was receiving full assistance to eat breakfast by the DON. His food was minced and moist and he was observed to be chewing and swallowing his food with no coughing or difficulties observed. The Care Plan Report indicated, “The resident is at risk for falls r/t history of falls, dependent for transfers, hx of alcohol use, seizures, side effects of medications. Date Initiated: 08/10/2024 Revision on: 08/13/2025”. The Goal indicated, “The resident will not sustain serious injury through the review date. Date Initiated: 06/18/2024 Revision on: 07/10/2025…” An intervention included, “10/2/2024: Make sure resident has adequate hydration and nutrition in the form of bowl of nuts and water in his cup. Date Initiated: 10/02/2024 Revision on: 04/21/2025”. A Physician’s Order dated 12/9/24 at 11:05 AM indicated a Mechanical Soft/Minced & Moist 5 texture diet. A Nutritional Status note dated 7/9/25 at 7:43 PM indicated, “Nurse performed the heimlich maneuver, resident coughed and started to breath. Had aids reposition resident at a 90% angle, slowdown and do smaller bites. Informed admin and doctor. Will refer to speech therapy for a swallow evaluation.” A Physician’s Order dated 8/12/25 at 11:35 AM indicated a Puree/Puree 4 texture, Nectar/Mildly Thick 2 consistency diet. On 8/13/25 at 1:53 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated resident 12 was fully dependent on staff to eat and was on a pureed diet. LPN 4 stated he takes his medications crushed and in pudding. On 8/14/25 at 10:30 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated she was not aware of resident 12 having a choking incident but thought he was on a puree diet. On 8/19/25 at 11:40 AM, an interview was conducted with LPN 3. LPN 3 stated care plans should be reviewed quarterly and as needed. LPN 3 stated the DON and dietitian should update care plans as well. On 8/19/25 at 2:21 PM, an interview was conducted with the Registered Dietician (RD). The RD stated resident 12 was on a puree diet and that a bowl of nuts was not appropriate. On 8/19/25 at 2:54 PM, an interview was conducted with the DON. The DON stated the bowl of nuts was an intervention that was left over from before. The DON stated she would resolve that intervention. 3. Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, type 2 diabetes mellitus, delirium due to known physiological condition, major depressive disorder, generalized anxiety disorder, chronic pancreatitis, essential hypertension, and cognitive communication deficit. Resident 47's medical record was reviewed from 8/4/25 through 8/20/25. An admission MDS assessment dated [DATE] indicated resident 47 had a BIMS score of 3. A BIMS score between 0 and 7 indicated severe cognitive impairment. It further indicated wandering behaviors were not exhibited. A Social Services Note dated 6/7/24 indicated, “…[Resident 47] is a high wander risk. He is often walking around the building and outside in the backyard. Staff is able to check on him frequently and provide activities to reduce risk of wandering. [Resident 47] has not left facility unattended.” A Behavior Note dated 6/18/24 indicated, “Resident brought all of his things out by the front door and began trying to force the door open. I was able to redirect him and assist him in taking his things back to his room…He is more calm at this time but has been hovering the nurses station and wanting to talk and tell me about how he will be leaving this place soon to go to ‘the real Utah’.” A Behavior Note dated 6/19/25 indicated, “Resident exit seeking. He yelled at med tech rude comments when trying to guide him away from the front door which he was blocking people from entering or exiting. I was able to ask resident to move away from the door and took his things back to his room…”. A Physician progress Note dated 6/25/24 indicated resident 47 had been more aggressive and had characteristic behaviors of sundowning and exit seeking. A Nursing Progress Note dated 6/27/24 indicated, “Resident very combative, wants to get out of this place. When nurse asked pt [patient] to please move from infront [sic] of her cart, resident pushed the nurse into the cart. Resident continued to threaten nurse and swing at her and the CNA's…” A Nursing Progress Note dated 7/11/24 indicated, “…[Resident 47] has been asking people to open the door for him recently. But has not been combative with staff, just frustrated when they do not let him out. He often tells staff there is someone waiting for him just outside the door, which is not true.” It should be noted that there were no new approaches documented on the care plan for exit seeking behaviors since admit date of 4/22/24. A Nursing Progress Note dated 7/12/24 indicated, “Resident had been sitting next to the nurses cart dozing off. Nurse started to prep residents medications and turned to talk with resident. Staff search the facility for resident to no avail. A code [NAME] was called by nurse and the police were called. Eventually, resident was found at [City name redacted] [Store name redacted] [The store was approximately 6.8 miles from the facility]. Resident reports he went out the front door. He also reported that he took a bus to [City name redacted]. DON notified, MD notified, Family notified, Management notified and searched for resident.” A Nursing Progress Note dated 8/3/24 indicated, “Resident went to