Every finding on record at Onyx Care of Bernice

Based on interviews, observations, and record reviews, the facility failed to ensure a resident with a urinary indwelling catheter received necessary treatment and services, consistent with professional standards to promote healing and prevent infections for 1 (#92) of 3 residents reviewed for urinary catheters. Findings:Review of the record for Resident #92 revealed and admission date of 05/13/2023 and readmission date of 05/14/2026 with diagnoses that included dementia, obstructive and reflux uropathy, long term use of anticoagulants, anemia, and schizophrenia. Further review of the record revealed resident was readmitted to the facility on [DATE]. Review of hospital discharge orders included instruction for indwelling urinary catheter to gravity. Further review revealed, upon Resident #92's return, S10LPN failed to: 1) document the presence of the indwelling urinary catheter, and 2) implement appropriate interventions for care of the indwelling urinary catheter. Review of the quarterly MDS assessment dated [DATE] revealed Resident #92 was frequently incontinent of bladder and had no urinary appliances. Review of the indwelling urinary catheter plan of care revealed interventions included: 1) monitor and document intake and output per facility policy, and 2) monitor/record/report to physician signs and symptoms of a urinary tract infection. On 05/18/2026 at 9:09 a.m., an observation of Resident #92 revealed an indwelling urinary catheter draining tea colored urine. On 05/18/2026 at 10:00 a.m., S2DON reported the facility did not have a policy to address indwelling urinary catheters.On 05/18/2026 at 1:30 p.m., review of Resident #92's current MAR revealed no documented evidence of urine monitoring and catheter care every shift.On 05/18/2026 at 2:00 p.m., review of Resident #92's current physician's orders revealed no orders for the monitoring of urine, urinary catheter care, or to record intake and output every shift. An interview on 05/19/2026 at 11:20 a.m. with S11RN confirmed indwelling catheter care orders, which included urine monitoring and catheter care every shift, were not implemented upon Resident #92's return. An interview on 05/19/2026 at 11:30 a.m. with S10LPN confirmed he failed to document the presence of the indwelling urinary catheter. On 05/20/2026 at 3:00 p.m. S2DON confirmed the facility failed to implement appropriate interventions for care of a urinary catheter for Resident #92 when she was readmitted to the facility on [DATE].

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable, and homelike environment for 1 (#9) of 6 sampled residents reviewed for environment. The facility failed to ensure Resident #9's door to a shared bathroom remained in good repair. Findings:On 05/18/2026 at 8:00 a.m. and 05/19/2026 at 8:15 a.m., an observation of Resident #9's room revealed a shared bathroom between Resident #9's room and the adjacent resident room. Further observation revealed the bathroom door was unable to close completely due to the door hitting the door frame when attempting to close.On 05/19/2026 at 9:37 a.m., an observation conducted with S1Administrator confirmed Resident #9's bathroom door was unable to close completely due to door hitting the frame, and needed to be repaired.

Based on observations and interviews, the facility failed to ensure it maintained an effective pest control so that the facility was free of pests by having flies throughout the facility on all days of the survey.Findings: Observations on 05/18/2026, 05/19/2026, and 05/20/2026 revealed multiple flies in the following residents' rooms for Resident's #70, #74, #75, #48, #40, #72, #23, #86, #54, #87, and #59.Further observations revealed flies in the activity room on all days of the survey. On 05/19/2026 at 3:00 p.m., S1Administrator was informed of the numerous amount of flies in resident rooms and throughout the facility observed during each day the survey.Observation on 05/18/2026 and 05/19/2026 revealed the fluorescent fly light next to exit door by the activity room was not plugged into an outlet. On 05/19/2026 at 3:30 p.m. S1Administrator confirmed the fly light was not plugged into the outlet.

Based on observation and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff, and public by having various hazardous and unsanitary items accessible.Findings:Observation on 05/18/2026 at 1:52 p.m. revealed two residents sitting outside in closed courtyard area off north end of facility with no staff present. The gate on the northwest end of property was open with no staff present. Further observation revealed the following hazards and unsanitary items in proximity of residents: 1) a toilet sitting on side walk that contained dirty gloves, cigarette butts and a rags inside it. 2) various paints, calking, rusted saw blades and sharps accessible to residents. 3) There was also numerous cigarette butts observed scattered on sidewalk next to building.On 05/19/2022 at 9:20 a.m., an interview with S7RN Nurse Supervisor, confirmed the items listed above were accessible to residents and should be removed.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection by failing:1) to ensure a nurse administered medications using appropriate infection prevention and control practices;2) to ensure chemical containers were not stored directly on the floor;3) to ensure the entrance door to the laundry room was free of leaks; and 4) to ensure a portable sink in the laundry room had an appropriate drainage system.Findings:Resident #6 Review of the facility's Medication Administration policy and procedure dated 03/01/2026 revealed the following in part: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline in part are for staff to cleanse hands before and after administration of medication. Observation on 05/19/2026 at 1:10 p.m. revealed S6LPN prepared medications for Resident #6. Further observation revealed S6LPN did not sanitize her hands prior to preparing medications for Resident #6. Further observation revealed S6LPN removed an Oxycodone Hydrochloride, 1 tablet, and Baclofen 10mg, 1 tablet, from the container and dropped the pills on top of the medication cart which had not been sanitized and was wet. S6LPN proceeded to pick up the pills with an ungloved and unsanitized hand, placed the pills in a medication cup and administered the medications to Resident #6. Interview with S2DON on 05/19/2026 at 3:02 p.m. confirmed that S6LPN should have sanitized her hands prior to preparing the medications for Resident #6 and that the contaminated medication should not have been administered to Resident #6. An observation of the laundry room on 05/20/2026 at 1:08 p.m. revealed a bucket of water was observed under a portable sink with a pvc pipe draining water directly into a bucket. Further observation revealed there was not a proper drain system to drain the water from the sink. Further observation revealed seven chemical containers were sitting directly on the floor. Further observation of the laundry room revealed the entrance door was not sealed properly and the floor was wet. An interview on 05/20/2026 at 1:15 p.m. with S5Laundry Worker confirmed the observation findings listed above. S5Laundry Worker revealed the portable sink drains into a bucket and they have to empty it multiple times daily, and the wet spot noted on the inside entrance into the laundry room was due to the laundry room door leaking. S5Laundry Worker further confirmed the seven chemical containers should not be directly on the floor. Observation on 05/20/2026 at 1:22 p.m. of the laundry room with S1Administrator revealed all of the above findings. At this time S1Administrator confirmed the portable sink should have a proper drainage system, chemical containers should not be directly on the floor in the laundry room, and the laundry room door should be sealed appropriately.

Based on observations and interviews the facility failed to store, prepare, distribute and serve food under sanitary conditions by having 1) equipment in the kitchen in need of cleaning and 2) a Dietary Worker not wearing gloves when touching food.Findings: Review of the Facility's policy for On Tray Dietary Policies and Procedures (2025 edition) revealed the following, in part: Gloves for Food HandlingPolicy: Disposable gloves should be used appropriately by all employees. Procedure:8. Employees should never use bare hand contact with any ready-to-eat food. On 05/18/2026 at 8:00 a.m. observation of the kitchen revealed a deep fryer with a grease buildup on the outside of the fryer. On 05/18/2026 at 8:10 a.m. S8Dietary Manager confirmed the deep fryer needed to be cleaned. 05/18/2026 at 11:50 a.m. observation of preparation of the lunch meal revealed S9Dietary Worker touched potato chips with his bare hand and placed the chips in a plastic bag for resident consumption. On 5/18/26 at 12:00 p.m. S8Dietary Manager was informed S9Dietary Worker touched potato chips with his bare hand. S8Dietary Manager confirmed S9Dietary Worker should have used gloves when touching the potato chips.

Based on observations, record review, and interview, the facility failed to ensure that 1) all drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles by failing to have the strength labeled on a narcotic medication administered to Resident #6, and 2) failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access by having an unlocked medication cart outside and accessible to residents and staff. Findings:1) Review of the facility's policy on medication administration dated 03/01/2026 revealed, in part: check medication administration record prior to administering medication for the right medication, dose, route, patient, and time. Remove medication from drawer and read label three times; when removing from drawer, before pouring, and after pouring. If the label is wrong send medications to pharmacy for relabeling or call pharmacy to send a new label.Observation of the medication pass on 05/19/2026 at 1:10 p.m. revealed S7LPN administered a narcotic medication, Oxycodone-Acetaminophen, one tablet to Resident #6. The pharmacy label did not have the strength of the medication labeled on the medication card.Review of Resident #6's May 2026 physician orders revealed an order for Oxycodone with Acetaminophen 10-325 mg, give one tablet by mouth three times a day related to chronic pain.On 05/19/2026 at 3:02 p.m., S2DON confirmed the Oxycodone Hydrochloride label for Resident #6 did not have the strength of the narcotic listed on the label. Further interview with S2DON confirmed S7LPN should not have administered the narcotic until the pharmacy label was correct.2. Review of the facility's policy on medication storage dated 03/01/2026 revealed the following, in part: Medication supply must be accessible only to license nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. Medication rooms, carts, and medication supply rooms are kept locked at all times or must be attended by authorized personnel. Only licensed nurses, pharmacists, and those lawfully authorized are allowed access to medication areas.Observation on 05/19/2026 at 9:00 a.m. revealed an unlocked medication cart located on the sidewalk in the enclosed courtyard. Further observation revealed that the cart contained various creams and ointments that included following: Clobetasol Propionate cream, 30 grams; three Duoderm Hydroactive gel, 30 grams tubes; [NAME] external analgesic lotion, 7.5 ounces; Santyl ointment, 30 grams; Iodosorb gel, 1.4 ounces; silver antimicrobial wound gel, 1.4 ounces; and one bottle of Co Q-10 50 mg, 30 soft gel tablets with an expiration date of 12/2022.On 05/19/2026 at 9:20 a.m., an interview with S7RN Nurse Supervisor confirmed the medication cart was unlocked and that medications were currently accessible to residents.

Based on observations, record reviews, and interviews the facility failed to ensure residents were assessed for the risk of entrapment prior to installation of bed rails for 2 (#5 and #45) of 2 residents reviewed for accident hazards.Findings:Resident #5Review of the medical record for Resident #5 revealed an admission date of 01/20/2017 with diagnoses that included dementia, cognitive communication deficit, bipolar, and schizoaffective disorder. Review of the May 2026 physician orders revealed an order dated 11/04/2024 for assist rails to the bed times two for mobility and to monitor every shift.Observations of Resident #5 on 05/18/2026 at 4:00 p.m. and 05/19/2026 at 3:15 p.m. revealed the resident was in the bed with bilateral assist rails in the up position. Review of Resident #5's record revealed no documented evidence of a risk for entrapment assessment completed prior to the installation of the assist rails to the resident's bed. Interview on 05/20/2026 at 10:35 a.m. with S1Administrator confirmed the facility failed to document an assessment for risks of entrapment prior to the installation of assist rails on Resident #5's bed.Resident #45Review of the record revealed an admission date of 12/26/2022 with diagnoses including vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic obstructive pulmonary disease, and asthma.Review of the May 2026 Physician's Orders for Resident #45 revealed an order dated 04/14/2025 for resident to have assist rails times two for turning and repositioning.Observations of Resident #45 on 05/18/2026 at 9:15 a.m., 05/19/2026 at 8:58 a.m., 05/19/2026 at 12:05 p.m., and 05/20/2026 at 1:30 p.m. revealed the resident's bed had bilateral assist rails in the up position in place. Review of Resident #45's record revealed no documented evidence of an assessment completed prior to the installation of bilateral assist rails to the resident's bed.Interview on 05/20/2026 at 10:35 a.m. with S1Administrator confirmed the facility failed to document an assessment for risks of entrapment prior to the installation of assist rails on Resident #45's bed.

Based on observations, record reviews and interviews the facility failed to ensure staff maintained infection control practices by not following Enhanced Barrier Precautions (EBP) for 2 (#61, #65) of 2 residents observed during care who were on EBP and by having staff personal items in the medication storage room. Findings: Review of the facility's EBP policy and procedure dated April 2024 revealed: Policy Subject: Enhanced Barrier Precautions Policy: Enhanced Barrier Precautions are indicated for residents with infections or colonization with a Centers for Disease Control (CDC)-targeted Multi Drug Resistant Organisms (MDRO) when contact precautions do not apply or for residents with wounds and/or indwelling medical devices without secretions/excretions that are unable to be covered/contained & are not known to be infected/colonized with any MDRO during high-contact resident care activities as these residents are at an increased risk of being infected. Definition 1. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) in Nursing Homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). 2. Enhanced Barrier Precautions only require use of gown/gloves when performing high contact resident activities: a. Dressing b. Bathing/showering c. Transferring (in room, shower/tub rooms, and therapy gyms) d. AM/PM Care e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy, or ventilator h. wound care: any skin opening requiring a dressing 3. Duration: Enhanced Barrier Precautions are intended to remain in effect for the duration of the resident stay or until the wound in closed/medical device removed. Responsibility All Staff Equipment 1. Door sign that reads Enhanced Barrier Precautions or Visitors Must See Nurse Before Entering. 2. Supply of gowns, gloves and plastic bags. Procedure 1. A private room is not required. Residents may be out of the room, attend activities and therapies and any other activities of their choosing. 2. Education family and/or resident on the precaution being initiated and procedures to be maintained. 3. Apply protective equipment as indicated prior to providing any high contact resident care as listed above. a) Gloves- utilized during the course of providing high contact care. Remove gloves before leaving the room. b) Gown- apply gown before providing high contact care. Additional Personal Protective Equipment (PPE) may be indicated under Standard Precautions if splashing is anticipated such as tracheostomy care or wound irrigation. c) Resident Care Equipment- normal procedure of cleaning and disinfecting equipment before use on another resident. d) Explain all procedures to the resident before initiating care. e) Bag used linen(s), dispose of gown and gloves in waste receptacle after care is completed. f) Wash hands before leaving the room and transfer bagged linen to holding room. g) Sanitize hands Resident 61 Review of the record for resident #61 revealed diagnoses in part of obstructive and reflux uropathy, diabetes insipidus, benign prostatic hyperplasia without lower urinary tract symptoms, and chronic kidney disease. Review of the Physician's order dated 02/20/2025 revealed an order for EBP due to indwelling catheter. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #61 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Further review of the MDS revealed resident #61 required partial/moderate assistance with toileting hygiene. Review of the current plan of care revealed resident #61 was at risk for injury/infection. Resident #61 had a Foley catheter due to diagnosis of benign prostatic hypertrophy. Further review of the current plan of care revealed resident #61 required EBP. On 03/17/2025 at 9:20 a.m. observation of the outside of resident #61's door revealed a sign that indicated resident #61 was on EBP. Further observation revealed gloves and gowns were available for use. On 03/17/2025 at 9:22 a.m. S9Licensed Practical Nurse (LPN) was observed going into resident #61's room and only applied gloves. Further observation revealed S9LPN touched the indwelling Foley catheter. On 03/17/2025 at 9:53 a.m., an interview with S9LPN confirmed she only wore gloves when she went in resident #61's room and handled the indwelling catheter. Resident 65 Review of the record for resident #65 revealed diagnoses in part of Alzheimer's disease, dysphagia, seborrheic dermatitis and aphasia. Review of the Physician's order dated 02/03/2025 revealed an order for EBP due to Percutaneous Endoscopic Gastrostomy (PEG) tube. Review of the quarterly MDS assessment dated [DATE] revealed resident #65 had a BIMS that was unable to be assessed. Resident #65 required substantial or maximal assistance with all activities of daily living skills. Review of the current plan of care revealed resident #65 required assistance with activities of daily living due to his cognitive impairment related to Alzheimer's. On 03/19/2025 at 8:40 a.m. observation of resident #65's door revealed a sign that indicated resident #65 was on EBP. Further observation revealed there was a supply of gloves and gowns in a cart hanging on the resident's door. On 03/19/2025 at 8:45 a.m. observation of resident #65 during a shower revealed S6Certified Nursing Assistant (CNA) and S7CNA transferred resident #65 from the wheelchair to the shower chair only wearing gloves. S6CNA and S7CNA did not wear a gown. Further observation of the shower performed by S6CNA revealed she only wore gloves and no gown during the shower. Observation of transferring resident #65 from a shower chair to the wheelchair revealed S8CNA and S6CNA transferred resident #65 back to the wheelchair only wearing gloves. S6CNA and S8CNA did not wear a gown. S6CNA then placed a shirt on resident #65, a clean brief and put on his pants. S7CNA assisted S6CNA with standing resident #65 to pull up his pants. S6CNA and S7CNA only wore gloves and no gown. On 03/19/2025 at 9:43 a.m., an interview with S6CNA, S7CNA and S8CNA confirmed they only used gloves and did not put on a gown while performing the resident's shower or transferring the resident. S7CNA further stated that she was unaware that she had to use a gown when she assisted resident #65 in the shower. On 03/19/2025 at 2:30 p.m. S2Director of Nursing (DON) and S3Clinical Operations were notified that S6CNA, S7CNA and S8CNA did not use appropriate personal protective equipment (PPE) when providing care to resident #65. 32231 Medication Storage Room On 03/18/2025 at 11:10 a.m., an observation of the medication storage room with S5Registered Nurse (RN)/Wound Care Nurse (WCN) revealed two large purses lying on top of and in direct contact with the medication preparation countertop. On 03/18/2025 at 11:13 a.m., S10Registered Nurse (RN) Unit Manager was notified of the above findings. She confirmed that the purses should not have been stored inside of the medication storage room and on the top of and in direct contact with the countertop due to cross contamination. On 03/19/2025 at 3:25 p.m., S1Executive Director, S2Director of Nursing, and S3Clinical Operations were notified of the findings regarding the purses being stored in the medication storage room.