Conference Room, opened the window, kicked the screen off, and climbed the window going outside. Staff members went outside right away, and helped resident back inside the building…” It should be noted that there were no new approaches documented on the care plan after this incident. A Behavior Note dated 8/5/24 indicated, “Resident found standing on the planter box in the backyard and trying to hop over the fence. I was able to get him back down but he initially tried harder to hop the fence when he saw us until I climbed onto the planter with him. He then allowed us to help him down…” It should be noted that there were no new approaches documented on the care plan after this incident. A Nursing Progress Note dated 8/9/24 indicated, “Resident was found on state street in [City name redacted] by a staff member and brought back to the facility just as the nurse was looking for the resident. Resident was asked how he got out of the facility and the resident reports he exited the front door. He reports he does not remember who let him out…”. A Nursing Progress Note dated 8/20/24 indicated, “resident attempted to elope and was found still on the facility premisis [sic] by a physical therapy personelle [sic] around 1805 [6:05 PM]. when asked how he got out he was not an accurate hisotrian [sic] and said he went through the front door but also said he jumped over the fence. upon further investigation, staff found an outside chair pushed up against the west fence and this is how we presume he got outside. Notified administration, ADON [Name redacted][Assistant Director of Nursing], and will continue checking his where abouts every hour. messaged management aboutgetting [sic] the outside chairs perminantely [sic] secured to the ground and kept away from the fences to prevent this from happening again in the future. Chairs are temporarily secured and unable to be moved at this time.” It should be noted that there were no new approaches documented on the care plan after this incident. A Nursing Progress Note dated 8/20/24 indicated, “we did hourly checks until he stopped exit seeking which was at 2100 [9:00 PM]. we checked every hour since 1800 [6:00 PM] shortly after he tried eloping…”. A Behavior Note dated 8/28/2024 indicated, “Resident has been exit seeking and becoming more and more determined to leave as he has bumped people leaving, circled around the door, and even pushed people to get through. He is also bringing his items out from his room and leaving them by the front door in an attempt to leave with his things. MD and NP [Nurse Practitioner] notified of worsening behavior.” A Nursing Progress Note dated 8/28/24 indicated, “resident is extremely anxious and agitated tonight. tried exiting the building twice. tried opening a locked door to the conference room and almost broke it because he was agressively [sic] pulling the handles. redirects with multiple people repeating the same direction.” A Behavior Note dated 9/2/24 indicated, “Resident caught climbing planters and trying to hop the fence…”. It should be noted that there were no new approaches documented on the care plan for exit seeking behaviors since 8/12/24. A Nursing Progress Note dated 10/2/24 indicated, “Resident was found 1.5 blocks from the facility walking towards the [Store name redacted] by the [City name redacted] police. Facility was called and a staff member went and picked resident up and brought him back to the facility…”. The care plan Problems initiated on 4/22/24 indicated, “Resident exhibits/at risk for behaviors such as wandering, agitation, aggression, refusal of cares, wandering, exit seeking and elopement, related to delirium, insomnia, cognitive communication deficit” and “The resident is an elopement risk r/t wandering and exit seeking behaviors, history of elopement.” Approaches were updated after the first documented elopement on 7/11/24 and initiated on 7/12/24 which included: a. Memory care unit; b. Orient and reorient on an ongoing basis; c. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; and d. Re-educate resident regarding safety and risk of leaving. Approaches were updated after the second documented elopement on 8/9/24 and initiated on 8/12/24 which included: a. If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; b. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed; c. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. No new Approaches were updated on the care plan after the third documented elopement on 8/20/24. Approaches were updated after the fourth documented elopement on 10/2/24 and initiated on 10/2/24 which included: a. Evaluate all windows to make sure they are secured within guidelines for wander safety. Re-secure window resident went through. An incident report dated 7/11/24 indicated, “Window stops placed at all windows…” On 8/14/25 at 2:42 PM, LPN 4 stated she did not know who updated the care plans. On 8/18/25 at 12:45 PM, an interview was conducted with the DON. The DON stated after an incident occurs, it would be reviewed to see what happened, discussed in morning meeting, and then new interventions would be put into the care plan. On 8/19/25 at 12:25 PM, an interview was conducted with the Administrator (Admin). The Admin stated interventions should have been implemented after the resident attempted to hop over the fence by standing on the planter on 8/5/24.