Based on observations, review of the Order Listing Report, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by 1) having exposed and unlabeled food items in the freezer and refrigerator, 2) placing contaminated food preparation utensils on top of and in direct contact with resident foods, and 3) testing the dishwasher sanitizer level with expired test strips. According to the Order Listing Report provided by S11Dietary Manager (DM), there was a total of 79 residents that received a meal tray from the kitchen. Findings: On [DATE] at 8:30 a.m., an observation of the kitchen with S11Dietary Manager (DM) revealed there was one upright freezer that had one opened box of riblet pork patties and one opened box of hamburger patties that were exposed to air and not labeled with an open date. Further observation of the upright freezer revealed one opened box of chicken bread that was not labeled with an open date. Further observation of the kitchen revealed one refrigerator that had an opened box of pie dough and a second refrigerator that had one opened box of sausage patties that were not labeled with an open date. S11DM confirmed the opened, air exposed, unlabeled food items should not have stored inside of the freezer and refrigerator and available for resident consumption. Observation of the kitchen further revealed S11Dietary Manager testing the dishwasher for the sanitizer level. After she had completed the testing, on observation of the test strip bottle revealed an expiration date of ,d+[DATE]. S11Dietary Manager was present and confirmed the bottle of test strips was expired. On [DATE] at 11:30 a.m., an observation of the steam table revealed one large pan of cornbread that had been cut into individualized pieces. Further observation revealed a large spatula and a pair on tongs lying inside of the pan of cornbread. During the food service, S12Dietary [NAME] was observed handling both the tongs and spatula with her bare hands. She was further observed handling and placing them on top of the cornbread with her bare hands. Both the tongs and spatula were on top of and in direct contact with the cornbread that was served to the residents. S13Dietary [NAME] was observed preparing the resident's plates for the meal service. During the observation, S13Dietary [NAME] touched the inside of the plates with her bare fingers and /or thumb. On [DATE] at 12:40 p.m., S11Dietary Manager and S18Regional Director of Nutritional Services were notified of the above observations and confirmed that S12Dietary [NAME] should not have placed the spatula and tongs on top of and in direct contact with the cornbread and further confirmed that S13Dietary [NAME] should not have touched the inside of the plates with bare fingers and or/hands due to cross contamination. On [DATE] at 3:30 p.m., S1Executive Director, S2Director of Nursing, and S3Clinical Operations were notified of the above findings.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out Activities of Daily Living (ADL) receives the necessary services to maintain good personal hygiene for 1 (#73) of 6 (#15, #26, #27, #56, #65, and #73) residents reviewed for ADL care. The provider failed to ensure resident #73's fingernails were trimmed and cleaned. Findings: Review of the medical record revealed resident #73 was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed that resident #73 was severely impaired with his daily decision making skills and he required substantial/maximal assistance with personal hygiene. Review of the medical record revealed resident #73 was care planned for an ADL self-care deficit and he required extensive assistance with ADLs related to Alzheimer's disease. The documented approaches included in part, bathing/showering: check nail length, trim and clean on bath days and as necessary. On 03/17/2025 at 9:40 a.m., and 03/18/2025 at 9:54 a.m., observations revealed resident #73 sitting in a wheelchair in front of the nurse's station. Further observation revealed resident #73 had long fingernails to both hands, they were long, untrimmed and had thick buildup of grime underneath the nail beds of both hands. On 03/18/2025 at 9:55 a.m., S15Certified Nursing Assistant (CNA) was notified of the observations of resident #73's fingernails being long, untrimmed with a buildup of grime underneath the nail beds of both hands. After observing resident #73's hands, S15CNA confirmed that resident #73's fingernails needed to be trimmed and cleaned. On 03/18/2025 at 11:04 a.m., S10Registered Nurse (RN), Unit Manager was notified of the above findings. After observing resident #73's hands, she confirmed that resident #73's fingernails needed to be trimmed and cleaned.

Based on observations and interview the facility failed to ensure all mechanical equipment was maintained in safe operating condition by having a can opener in the kitchen with a large buildup of metal shavings and by having the deep fryer with grease buildup in lower compartment. Findings: On 03/17/2025 at 8:30 a.m. observation of the kitchen with S11Dietary Manager revealed the large commercial can opener had a large buildup of metal shavings underneath the blade. Further observation of the kitchen area with S11Dietary Manager of the deep fryer revealed there was an oil spill and buildup of thick greasy particles on the inside of the fryer's lower compartment. On 03/19/2025 at 3:25 p.m. S1Executive Director, S2Director of Nursing (DON) and S3Clinical Operations were notified of the above findings.

Based on observations, record reviews, and interviews, the facility failed to ensure the Licensed Practical Nurse (LPN) must have the appropriate competencies to provide nursing and related services necessary to care for resident's needs as identified and described in the plan of care for 1 (#2) of 7 (#2, #4, #12, #15, #43, #44, and #50) residents reviewed for accidents. Findings: Review of the medical record revealed resident #2 was admitted to the facility on [DATE] with diagnoses that included in part, hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, and schizophrenia. Review of the March 2025 Medication Administration Record (MAR) revealed an order dated 02/20/2025 to monitor placement for palm protector to left hand contractor each shift every day and night shift. Further review of the March 2025 MAR revealed S9LPN had initialed on the MAR on 03/18/2025 (day shift), to indicate that resident had been monitored for the palm protector placement to resident #2's left hand. On 03/17/2025 at 1:43 p.m., and 03/18//2025 at 8:45 a.m., observations revealed resident #2 was lying in bed with a contracture observed to his left hand. Further observation revealed there was no type of splint device in place to the resident's hand. On 03/18/2025 at approximately 2:35 p.m., S9LPN was notified of resident #2's physician's order to monitor placement for palm protector to resident #2's left hand contracture on the day shift. She was further notified of the observations of resident #2 not having the palm protector in place during the observations. S9LPN confirmed that she had initialed the monitoring of the device. She further confirmed that she did not actually observed the hand protector in resident #2's left palm at the time she documented the monitoring on 03/18/2025 for the day shift. On 03/18/2025 at 10:34 a.m., S1Registered Nurse/Unit Manager was notified the above findings regarding resident #2's contracted hand. On 03/19/2025 at 3:30 p.m., S1Executive Director, S2Director of Nursing, and S3Clinical Operations were notified of the above findings.