Based on interview and record review, the facility used individuals working in the facility as a nurse aide for more than 4 months, on a full-time basis. Specifically, seven Nursing Assistants were providing resident cares despite working at the facility for more than 120 days and not being certified.Findings included: On 8/12/25, the list of Nursing Assistants (NAs), Certified Nursing Assistants (CNAs) and Environmental Aides provided by the facility was reviewed and revealed the following:NA 1 was listed as an environmental aide and had a hire date listed as 12/6/24. NA 2 was listed as an environmental aide and had a hire date listed as 12/3/24.NA 3 was listed as an environmental aide and had a hire date listed as 12/17/24. NA 4 was listed as an environmental aide and had a hire date listed as 3/10/25.NA 5 was listed as an environmental aide and had a hire date listed as 1/3/25. NA 6 was listed as an environmental aide and had a hire date listed as 11/7/23.NA 7 was listed as an environmental aide and had a hire date listed as 1/30/24.The facility staff schedule for the week of 8/3/25 through 8/9/25 and 8/10/25 through 8/16/25 were reviewed. NA 1, NA 2, NA 3, NA 4, NA 5, NA 6 and NA 7 were all scheduled and assigned a section of the facility to provide cares for residents during those weeks. On 8/12/25 at 11:10 AM, an interview was conducted with NA 6. NA 6 stated she had worked at the facility a while but was not certified because she had let her Certified Nursing Assistant (CNA) license expire. On 8/20/2025 at 8:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the environment aides were CNAs in training. The DON stated that they did the same duties as the CNA's but were not certified. The DON stated they should be certified and have tested 120 days from hire. The DON stated she knew that NAs 2, 4 and 7 had taken the class and just needed to take the test. The DON stated the DON in training (DON IT) was over the NA certification. On 8/20/2025 at 9:12 AM, an interview was conducted with the DON IT. The DON IT stated that when the NAs started work at the facility they were told to get their CNA certification. The DON IT stated that the facility did not have a specific program that they went through, they left it up to the employee to get signed up. The DON IT stated it was her responsibility to follow through with and ensure the NAs had completed their training and had taken the test. The DON IT reviewed the list of environmental aides with this surveyor and stated that each of them had gone over the 120 days and should have had it completed in order to be certified. The DON IT stated she had not kept up on making sure the NAs were certified within the 120 days.

Based on observation and interview, the facility did not have menus that met the nutritional needs of residents in accordance with established nutritional guidelines, did not follow the menu, and although the menus were reviewed by the facility's dietitian, did not demonstrate nutritional adequacy given the resident population. Specifically, the menus were altered from their original form to include the removal of the continental breakfast, a snack during the lunch time, and a larger dinner meal. A snack was then offered in the evening, although it could not be determined to be substantial to meet nutritional needs. Resident identifiers: 5, 18 and 25. Findings included: On 8/4/25 the breakfast meal was observed. Residents were served 2 pieces of French toast, a bowl of hot cereal, a bowl of cold cereal if they wanted one, one sausage link, 4 oz (ounces) of orange juice and 8 oz of milk. On 8/5/25 at 12:52 PM, an observation was made of the lunch meal. Residents were being served 1 slice of cheese pizza and their choice of lemonade or water. An interview was conducted with CNA 1 who stated the lunch meal was not a special meal, but sometimes the residents had pizza for lunch.On 8/5/25 at 1:01 PM, an observation was made of the posted weekly menu. The lunch menu for 8/5/25 listed 1 slice of cheese pizza and beverage of choice. The lunch menu items for the remainder of the week were as follows: 8/4/25-1 Deli Swiss sandwich, 1 (oz) watermelon, beverage of choice.8/6/25-1 BBQ pulled pork on a bun, 1 oz chips, 1 c (cup) beverage of choice.8/7/25-1 Hawaiian grilled cheese, 1 oz chips.8/8/25-1/2 cup fruit cocktail, 1 cup beverage of choice.8/9/25-1 chicken patty sandwich, 3 oz fries, 1 cup beverage of choice.An observation of the posted breakfast menus were as follows: 8/4/25-French toast, 2 each, 3/4 c of hot cereal, 1 oz of cold cereal, 1 sausage link, 4 oz of 100% orange juice, 8 oz milk.8/5/25-3x [by] 2 inch piece of Mediterranean quiche, 3/4 c of hot cereal, 1 oz of cold