Based on observations, record reviews and interviews the facility failed to ensure a resident's comprehensive plan of care was implemented for 2 (#2 and #34) of 2 residents reviewed for care plans by, not providing heel protectors and /or a palm protector as ordered by the physician. Findings: Resident 34 Review of the record for resident #34 revealed an admitted [DATE] with diagnoses including cerebral infarction, contracture to right and left hand, diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, heart disease, anemia, schizophrenia, right below the knee amputation, hyperlipidemia, and diabetic neuropathy. Review of the physician's orders revealed an order dated 11/04/2024 to ensure heel protectors in place every shift related to diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #34 was independent with cognition for daily decision making. Resident #34 was totally dependent on staff for mobility, transfers and toilet use and required extensive assistance with eating. Review of the current care plan revealed resident #34 had an activities of daily living (ADL) self-care performance deficit related to activity intolerance. The interventions included to use heel protectors while in the bed. On 03/17/2025 at 1:00 p.m., and 3:00 p.m. observations of resident #34 revealed she was in the bed without a heel protector on her left foot. On 03/17/2025 at 3:05 p.m. S16Licensed Practical Nurse (LPN) confirmed resident #34 should have on a heel protector on the left foot while in the bed. On 03/19/2025 at 2:00 p.m. S2Director of Nursing (DON) was notified that resident #34 did not have the heel protector on while in the bed on 03/17/2025. 32231 Resident #2 Review of the medical record revealed resident #2 was admitted to the facility on [DATE] with diagnoses that included in part, hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, and Schizophrenia. Review of the March 2025 medication administration record revealed an order dated 02/20/2025 at 6:00 p.m., to monitor placement for palm protectors to left hand contractures each shift. On 03/17/2025 1:43 p.m., 03/18/2025 at 8:45 a.m., and 03/18/2025 at 1:45 p.m., observations revealed resident #2 was lying in bed with a contracture observed to his left hand. Further observation revealed there was no type of splint device in place to the resident's hand. On 03/18/2025 1:49 p.m., an observation revealed resident #2 was lying in bed with a contracture observed to his left hand with no type of splint device in place. S5Registered Nurse (RN) / Wound Care Nurse (WCN) was present and observed resident #2's contracted hand. She confirmed that resident #2 did not have any type of splint device in place at that time. After reviewing the March 2025 physician's orders with S5RN/WCN, she confirmed resident #2 was to have a palm protector to the left hand contracture and be monitored for placement every shift. On 03/18/2025 at 10:34 a.m., S1Registed Nurse/Unit Manager was notified the above findings regarding resident #2's contracted hand. On 03/19/2025 at 3:30 p.m., S1Executive Director, S2Director of Nursing, and S3Clinical Operations were notified of the above findings.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#51 and #70) of 5 (#35, #51, #65, #70, and #78) residents' rooms observed. The failed practice was evidenced by resident's air/heating units needed cleaning. Findings: Resident 51 On 03/17/2025 at 12:27 p.m. observation of the air/heating unit in resident #51's room revealed the vents contained a black substance. On 03/18/2025 at 1:00 p.m. observation of the air/heating unit in resident #51's room with S1Executive Director confirmed the vents contained a black substance and needed to be cleaned. Resident 70 On 03/17/2025 at 12:28 p.m. observation of the air/heating unit in resident #70's room revealed the vents contained a buildup of dust and grime. On 03/18/2025 at 1:10 p.m. observation of the air/heating unit in resident #70's room with S1Executive Director confirmed the vents contained a buildup of dust and grime and needed to be cleaned.

Based on observation, record review and interview, the facility failed to protect the resident's right to be free from physical abuse and psychosocial harm by staff for 1 (#1) of 3 (#1,#2, #3) sampled residents. The deficient practice resulted in actual harm for resident #1 (who was cognitively impaired) on 06/27/2024 at 9:01 p.m. when S4CNA (certified nursing assistant) physically abused resident #1 by using her left hand to grab the back of resident #1's shirt in an attempt to pull him towards his room. At this time resident #1 turned his back to S4CNA and his left elbow made contact with S4CNA's left shoulder. S4CNA used her closed right hand to make contact with the back of resident #1's head and then wrapped both her arms around resident #1's chest. Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Abuse Prevention Policy dated July of 2018 revealed the following: The facility is committed to protecting the residents from abuse by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogated, sponsors, friends, visitors or any other individuals. Physical abuse includes hitting, slapping, pinching, and kicking. Review of resident #1's health record revealed an admitted [DATE] with diagnoses of, but not limited to, Schizoaffective disorder, drug induced subacute dyskinesia, bipolar disorder, anxiety disorder, with other behavioral disturbance. Review of resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 99 which indicated the resident was unable to complete the Brief Interview for Mental Status. Further review revealed the resident was independent with all activities of daily living. Review of resident #1's care plan revealed the interventions used to prevent escalating agitation and behaviors were to provide 1:1 CNAs on the 6:00 p.m. to 6:00 a.m. shifts; redirection of situations that cause the resident to become agitated and increased behaviors. Review of the facility's investigation documentation revealed the following: The incident was reported to the Administrator and Director of Nurses at 9:23 p.m. by S5LPN (Licensed Practical Nurse) that was working in the unit. S5LPN reported that resident #1 had hit S4CNA and she wanted to go to the emergency room to be evaluated, the administrator instructed the LPN to obtain a urine drug screen and have her fill out the workers comp forms located at the nurses station. S2DON (Director of Nursing) asked S5LPN to get statements from all staff and assign someone else to sit 1:1 with resident #1. On 06/28/2024 at 08:00 a.m. S2DON was reading staff statements on the incident that occurred between resident #1 and S4CNA and she observed a statement by S6CNA that stated S4CNA had grabbed the resident around his neck, for clarification S2DON reviewed the video footage at 8:37 a.m. on 06/28/2024. After viewing the video footage by the S2DON she concluded that resident #1 and S4CNA were walking back from the nurse's station towards resident #1's room. Resident #1 was walking in front of S4CNA when he stopped and turned around and appears to be yelling at her. S4CNA was facing the back door and resident #1 was standing to her left facing her, S4CNA then using her left hand grabs the back of resident #1's shirt and attempts to pull him towards his room. At this time the resident turns and uses (his back is to S4CNA) left elbow to make contact with S4CNA's left shoulder. At this time S4CNA used her closed right hand to make contact with the back of resident #1's head as she wraps both arms around resident #1's chest. After viewing the footage S4CNA was asked to come back to the facility to be interviewed by the DON, Executive Director and Human Resource director. Review of the documentation in regards to the interview on 06/28/2024 at 10:21 a.m. with S4CNA stated she was asked why she went to the emergency room after the incident between her and resident #1. S4CNA responded that her right ear was hurting and it felt like there was fluid behind it after resident #1hit me five times to that ear. After the interview it was determined that the CNA receive a level one category write up and was suspended until further evaluations could be completed. 06/28/2024 at 11:10 a.m. the police were contacted by S1Executive Director and S4CNA left the facility with the police. On 07/11/2024 at 9:45 a.m. review of the video with no date or time stamp revealed footage of resident #1 walking in front of S4CNA, when he stopped and turned around. It appeared he was yelling at her. S4CNA was facing the back door and resident #1 was standing to her left facing her. S4CNA then used her left hand and grabbed the back of resident #1's shirt and attempted to pull him. At this time resident #1turned with his back to S4CNA, his left elbow, as his body was rotating, made contact with S4CNA's left shoulder. S4CNA used her closed right hand to make contact with the back of resident#1's head as she wrapped both of her arms around resident #1's chest. The video was reviewed with S2DON and S3Corprate Nurse in attendance and verified the video is of the incident that occurred on 06/27/2024 at 9:01 p.m. Interview on 07/12/2024 at 01:30 p.m. S2DON confirmed resident #1 had behaviors on a daily basis and was 1:1 care during the shift of 6:00 p.m. to 6:00 a.m. The resident was in the locked unit due to his behaviors. Resident #1 was accepted and transferred to a local behavioral unit for evaluation and medication adjustments 06/28/2024 due to his increased agitation. S2DON stated resident #1 would be admitted back to the facility today. S2DON confirmed S4CNA was terminated from employment effective 07/01/2024 when the investigation was completed. Interview on 07/15/2024 at 08:40 a.m. S4CNA confirmed she worked in the behavioral unit on the evening of 06/27/2024. S4CNA stated she was assigned to work 1:1 with resident #1. S4CNA stated they had walked to the nurse's station for resident #1 to use the phone, resident #1 was told the phone was not working and he became very agitated and was yelling at her as they walked down the hall. S4CNA stated she attempted to direct resident #1 to his room, by grabbing the back of his shirt and then she remembered trying to place her arms around him to stop him from hitting her. S4CNA stated she did not watch the video of the incident and did not want to see it because she would get upset at seeing it again. During a phone interview on 07/15/2024 at 09:10 a.m. S5LPN stated she worked in the unit the night of 06/27/2024 when the event occurred between S4CNA and resident #1. S5LPN confirmed that she was at the nurse station and heard resident #1 yell. When she went down the hall, S6CNA was attempting to get between S4CNA and resident #1. S5LPN called out the resident's name and he let go of S4CNA. After assessing resident #1, he was then redirected to his room. S5LPN confirmed she then called S1Executive Director and reported the altercation between resident #1 and S4CNA. S5LPN confirmed she told S1Executive Director that S4CNA told her she wanted to be evaluated at the local hospital due to resident #1 hitting her in head during the altercation. S5LPN stated she was directed by S1Executive Director in regards to the workman's comp forms to be completed before S4CNA left to be evaluated at the local hospital. During a phone interview on 07/15/2024 at 09:40 a.m. S6CNA stated she worked in the unit the night of 06/27/2024 when the incident occurred between S4CNA and resident #1. S6CNA confirmed she was coming in from the 9:00 p.m. smoke break and was walking up the hallway. S4CNA and resident #1 were walking back towards his room. Resident #1 turned to S4CNA and said something to her, like stop following me and get away from me. S4CNA grabbed resident #1 telling him let's go to your room and resident #1 hit S4CNA. S6CNA reported she tried to separate resident #1 and S4CNA, then the nurse came. After it was over S6CNA told S4CNA not to grab the resident around the neck. On 07/15/2024 at 8:30 a.m. an observation of resident #1 revealed he was sitting in the television room in the unit. Resident #1 was unable to answer questions asked by the surveyor. The facility implemented the following actions to correct the deficient practice with completion on 07/01/2024. 1. Body audits completed on all residents in the unit to ensure residents did not have any new injuries. 2. Social Service Director interviewed all residents in the unit to ensure residents feel safe, asked if they have ever been abused or witnessed abuse. All residents answered they felt safe 3. Social Service Director assessed residents for PTSD (post traumatic stress disorder), with no signs or symptoms noted 4. The acuity of residents in the unit were assessed to ensure the acuity was not high enough to need more staff. 5. Human Resources completed OIG (Office of Inspector General) checks and ran employees who work in the unit on all shifts through abuse registry including agency staff for a total of 24 employees. No issues found 6. Initiated In-services for Abuse/neglect/combative and de-escalating situations 7. Reviewed policies on abuse-no changes made 8. Reviewed facility staffing scheduled for the unit 9. Staff retrained with competency on de-escalation 10. Emergency resident council meeting held with 19 residents attending-no complaints voiced In-Services completed for the following: Residents Rights, Customer Service, Reporting Abuse, Staff Burnout, Residents have the right to live in the facility free from abuse, Treat each resident with respect as if they are our family, When abuse is observed or suspected always report to the Executive Director who is the abuse coordinator, Burnout handout with ways to combat burnout and stress at work. If it is seen that a resident is getting agitated with an employee, notify the charge nurse and ask to change sections with another employee. Abuse prevention- staff member vs. resident Combative Residents vs staff member De-escalation staff member vs Resident- during the risk behavior always call for help De-escalation training and competency QAPI (Quality Assurance and Performance Improvement): 1. QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This will be completed by interviewing a random sample of residents by the DON (director of Nurses) three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. 2. An additional QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This monitor will be conducted by reviewing a random sample of Incident and Accident reports by the DON three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. 3. An additional QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This monitor will be conducted by reviewing a random sample of nurse's note by the DON three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. The effectiveness of the corrective actions will be discussed weekly for four weeks at the Quality Assurance and Performance Improvement meeting with findings added to the minutes. Additional in-services and or corrective actions will be implemented as needed.