cereal, 4 oz of 100% juice, 8 oz milk.8/6/25-1 cheese omelet, 3/4 c of hot cereal, 1 oz of cold cereal, 4 oz of 100% juice, toast of choice, 8 oz of milk.8/7/25-1 Morning [NAME] muffin with coconut, 3/4 c of hot cereal, 1 oz of cold cereal, 1 hard boiled egg, 4 oz of fruit yogurt parfait, 4 oz of 100% juice, 8 oz of milk.8/8/25-1 breakfast biscuit and gravy, 3/4 c hot cereal, 1 oz cold cereal, 1 fried egg, 4 oz 100% juice, 8 oz milk8/9/25-2 homestyle waffles, 3/4 c hot cereal, 1 oz cold cereal, 1 oz sausage link, 4 oz of 100% juice, 8 oz milk.An observation of the posted dinner menus were as follows: 8/4/25-8 oz chicken rice bake, 1/2 cup farm fresh vegetables, 1 oz roll with margarine, 8 oz milk, double chocolate chip cookie.8/5/25-3 oz BBQ pork ribs, 1/2 cup sweet potato casserole, 1/2 c Harvard beets, 1 baked roll, 1 cup milk, 3x2 inch marble cake.8/6/25-3 oz hamburger steak with gravy, 1/2 c garlic herb mashed potatoes, 1/2 c peas and mushrooms, 1 baked roll, 1 cup milk, 1/2 cup cherry fluff.8/7/25-RESIDENT CHOICE MEAL-Sweet and sour chicken, fried rice, oriental veggies, egg roll, fortune cookie, ice cream.8/8/25-3 oz lemon garlic fish, 3 oz fries, 1/2 c California blend (vegetables), 3x2 inch piece fresh cornbread, 1 cup milk, 1 snickerdoodle.8/9/25-1 cup burgundy beef and noodles, 1/2 cup buttered carrots, 1 baked roll, 1 cup milk, 3x2 inch apple walnut cake. On 8/11/25 at 12:38 PM, an observation was made of the lunch meal which consisted of 1 small piece of vegetarian quiche and a beverage. On 8/11/25 at 1:10 PM, an interview was conducted with the Dietary Manager (DM) who stated a snack was provided to the residents at 7:00 PM each night. The DM stated the snack was provided in the dining room, and to the residents in their rooms if they chose not to go to the dining room. The DM stated the snacks that were available were sandwiches, fruit, yogurt, applesauce, pudding, cheese sticks, fruit, cookies, crackers, chips, milk, and punch. The DM stated residents could choose 2 items initially and could ask for more after everyone had been given the opportunity to have a snack. On 8/12/25 at 12:32 PM, an observation was made of resident 18 who was sitting at a table for the lunch meal. Resident 18 asked for 1/2 of a sandwich. The CNA stated that was what was being served. The CNA proceeded to place some cut up sandwich pieces into a bowl with serving tongs, and then pour some ice water into a cup. The sandwich pieces were not measured for the amount that was served. Resident 18 was not offered chips, which were listed on the menu.On 8/12/25 at 12:38 PM, an observation was made of a CNA serving 1 unknown scoop size of pureed sandwich into a Styrofoam bowl for a resident. There was no substitution for the chips that were supposed to be offered for the meal.On 8/12/25 at 12:42 PM, an observation was made of a CNA serving sandwiches in the [NAME] hallway. Resident 25 and his wife were getting ready to leave the building and asked if they could have a sandwich. The CNA put 1/2 a sandwich on a plate for each of them and offered them a drink. The CNA did not offer chips with the meal. The CNA told resident 25 to enjoy his snack.On 8/12/25 at 12:51 PM, an interview was conducted with Nursing Assistant (NA) 6 who stated the staff called the lunch meal a snack, but it was really the lunch meal. On 8/12/25 at 1:03 PM, an interview was conducted with the DM who stated the lunch meal was a sub (submarine) sandwich that included a slice of ham, a slice of turkey, and a slice of salami, a slice of provolone cheese, lettuce, tomato, onion, and mayonnaise. The DM stated residents were first served 1/2 of a sandwich but could ask for more if they wanted more. The DM stated a 1/2 cup scoop was being used for the puree serving. The DM stated the CNAs should be asking each resident if they wanted chips with their sandwich. The DM looked at the spreadsheet for the lunch meal which stated that the chips were to be pureed in with the sandwich. The DM stated she did not know if that was done. The DM asked [NAME] 1 if he had done that when preparing the meal and he stated he had not. The DM stated there was no substitution offered for the chips for residents who received a pureed sandwich. The DM stated the CNAs were supposed to be using a 1/2 cup scoop for serving the bite sized sandwich pieces. [NAME] 1 stated he put the serving tongs on the serving tray instead of the scoop. The DM stated the lunch meal was a light lunch. The DM stated they served brunch from 8:30 until 11:00, the snack during the noon hour, and dinner, which was the larger meal at 4:00. The DM stated residents were able to eat any time of the day because snacks were available.On 8/14/25 at 8:45 AM, an observation was made of the breakfast meal which consisted of 1 breakfast burrito, a bowl of oatmeal, 2 orange slices and a glass of milk. The menu listed: 1 breakfast burrito, 3/4 c of hot cereal and 1 oz cold cereal and 1/4 c fresh tomato salsa, 1/2 100% juice, 1 cup milk.The pureed breakfast burrito appeared orange in color. Residents were observed to be picking the insides out of the tortilla. Some residents were observed to have pancakes, and resident 5 stated he did not like his breakfast. On 8/19/25 at 12:07 PM, an interview was conducted with the DM who stated the meal service with the light lunch has always been that way. The DM stated it works for this particular building and population. The DM stated the menu system used in the facility required that she make substitutions and alterations for the lunch/snack. The DM stated the residents that were losing weight were the residents who were in the dining room eating meals. The DM stated residents who were hungry were able to tell them if they wanted something to eat.On 8/19/25 at 1:54 PM, an interview was conducted with the Registered Dietitian (RD) who stated the menus were modified a little bit. The RD stated a continental breakfast was served from 7-9 in the morning and brunch was served from 9-11 AM. The RD stated a lunch/snack was served during the noon hour. The RD stated the DM made the modifications for the lunch/snack and the RD approved those modifications. The RD stated that the average calories per day provided by the menu was 2000. The RD stated for the week, some days might be more, and some might be less. The RD stated the facility had been doing 5 meals each day for more than 8 years and that it worked well for the facility. The RD stated resident weights were looking good. The RD stated not every resident was able to relay if they were hungry. The RD stated the staff knew the residents well and monitored the resident's weight. The RD stated if a resident was not eating, then more interventions would be put into place for that resident. On 8/20/25 at 11:59 AM, an interview was conducted with the DM who stated the RD relied on her for a lot of things because she had so many buildings to cover. The DM stated the RD allowed her to run the department. The DM stated the CNAs knew the residents and their behaviors and were able to determine what their needs were. The DM stated that she was not at the facility in the evenings and did not know how to monitor what snacks the residents were getting. The DM stated the residents were able to choose 2 items and after everyone had the opportunity to have a snack, additional snack items could be taken. The DM stated if a substitution was needed for a menu item, such as for a puree diet, she could offer mashed potatoes with gravy in place of the starch or applesauce for fruit. The DM stated she did not know where it was documented what snack items the residents were choosing and how much they were eating. The DM stated staff were not looking at the resident's orders for snacks, residents were just being asked if they wanted a snack and it was being provided to them.On 8/20/25 at 12:50 PM, an interview was conducted with CNA 1 who stated the items in the refrigerator that were offered for the evening snack were the same that were offered for the continental breakfast. CNA 1 stated there was no place in the resident's medical record to document if the resident ate during the continental breakfast or the evening snack. CNA 1 stated only residents who were able to feed themselves were able to eat the continental breakfast. On 8/20/25 at 1:15 PM, a second interview was conducted with the RD. The RD stated when the current DM started she discontinued the muffins and sweet rolls from the continental breakfast and incorporated things such as hard boiled eggs. The RD stated the DM also took away the scheduled times for the continental breakfast and the regular breakfast. The RD stated residents could get breakfast when they wanted it. The RD stated in the medical record meals were documented as breakfast, lunch and dinner. The RD stated that based on the 3 meal menu, the calories should be meeting the nutritional needs of the residents. The RD stated the menu provided 2000 calories and 80 grams of protein on average each day, not including the snacks or added intake during the continental breakfast time. The RD did not know where snacks acceptance were documented. The RD stated residents that were experiencing weight loss were being followed in the skin and weight meetings. The RD acknowledged the level of cognitive impairment among the residents at the facility and that some may not have the ability to verbalize their needs.