Based on observations and interviews, the facility failed to ensure it was equipped to allow residents' to call for staff assistance through a communication device by failing to ensure call lights were accessible for 4 (#4, #10, #37, #84) of 4 (#4, #10, #37, #84) sampled residents reviewed for call light accessibility. Findings: Resident #4 On 02/19/2024 at 9:47 a.m., observation of resident #4 revealed resident was in bed and the call bell was hanging on the wall out of the resident's reach. Resident #4 was able to state he could use the call bell if he needed something. On 02/20/2024 at 8:45 a.m. observation of resident #4 again revealed the resident was in the bed and the call bell was hanging on the wall out of the resident's reach and observation again at 2:00 p.m. the call bell remained hanging on the wall out of the resident's reach. Resident #10 On 02/19/2024 at 10:56 a.m., resident #10 was sitting in her room. The call light cord was draped around the call light box and was not within her reach. Interview with the resident revealed she was alert and oriented x4. The resident reported she was blind and that she could use the call light if it were within her reach. On 02/19/2024 at 02:00 p.m., observation of resident #10 revealed she was seated in her room and the call light was out of her reach. On 02/20/2024 at 9:50 a.m., observation of resident #10 revealed she was seated in her room and the call light was out of her reach. On 02/20/2024 at 1:30 p.m., observation of resident #10 revealed she was seated in her room and the call light was out of her reach. On 02/21/2024 at 8:30 a.m., observation of resident #10 revealed she was in bed and the call light was out of her reach. S1Administrator confirmed the call bell was not accessible to the resident. Resident #37 On 02/19/24 at 9:25 a.m., observation of resident #37 revealed the resident was in bed and the call bell was hanging on wall out of the resident's reach. Resident #37 was able to state he could use the call bell if he needed something. On 02/19/24 at 10:25 a.m., resident #37 was in his room in his bed and requested another snack but the resident call bell was hanging on the wall out of the resident's reach. On 02/19/24 at 1:39 p.m., resident #37 was heard hollering through the closed door for someone to help him. The door was opened and observation revealed resident #37 attempting to transfer unassisted calling for someone to help him. Further observation revealed the call bell was hanging on the wall out of the resident's reach. On 02/20/24 at 8:49 a.m., observation of resident #37 revealed he was in the bed and the call bell was hanging on the wall out of the resident's reach. On 02/21/24 at 8:50 a.m. observation of resident #37 revealed he was asleep in bed. Further observation revealed the call bell was hanging down between the bed and wall and out of the resident's reach. Resident #84 On 02/19/2024 at 9:24 a.m., observation of resident #84 revealed he was lying in bed with the call bell hanging on the wall out of the resident's reach. Attempted interview with resident #84 revealed he spoke mostly Italian and was difficult to understand but would be physically able to use the call bell if it were within reach. On 02/20/24 at 8:47 a.m., observation of resident #84 revealed he was lying in the bed and the call bell was hanging on the wall out of the resident's reach and observation again at 2:30 p.m. revealed the call bell remained out of the resident's reach. On 02/21/24 at 10:45 a.m., interview with S2 Corporate Nurse agreed the call bells should not be hanging on the wall out of the resident's reach. 19098

Based on record review and interview, the facility failed to assist residents in obtaining routine dental care for 1 (#50) of 1 sampled resident reviewed for dental. Findings: Review of the medical record for resident #50 revealed the resident was admitted on [DATE] with diagnoses including cerebral infarction, hemiplegia right dominant side, diabetes, edema, aphasia, depression, hypertension, heart disease, and pain. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. An interview with resident #50 on 02/19/2024 at 10:30 a.m. revealed his right upper back tooth hurt. Resident #50 stated he reported it to someone. Review of resident #50's dental note dated 01/18/2023 revealed: extraction, erupted tooth or exposed root - the patient needs a new consent form to proceed with the extraction. The current consent is older than 6 months. Review of resident #50's dental note dated 10/24/2023 revealed: pain with upper teeth, would like them extracted. Discussed outstanding consent with Director of Nursing and will get that re-signed due to expiration of previous consent being outdated. An interview with S8Social Services on 02/21/2024 at 9:45 a.m. revealed the resident and the resident's physician are to sign the consent form that was completed by the dentist. Interview with S8Social Services confirmed she had not sent the consent to the physician at this time. An interview with S2Corporate Nurse and S3Director of Nursing on 02/21/2024 at 11:00 a.m. confirmed resident #50's dental needs should have been addressed timely.

Based on observation, record review and interviews, the facility failed to ensure the resident environment remained free of accident hazards by failing to conduct a smoking safety assessment for 1 (#67) of 1 (#67) sampled residents reviewed for smoking. Findings: Review of the medical record revealed resident #67 had diagnoses which included Schizophrenia, seizures, major depression and Bipolar disorder. Review of the Smoking Evaluation Tool dated 12/15/2023 indicated the resident did not smoke. On 02/20/2024 at 10:00 a.m., interview with S4Certified Nursing Assistant (CNA) revealed resident #67 smoked cigarettes. On 02/20/2024 at 11:10 a.m., observation of resident #67 revealed he was smoking a cigarette during the designated smoke break. On 02/20/2024 at 12:25 a.m., interview with S5Licensed Practical Nurse (LPN) revealed at the time of the assessment on 12/15/2023, the resident did not smoke. She also reported when the resident resumed smoking a smoking safety assessment was not conducted.