Based on interview and record review, the facility did not provide training to their staff that at a minimum educated staff on activities that constituted abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property; and resident abuse and neglect prevention. Findings included: On 8/6/25 at 11:58 AM, an interview was conducted with Nursing Assistant (NA) 6. NA 6 stated they did education at the facility. NA 6 stated they just went over things that needed to be fixed. Usually the teaching was done during the in-service or the daily huddle that they had with everyone. NA 6 was not sure what the Quality Assurance and Performance Improvement (QAPI) meetings were about or if there was education that went over that stuff. On 8/19/25 at 1:33 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated they did get education at work but he was unsure what QAPI was. RN 2 stated they did education when there was something that needed to be corrected.During an interview on 8/19/25 at 9:15 AM, the Administrator stated there had been training done on abuse every month. The Administrator stated they discussed the types of abuse that could happen in a facility. The Administrator stated they did not have a way to determine if the information was understood by the staff but they just kept educating on it monthly. The Administrator stated the staff in-services did not provide education on a person's ability to give consent so the staff were not educated on that area. The Administrator stated that he had sent over the facility in-services to the survey team.It should be noted, none of the in-service staff trainings from 1/16/25 through 7/17/25 that were provided by the facility on 8/19/25 included agendas for abuse training. Agendas for dementia, assault, de-escalation and speech/space/grace trainings were provided but none of these trainings defined abuse, explained types of abuse, what to do when abuse occurred, who to report the abuse to and who had the ability to give consent.A follow up interview was conducted on 8/20/25 at 8:57 AM with the Administrator. The Administrator stated they have tried to ensure everyone understood the teaching when it was provided, but staff may not practice what was taught when they were working. The Administrator stated they were trying to make sure the education encompassed the entire problems addressed during QAPI. The Administrator stated that the abuse training needed to be updated and they were trying to make that better. [Cross refer to F600]

Based on interview and record review it was determined, for 1 of 32 sampled residents, that the facility did not notify the resident's physician when there was a need to alter treatment or a significant change in the resident's physical, mental, or psychosocial status. Specifically, a resident reported that his as needed (PRN) medication to treat symptoms of Parkinson's Disease was ineffective and the physician was not notified. Additionally, a resident reported that their TUMS medication was ineffective in treating their symptoms of reflux and the physician was not notified. Resident identifiers: 24 and 41.Findings included:1. Resident 41 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, dementia, anxiety disorder, mild cognitive impairment, and neurocognitive disorder with Lewy Bodies. On 8/4/25 at 10:35 AM, an interview was conducted with resident 41. Resident 41 stated that he had a tremor when his medication was not administered when it needed to be. Resident 41 stated he had to request the medication between every 3 to 6 hours. Resident 41's medical records were reviewed. Resident 41's physician orders revealed the following: a. Carbidopa-Levodopa Oral Tablet 25-100 milligrams (mg), give 1 tablet by mouth as needed for breakthrough Parkinson's symptoms. b. Inbrija (Levodopa) Inhalation Capsule 42 mg, inhale orally every 4 hours as needed for Parkinson's symptoms. c. Vistaril (Hydroxyzine) Oral Capsule 25 mg, give 25 milligram every 12 hours as needed for itching. Review of resident 41's August Medication Administration Record (MAR) revealed the following: a. On 8/5/25, the Carbidopa-Levodopa PRN medication was documented as ineffective. b. On 8/6/25, the Inbrija medication was documented as ineffective. c. On 8/5/25, the Vistaril medication was documented as ineffective. No documentation could be found that indicated that the physician was notified of resident 41's ineffective medication treatments. On 8/20/25 at 10:15 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 41's Carbidopa-Levodopa was to treat his Parkinson's disease. RN 2 stated that the Inbrija inhalation was to treat his breakthrough symptoms of Parkinson's. RN 2 stated that resident 41's Parkinson's symptoms included excessive shaking, unsteady gait, and shuffling. RN 2 stated that resident 41 would ask for the PRN medication if he noticed that the symptoms were worsening. RN 2 stated that the Vistaril was ordered for itching but that resident 41 reported it helped with his tremors. RN 2 stated that he would conduct a quick assessment and ask resident 41 how he was feeling or if he was experiencing those symptoms. RN 2 stated that the symptoms did not go away but lessened in severity with the medication. RN 2 stated that the timeframe for following up on the effectiveness of the medication administration was 30 minutes to 1 hour after administration. RN 2 stated that if the resident reported that the medication was ineffective he would notify the provider. RN 2 stated that he would document that the provider was notified in a progress note. On 8/20/25 at 10:23 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should notify the provider when a medication was ineffective to see if there were any other interventions that should be provided. The DON stated that the nurse should document that the provider was notified in a progress note. 2. Resident 24 was admitted to the facility on [DATE] with diagnoses which included vascular dementia, bipolar disorder, borderline personality disorder, morbid obesity, hypertension and type 2 diabetes mellitus. Resident 24's medical records were reviewed. On 7/24/25, the physician ordered Tums Oral Tablets 500 mg, give 2 tablets by mouth every 2 hours as needed for heartburn and indigestion. Do not exceed 15 tablets in a day. On 7/24/25 at 10:30 AM, resident 24's July MAR documented that the Tums medication was ineffective. The MAR did not document that any additional doses were administered. No documentation could be found that indicated that the physician was notified of resident 24's ineffective medication treatments. On 8/18/25 at 9:55 AM, an interview was conducted with the DON. The DON stated that if medication was documented as ineffective the nurse should follow-up with the resident to see what other options had worked in the past and the the nurse should notify the provider to see if anything else could be ordered or administered. The DON stated that no documentation could be found to indicate that the provider was notified of the ineffective medication administration. The DON stated that no documentation could be found to indicate that the nurse administered any additional doses of Tums after the ineffective dose was administered.