Based on record reviews, observations, and interviews, the facility failed to treat each resident with respect and dignity and 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 for 3 (#56, #65, and #75) of 3 (#56, #65, and #75) sampled residents reviewed for dignity. Resident #56 and resident #65 were pulled backwards in their gerichairs down the hall to their rooms. Resident #75 was assisted with eating by a staff member who stood beside him at the table in the dining room. Findings: Resident #56 Review of the medical record for resident #56 revealed the resident was admitted on [DATE] with diagnoses including dementia, joint replacement surgery, osteoarthritis, heart disease, edema, and pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had independent cognitive skills for daily decision making. The resident required extensive assistance with bed mobility, transfer and toilet use. Observation on 02/19/2024 at 10:00 a.m. revealed the resident was up in his gerichair in front of the nurse's station. Observation on 02/19/2024 at 10:11 a.m. revealed S6Certified Nursing Assistant (CNA) pulled resident #56 backwards in his gerichair down the hall to his room. An interview with S2Corporate Nurse and S3Director of Nursing (DON) on 02/21/2024 at 11:00 a.m. confirmed S6CNA should not have pulled resident #56 backwards down the hallway to his room. Resident #65 Review of the medical record for resident #65 revealed the resident was admitted on [DATE] with diagnoses including hypertensive heart disease, Alzheimer's, dysphagia, cerebral infarction, dementia, flaccid hemiplegia, and gastrostomy. Review of the admission MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident had range of motion impairment on one upper extremity and both lower extremities. The resident was dependent for mobility. Observation on 02/20/2024 at 3:00 p.m. revealed resident was up in her gerichair in front of the nurses station. Observation on 2/20/2024 at 3:45 p.m. revealed S6CNA pulled resident #65 backwards down the hallway to her room. An interview with S2Corporate nurse and S3DON on 02/21/2024 at 11:00 a.m. confirmed S6CNA should not have pulled resident #65 backwards down the hallway to her room. Resident #75 Review of the medical record for resident #75 revealed the resident was admitted on [DATE] with diagnoses including dementia, epileptic seizure, pain, chronic obstructive pulmonary disease, hypertension, emphysema, insomnia, diabetes, edema, and cardiac pacemaker. Review of the yearly MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Review of the care plan revealed one person assist with activities of daily living as needed or requested by resident. Observation on 02/19/2024 at 12:05 p.m. revealed S7Licensed Practical Nurse (LPN) was standing up beside resident #75 while assisting the resident with eating at the dining room table. An interview with S2Corporate nurse and S3DON on 02/21/2024 at 11:00 a.m. confirmed S7LPN should not have been standing while assisting resident #75 with eating.

40238 Based on record review, observation and interview, the facility failed to ensure a resident's right to be free from resident to resident physical abuse for 4 (Residents #2, #3, #4, #5) of 5 (Residents #1, #2, #3, #4, #5) residents reviewed for abuse. The facility failed to provide sufficient, competent direct care staff to ensure resident safety was maintained in the secure unit. The Immediate Jeopardy began on 11/16/2023 as a result of the secure unit having: 1) a resident to resident physical abuse altercation on 11/16/2023 between Resident #2 and Resident #3 which occurred when Resident #2 grabbed Resident #3 by the neck and hit him in the back of the head with a closed fist. Resident #3 retaliated and hit Resident #2 with a closed fist. The incident occurred in the dining room of the secure unit. The facility failed to ensure staff monitored the television/dining room. 2) a resident to resident physical abuse altercation on 12/04/2023 between Resident #4 and Resident #5 which occurred when Resident #4 entering Resident #5's room and hit him in the face multiple times with a closed fist leaving a bruise to the left eye. The facility failed to ensure resident safety by allowing Resident #4 to enter Resident #5`s room and physically abuse him. By the facility failing to immediately address the need to provide sufficient, competent direct care staff after the above two physical abuse altercations, there was a high likelihood that additional severe harm, injury, or death could occur to the residents residing on the secure unit. S1Administrator, S4 DON (Director of Nursing), and S3 Corporate Nurse were notified of the Immediate Jeopardy on 12/14/2023 at 12:50 p.m. The Immediate Jeopardy was removed on 12/14/2023 at 10:52 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at the potential for more that minimal harm for 32 resident in the secure unit. Findings: Cross Reference F741 Review of the Abuse Prevention Policy revealed in part under Preventions: 5. Examples of steps that the facility may put in place immediately to prevent further potential abuse includes, but are not limited to, staffing changes, increase supervision, protection from retaliation, and follow-up counseling for the resident(s). Resident #2 and Resident #3 Review of the facility's reported incidents revealed an incident that occurred on 11/16/2023 between Resident #2 and Resident #3. Resident #2 grabbed Resident #3 by the neck and hit him in the back of the head with a closed fist. Resident #3 retaliated and hit Resident #2 with a closed fist. Record review revealed Resident #2 was admitted to the facility on [DATE] and had active diagnoses that included major depressive disorder, anxiety disorder and unspecified mood disorder. Review of Resident #2`s most recent brief interview of mental status (BIMS) score completed on quarterly minimum data set (MDS) dated [DATE] revealed a BIMS score of 15 which indicated he was cognitively intact. Record review revealed Resident #3 was admitted to the facility on [DATE] and had current diagnoses that included schizoaffective disorder-bipolar type, anxiety disorder, major depressive disorder, personality disorder, and insomnia. Review of Resident #3`s most recent BIMS score completed on quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated he was cognitively intact. The incident on 11/16/2023 occurred on the secure unit in the television (TV)/dining room between Resident #2 and Resident #3. Resident #3 was using racial slurs toward facility staff. Resident #2 went in the TV/dining room and put his hands on the back of Resident #3's neck and told him to stop saying the N word and hit Resident #3. Resident #3 then reacted and hit him back. Both residents were assessed for injuries immediately and none were noted. On 12/12/2023 at 2:35 p.m., an interview with S12 Certified Nursing Assistant (CNA) revealed she was working on the day the occurrence happened between Resident #2 and #3 in the secure unit TV/dining room on 11/16/2023. S12 CNA reported she was in the TV/dining room with Resident #3 and other residents as Resident #2 was sitting in his wheelchair at the door. S12 CNA reported Resident #3 was using a racial slur, the N word, while screaming and cursing for no reason. She reported she heard someone calling out for help so she left the TV/dining room to assist another resident in their room and left the TV/dining room unattended. Resident #2 reported to S12 CNA he went into the TV/dining room and grabbed Resident #3 by the neck and hit him in the head. S12 CNA went on to say that Resident #3 retaliated and hit Resident #2. S12 CNA reported she ran back in the TV/dining room and separated the residents and neither resident had any noticeable injuries. S12 CNA confirmed the TV/dining room was left unattended by staff when the incident occurred. She reported the other staff members on duty at that time were taking care of the immediate needs of other residents and no one was available to monitor the TV/dining room. On 12/12/2023 at 12:05 p.m. an interview with S5 Licensed Practical Nurse (LPN)/ Unit Manager revealed she was working in the secure unit on the day of the incident but did not witness the altercation. S5 LPN reported there were 3 CNA`s working on the floor and 1 CNA sitting with a resident in his room as required for 1 on 1 monitoring. She reported after the incident occurred, she assessed both residents and found no apparent physical injuries. On 12/12/2023 at 12:15 p.m., an observation/interview was conducted with Resident #3 in his room. Resident #3 confirmed he said things that were offensive to people and he understood why the altercation between he and Resident #2 took place. Resident #3 did not want to talk about the details of the incident on 11/17/2023 and appeared anxious. Resident #3 confirmed he and Resident #2 hit each other with closed fists. On 12/12/2023 at 12:25 p.m. an observation/interview was conducted with Resident #2 in his room. Resident #2 confirmed on 11/17/2023, he grabbed Resident #3 by the back of the neck and hit him because he was using racial slurs. Resident #2 reported he was sent out to an acute behavioral health facility on 11/17/2023. Resident #2 reported he experienced increased anxiety due to being sent out of the facility to a mental health facility. Resident #4 and Resident #5 Review of the facility's reported incident dated 12/04/2023 revealed Resident #5 was physically abused by Resident #4. Resident #4 entered Resident #5's room and hit him in the face multiple times with a closed fist leaving a bruise to the left eye. Review of Resident #4's clinical record revealed the latest readmitted [DATE] from a behavioral hospital with the following diagnoses, in-part: Schizophrenia, anxiety disorder, suicidal ideations, cocaine abuse, heart disease, diabetes myelitis, pain, muscle spasm, impulse disorder, depression, and insomnia. Review of Resident #5's clinical record revealed an admitted [DATE] with the following diagnoses which included: Paranoid Schizophrenia, anxiety disorder, Dementia, Impulse disorder, Autistic disorder, benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident #4's Quarterly Minimum Data Sets (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 (Cognitively Intact). Review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS of 9 (Mildly Impaired). Review of Resident #5's Skin and Wound Evaluation form dated 12/04/2023 revealed a bruise under the left eye. Review of Resident #5's Nurses Notes revealed on 12/04/2023, Resident #5 reported Resident #4 hit him on the left side of the face 3 times. During an interview on 12/12/2023 at 12:10 p.m., Resident #5 confirmed physical abuse occurred on 12/04/2023 when Resident #4 hit him in the face. An observation on 12/12/2023 at 12:10 p.m. revealed a small yellow and purple bruise noted just below Resident #5's left eye which Resident #5 pointed to when he confirmed Resident #4 hit him in the face. Resident #4 was admitted to a behavioral hospital on 12/05/2023 and not available for interview. Review of the facility's incident reports revealed there were 9 other resident to resident physical abuse altercations that occurred on the secure unit within the past 6 months. During an interview on 12/18/2023 at 3:20 p.m., S3 Corporate Nurse agreed the facility failed to provide sufficient, competent direct care staff to ensure residents are monitored and safety is maintained in the secure unit. S3 Corporate Nurse confirmed interviews and/or assessments were not conducted with all residents residing in the secure unit after each resident to resident physical abuse altercation. S3 Corporate Nurse agreed the facility failed to provide effective interventions to address the physical safety and psychological care needs of the current 32 residents on the secure unit.