Based on interview and record review it was determined, for 1 of 32 sampled residents, the facility did not ensure an assessment accurately reflected the resident's status. Specifically, a resident was not assessed for activities on the Minimum Data Set (MDS) assessment. Resident identifiers: 41.Findings included:Resident 41 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, repeated falls, dementia, depressive episodes and Dorsalgia. On 8/4/15 at 10:48 AM, an interview was conducted with resident 41. Resident 41 stated he would like more activities and would like to get out more. Resident 41 stated he missed a trip to the aquarium and wanted to go to a local store.A MDS assessment dated [DATE] revealed resident 41 was not assessed for daily preferences related to activities. On 8/7/25, an interview was conducted with the MDS coordinator. The MDS coordinator stated the MDS was not completed and she did not know why they were not answered. The MDS coordinator stated section F should have been completed.

Based on observation, interview, and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 16 sampled residents, a resident tripped over a cord placed on the ground by a Certified Nursing Assistant (CNA) and suffered a patella fracture and a subarachnoid hemorrhage. Resident identifier: 21. Findings included: Resident 21 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, repeated falls, abnormalities of gait, presence of intraocular lens, fracture of right patella, subarachnoid hemorrhage, insomnia and mood disorder. Resident 21's medical record was reviewed on 11/27/23. Resident 21 had a BIMS (Brief Interview for Mental Status) score of 99 and was unable to interviewed when attempted by this surveyor. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented resident 21 required supervision and a one person physical assist with locomotion on and off the unit. A fall review completed on 6/28/23 documented resident 21 was a high fall risk. A Care plan focus dated 9/13/22 documented, the resident (21) was risk for falls r/t (related to) history of falls and impaired gait. Interventions dated 4/6/23 were increase supervision as resident wanders into other rooms and needs to supervised. A fall risk assessment dated [DATE] documented, resident was a high risk for falls and that Resident tripped over an oxygen concentrator cord on the floor. On 7/20/23 at 3:41 PM, Exhibit 358 initial entity report documented the resident had an injury of known origin. [Licensed Practical Nurse (LPN 2) called DON [Director of Nursing] and told him that resident [21] had fallen. She called on call provider and was told to send her to hospital for further workup and assessment. at 3:41 [DON] received a message from [LPN 2] that stated she called the hospital to follow up and was told that [resident 21] as in the ICU [Intensive Care Unit] with a patellar fracture and subarachnoid bleed. On 7/19/23 at 8:27 PM, a Nursing Progress note documented, Daughter [name omitted] and notify the fall [sic]. Resident is now been taken to [local hospital] ER [emergency room ] fr [for] [sic] treat and evaluation per [provider] on call for [medical doctor's] orders. On 7/20/23 at 3:26 AM, a Nursing Progress note documented, [Nurse] called [local hospital] ER and talked to the nurse. Resident was admitted to the ICU with intracranialsubdural arachnoid bleeding, and patella Fx [fracture]. On 7/20/23 at 10:03 AM, a Nursing Progress note documented, [Nurse] called [local hospital] ICU to get a follow up on [resident 21's] condition. they said the bleed was stable and no changes and that she most likely will not need surgery. They will monitor her and send her back. Family has been updated. On 7/22/23 at 2:04 AM, a Nursing Progress note documented, Resident got back from the hospital today after her fall. VS [vital] signs WNL [within normal limits] and patient LOC [level of consciousness] is also at baseline. No concerns at this time. On 7/23/23 at 3:46 AM, a Nursing Progress note documented, Resident [21] seemed to be in pain the afternoon and NOC [night] shift and was moaning and kept trying to change positions.PRN [as needed] pain medications given and she has slept all night. No concerns at this time. Exhibit 359 documented that the allegation was verified and that the corrective action would be Continued education and training. No education or training was documented as being provided to the staff after the incident occurred. On 11/29/23 at 3:40 PM, an interview