Based on observations, interviews, and record reviews the facility failed to ensure sufficient staffing to assure residents safety and maintain the highest practicable physical, mental and psychosocial well-being for 4 (Residents #2, #3, #4, #5) of 5 (Residents #1, #2, #3, #4, #5) residents reviewed for abuse. The facility failed to: 1. Provide sufficient direct care staffing to ensure residents safety. 2. Interview or assess all residents on the secure unit regarding concerns of physical abuse after incidents that involved abuse. The Immediate Jeopardy began on 11/16/2023 as a result of the secure unit having: 1) a resident to resident physical abuse altercation on 11/16/2023 between Resident #2 and Resident #3 which occurred when Resident #2 grabbed Resident #3 by the neck and hit him in the back of the head with a closed fist. Resident #3 retaliated and hit Resident #2 with a closed fist. The incident occurred in the dining room of the secure unit. The facility failed to ensure staff monitored the television/dining room. 2) a resident to resident physical abuse altercation on 12/04/2023 between Resident #4 and Resident #5 which occurred when Resident #4 entering Resident #5's room and hit him in the face multiple times with a closed fist leaving a bruise to the left eye. The facility failed to ensure resident safety by allowing Resident #4 to enter Resident #5`s room and physically abuse him. The lack of effective interventions to address the staffing and safety needs of the 32 residents on the secure unit since 11/16/2023 had a high likelihood of serious adverse outcomes that could include severe injury, harm, or death S1Administrator, S4 DON (Director of Nursing), and S3 Corporate Nurse were notified of the Immediate Jeopardy on 12/14/2023 at 12:50 p.m. The Immediate Jeopardy was removed on 12/14/2023 at 10:52 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at the potential for more that minimal harm for 32 resident in the secure unit. Findings: Cross Reference F835 Review of the Abuse Prevention Policy revealed in part under Preventions: 5. Examples of steps that the facility may put in place immediately to prevent further potential abuse includes, but are not limited to, staffing changes, increase supervision, protection from retaliation, and follow-up counseling for the resident(s). Resident #2 and Resident #3 Review of the facility's incident reports revealed an incident that occurred on 11/16/2023 between Resident #2 and Resident #3. Resident #2 grabbed Resident #3 by the neck and hit him in the back of the head with a closed fist. Resident #3 retaliated and hit Resident #2 with a closed fist. Record review revealed Resident #2 was admitted to the facility on [DATE] and had active diagnoses that included major depressive disorder, anxiety disorder and unspecified mood disorder. Review of Resident #2`s most recent brief interview of mental status (BIMS) score completed on quarterly minimum data set (MDS) dated [DATE] revealed a BIMS score of 15 which indicated he was cognitively intact. Record review revealed Resident #3 was admitted to the facility on [DATE] and had current diagnoses that included schizoaffective disorder-bipolar type, anxiety disorder, major depressive disorder, personality disorder, and insomnia. Review of Resident #3`s most recent BIMS score completed on quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated he was cognitively intact. The incident occurred on 11/16/2023 in the television (TV)/dining room of the secure unit between Resident #2 and Resident #3. Resident #3 was using racial slurs toward facility staff. Resident #2 went in the TV/dining room and put his hands on the back of Resident #3's neck and told him to stop saying the N word and hit Resident #3. Resident #3 then reacted and hit him back. On 12/12/2023 at 2:35 p.m., an interview with S12 Certified Nursing Assistant (CNA) revealed she was working on the day the occurrence happened between Resident #2 and #3 in the secure unit TV/dining room on 11/16/2023. S12 CNA reported she was in the TV/dining room with Resident #3 and other residents as Resident #2 was sitting in his wheelchair at the door. S12 CNA reported Resident #3 was using a racial slur, the N word, while screaming and cursing for no reason. She reported she heard someone calling out for help so she left the TV/dining room to assist another resident in their room and left the TV/dining room unattended. Resident #2 reported to S12 CNA he went into the TV/dining room and grabbed Resident #3 by the neck and hit him in the head. S12 CNA went on to say that Resident #3 retaliated and hit Resident #2. S12 CNA reported she ran back in the TV/dining room and separated the residents and neither resident had any noticeable injuries. S12 CNA confirmed the TV/dining room was left unattended by staff when the incident occurred. She reported the other staff members on duty at that time were taking care of the immediate needs of other residents and no one was available to monitor the TV/dining room. S12 CNA reported more direct care staff was definitely needed on that day and there were many other days when more staff was needed. On 12/12/2023 at 12:05 p.m. an interview with S5 Licensed Practical Nurse (LPN)/ Unit Manager revealed she was working in the secure unit on the day of the incident but did not witness the altercation. S5 LPN reported there were 3 CNA`s working on the floor and 1 CNA sitting with a resident in his room as required for 1 on 1 monitoring. S5 LPN confirmed the residents should not have been left in the TV/dining room unattended. Resident #4 and Resident #5 Review of the facility's reported incident dated 12/04/2023 revealed Resident #5 was physically abused by Resident #4. Resident #4 entered Resident #5's room and hit him in the face multiple times with a closed fist leaving a bruise to the left eye. Review of Resident #4's clinical record revealed the latest readmitted [DATE] from a behavioral hospital with the following diagnoses, in-part: Schizophrenia, anxiety disorder, suicidal ideations, cocaine abuse, heart disease, diabetes myelitis, pain, muscle spasm, impulse disorder, depression, and insomnia. Review of Resident #5's clinical record revealed an admitted [DATE] with the following diagnoses which included: Paranoid Schizophrenia, anxiety disorder, Dementia, Impulse disorder, Autistic disorder, benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident #4's Quarterly Minimum Data Sets (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 (Cognitively Intact). Review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS of 9 (Mildly Impaired). Review of Resident #5's Skin and Wound Evaluation form dated 12/04/2023 revealed a bruise under the left eye. Review of Resident #5's Nurses Notes revealed on 12/04/2023, Resident #5 reported Resident #4 hit him on the left side of the face 3 times. During an interview on 12/12/2023 at 12:10 p.m., Resident #5 confirmed physical abuse occurred on 12/04/2023 when Resident #4 hit him in the face. An observation on 12/12/2023 at 12:10 p.m. revealed a small yellow and purple bruise noted just below Resident #5's left eye which Resident #5 pointed to when he confirmed Resident #4 hit him in the face. Resident #4 was admitted to a behavioral hospital on 12/05/2023 and not available for interview. Review of the facility's incident reports revealed there were 9 other resident to resident physical abuse altercations that occurred on the secured unit within the past 6 months. During an interview on 12/13/2023 at 2:10 p.m., S3 Corporate Nurse reported the number of staff had not changed and had been consistently 3 CNA's working the floor and 1 CNA for the 1 on 1 resident care and 1 LPN and 1 unit manager on the secure unit since September 2023. During an interview on 12/13/2023 at 2:12 p.m., S4 DON reported there were 3 CNA's, 1 CNA for 1 on 1 resident care, and 1 LPN working as a staff nurse and unit manager on the secure unit on 11/16/2023. An observation on 12/13/2023 at 2:15 p.m. revealed S5 LPN was the only LPN working in the secure unit on the day shift and served as the staff nurse and unit manager. During an interview on 12/13/2023 at 2:45 p.m., S1 Administrator reported the secure unit was staffed with the minimum number of staff required. S1 Administrator reported since starting at the facility on 09/27/2023 the facility keeps 4 CNA's, 1 LPN and a Unit Manager in the secure unit. S1 Administrator acknowledged there had not been an increase in staff in the secure unit since she had been employed at the facility (09/27/2023). During a telephone interview on 12/13/2023 at 3:27 p.m., S6 Medical Director reported training alone was not enough to prevent abuse incidents in the secure unit. S6 Medical Director further reported more experienced staff was needed for the residents to get higher quality of care. An observation on 12/14/2023 at 9:10 a.m. revealed S5 LPN was working in the secure unit and was serving as the staff nurse and unit manager. An observation on 12/14/2023 at 7:05 p.m. revealed Resident #14 in the secure unit TV/dining room alone and unsupervised. Further observation revealed multiple residents standing outside of the TV/dining room in the hall. During an interview on 12/14/2023 at 7:15 p.m., S11 CNA, in the secure unit, reported she was employed as part time at the facility. S11 CNA further reported the secure unit was staffed with no more than 3 CNAs, 1 CNA for 1 on 1 resident care and 1 LPN. On 12/14/2023 at 7:20 p.m. an interview was conducted with S9 CNA. S9 CNA reported he had worked nights at the facility about 2 years and there had been occasions the facility needed more direct care staff in the secure unit. During an interview on 12/18/2023 at 3:20 p.m., S3 Corporate Nurse agreed the facility failed to provide sufficient, competent direct care staff to ensure residents were monitored and safety was maintained in the secure unit. S3 Corporate Nurse confirmed interviews and/or assessments were not conducted with all residents residing in the secure unit after each resident to resident physical abuse altercation.