was conducted with CNA 1. CNA 1 stated resident 21 needed extensive assistance with cares. CNA 1 stated resident 21 liked to explore the unit a lot, so we had to supervise her more than some of the other residents. CNA 1 stated resident 21 fell in the dining room in July and had gotten hurt. CNA 1 stated there were other residents in the dining room sitting at a table and an oxygen concentrator was moved closer to a resident at the table. The cord from the oxygen concentrator was across the floor and plugged into the wall. CNA 1 stated the passage was narrow that resident 21 was walking through and she tried to step over the cord and tripped and fell . CNA 1 stated resident 21 hit her knee and head when she fell . CNA 1 stated that having the cord across the floor was definitely a tripping hazard. CNA 1 stated LPN 2 and her went over to the resident 21 and she was lying on her back, was incoherent with rapid eye movements and did not respond for a minute. CNA 1 stated resident 21 would not respond to her name, then when resident 21 was asked if she was in pain she responded with yes. CNA 1 stated resident 21 had a gash above her eye brow. CNA 1 stated the ambulance was called and resident 21 was transferred to the hospital. CNA 1 stated she did not realize a cord across the floor could cause such a problem and we figured that we would not do that anymore. CNA 1 stated the facility had not provided education on tripping hazards but that LPN 2 had pulled the aides aside that worked that shift and told us not to do it. CNA 1 stated the incident and injuries to resident 21 could have been avoided. On 11/29/23 at 3:51 PM, an interview was conducted with LPN 2. LPN 2 stated resident 21 fell in the dining room and had gotten hurt. LPN 2 stated the tables had been pushed together, into a rectangle, and resident 21 was ambulating between the table and a nearby cabinet. LPN 2 stated it was a narrow passage and resident 21 fell . LPN 2 stated she told the aides to be careful because resident 21 did not see very well and she is unsteady and stumbled. LPN 2 stated she noticed resident 21 was limping after the fall and the medical doctor told them to send her to the hospital. LPN 2 was unaware of any education provided about tripping hazards provided by the facility. LPN 2 stated that she had talked with the aides on shift about falls. On 11/30/23 at 8:10 AM, an interview was conducted with CNA 3. CNA 3 stated the facility had a meeting every third Friday of the month for education. CNA 3 did not remember if tripping hazards had been part of the CNA education. On 11/30/23 at 8:30 AM, an interview was conducted with CNA 4. CNA 4 stated there was a staff meeting every month to go over education and topics that needed attention. CNA 4 stated fall prevention had been a topic, but mostly on how to transfer residents, not on tripping hazards. CNA 4 stated resident 21 did like to walk around a lot and that they had to watch her more than some of the other residents. On 11/30/23 at 10:17 AM, an interview was conducted with the DON. The DON stated the resident 21 had tripped over an oxygen concentrator cord in the dining room and had gotten injured. The DON stated after that incident, oxygen concentrators were left in the residents' rooms and portable oxygen tanks that could be attached to the wheelchairs or that were on carts would be used. The DON stated after there was an incident the staff made him aware and all of the staff involved would have a discussion about what had happened. The DON stated every day there is a huddle that was done to go over incidents that had happened or items that need attention and the huddle forms are passed through the staff for a week so everyone can see them. The DON stated monthly inservices were done to cover bigger trends that were being seen in the building. The DON could not remember if an inservice had been completed after resident 21's fall. On 11/30/23 at 10:35 AM, an interview was conducted with the Administrator (ADM). The ADM stated he was not the ADM at the time of the incident but realized it could have been avoided. The ADM stated they had made improvements to help keep all of the residents safe. On 11/30/23 the facility Fall Prevention Program was received and documented a guideline of, The Fall Prevention Program was designed to ensure a safe environment for all residents . With a purpose to include, .To ensure consistency in the implementation of preventive measures to assists with reduction of falls.