Based on interview and record review, the facility failed to administer its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 (Residents #2, #3, #4, #5) of 5 (Residents #1, #2, #3, #4, #5) residents reviewed for abuse. The administration failed to provide sufficient, competent direct care staff to ensure resident safety was maintained in the secure unit. The Immediate Jeopardy began on 11/16/2023 as a result of the secure unit having: 1) a resident to resident physical abuse altercation on 11/16/2023 between Resident #2 and Resident #3 which occurred when Resident #2 grabbed Resident #3 by the neck and hit him in the back of the head with a closed fist. Resident #3 retaliated and hit Resident #2 with a closed fist. The incident occurred in the dining room of the secure unit. The facility failed to ensure staff monitored the television/dining room. 2) a resident to resident physical abuse altercation on 12/04/2023 between Resident #4 and Resident #5 which occurred when Resident #4 entering Resident #5's room and hit him in the face multiple times with a closed fist leaving a bruise to the left eye. The facility failed to ensure resident safety by allowing Resident #4 to enter Resident #5`s room and physically abuse him. The lack of the facility's administration to address the physical abuse altercations and staffing needs of the residents residing in the secure unit has a high likelihood of adverse outcomes that includes severe injuries, harm, or death. S1Administrator, S4 DON (Director of Nursing), and S3 Corporate Nurse were notified of the Immediate Jeopardy on 12/14/2023 at 12:50 p.m. The Immediate Jeopardy was removed on 12/14/2023 at 10:52 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at the potential for more that minimal harm for 32 resident in the secure unit. Findings: Cross Reference F600 Cross Reference F741 Review of the Abuse Prevention Policy revealed in part under Preventions: 5. Examples of steps that the facility may put in place immediately to prevent further potential abuse includes, but are not limited to, staffing changes, increase supervision, protection from retaliation, and follow-up counseling for the resident(s). Resident #2 and Resident #3 Review of the facility's reported incidents revealed an incident that occurred on 11/16/2023 between Resident #2 and Resident #3. Resident #2 grabbed Resident #3 by the neck and hit him in the back of the head with a closed fist. Resident #3 retaliated and hit Resident #2 with a closed fist. Record review revealed Resident #2 was admitted to the facility on [DATE] and had active diagnoses that included major depressive disorder, anxiety disorder and unspecified mood disorder. Review of Resident #2`s most recent brief interview of mental status (BIMS) score completed on quarterly minimum data set (MDS) dated [DATE] revealed a BIMS score of 15 which indicated he was cognitively intact. Record review revealed Resident #3 was admitted to the facility on [DATE] and had current diagnoses that included schizoaffective disorder-bipolar type, anxiety disorder, major depressive disorder, personality disorder, and insomnia. Review of Resident #3`s most recent BIMS score completed on quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated he was cognitively intact. The incident on 11/16/2023 occurred on the secure unit in the television (TV)/dining room between Resident #2 and Resident #3. Resident #3 was using racial slurs toward facility staff. Resident #2 went in the TV/dining room and put his hands on the back of Resident #3's neck and told him to stop saying the N word and hit Resident #3. Resident #3 then reacted and hit him back. Both residents were assessed for injuries immediately and none were noted. On 12/12/2023 at 2:35 p.m., an interview with S12 Certified Nursing Assistant (CNA) revealed she was working on the day the occurrence happened between Resident #2 and #3 in the secure unit TV/dining room on 11/16/2023. S12 CNA reported she was in the TV/dining room with Resident #3 and other residents as Resident #2 was sitting in his wheelchair at the door. S12 CNA reported Resident #3 was using a racial slur, the N word, while screaming and cursing for no reason. She reported she heard someone calling out for help so she left the TV/dining room to assist another resident in their room and left the TV/dining room unattended. Resident #2 reported to S12 CNA he went into the TV/dining room and grabbed Resident #3 by the neck and hit him in the head. S12 CNA went on to say that Resident #3 retaliated and hit Resident #2. S12 CNA reported she ran back in the TV/dining room and separated the residents and neither resident had any noticeable injuries. S12 CNA confirmed the TV/dining room was left unattended by staff when the incident occurred. She reported the other staff members on duty at that time were taking care of the immediate needs of other residents and no one was available to monitor the TV/dining room. On 12/12/2023 at 12:05 p.m. an interview with S5 Licensed Practical Nurse (LPN)/ Unit Manager revealed she was working in the secure unit on the day of the incident but did not witness the altercation. S5 LPN reported there were 3 CNA`s working on the floor and 1 CNA sitting with a resident in his room as required for 1 on 1 monitoring. S5 LPN confirmed the TV/Dining room should not have been left unattended by staff while residents were in the room. On 12/12/2023 at 12:15 p.m., an observation/interview was conducted with Resident #3 in his room. Resident #3 confirmed he said things that were offensive to people and he understood why the altercation between he and Resident #2 took place. Resident #3 did not want to talk about the details of the incident on 11/17/2023 and appeared anxious. Resident #3 confirmed he and Resident #2 hit each other with closed fists. On 12/12/2023 at 12:25 p.m. an observation/interview was conducted with Resident #2 in his room. Resident #2 confirmed on 11/17/2023, he grabbed Resident #3 by the back of the neck and hit him because he was using racial slurs. Resident #2 reported he was sent out to an acute behavioral health facility on 11/17/2023. Resident #2 reported he experienced increased anxiety due to being sent out of the facility to a mental health facility. Resident #4 and Resident #5 Review of the facility's reported incident dated 12/04/2023 revealed Resident #5 was physically abused by Resident #4. Resident #4 entered Resident #5's room and hit him in the face multiple times with a closed fist leaving a bruise to the left eye. Review of Resident #4's clinical record revealed the latest readmitted [DATE] from a behavioral hospital with the following diagnoses, in-part: Schizophrenia, anxiety disorder, suicidal ideations, cocaine abuse, heart disease, diabetes myelitis, pain, muscle spasm, impulse disorder, depression, and insomnia. Review of Resident #5's clinical record revealed an admitted [DATE] with the following diagnoses which included: Paranoid Schizophrenia, anxiety disorder, Dementia, Impulse disorder, Autistic disorder, benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident #4's Quarterly Minimum Data Sets (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 (Cognitively Intact). Review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS of 9 (Mildly Impaired). Review of Resident #5's Skin and Wound Evaluation form dated 12/04/2023 revealed a bruise under the left eye. Review of Resident #5's Nurses Notes revealed on 12/04/2023, Resident #5 reported Resident #4 hit him on the left side of the face 3 times. During an interview on 12/12/2023 at 12:10 p.m., Resident #5 confirmed physical abuse occurred on 12/04/2023 when Resident #4 hit him in the face. An observation on 12/12/2023 at 12:10 p.m. revealed a small yellow and purple bruise noted just below Resident #5's left eye which Resident #5 pointed to when he confirmed Resident #4 hit him in the face. Resident #4 was admitted to a behavioral hospital on 12/05/2023 and not available for interview. During an interview on 12/13/2023 at 2:10 p.m., S3 Corporate Nurse reported the number of staff had not changed and had been consistently 3 Certified Nursing Assistants (CNA's) and 1 CNA for the 1 on 1 resident care and 1 Licensed Practical Nurse (LPN) and 1 unit manager on the secure unit since September 2023. During an interview on 12/13/2023 at 2:12 p.m., S4 DON reported there were 3 CNA's, 1 CNA for 1 on 1 resident care, and 1 LPN working as a staff nurse and unit manager on the secure unit that day. An observation on 12/13/2023 at 2:15 p.m. revealed S5 LPN was the only LPN working in the secure unit on the day shift and served as the staff nurse and unit manager. During an interview on 12/13/2023 at 2:45 p.m., S1 Administrator reported the secure unit was staffed with the minimum number of staff required. S1 Administrator reported since starting at the facility on 09/27/2023 the facility keeps 4 CNA's, 1 LPN and a Unit Manager in the secure unit. S1 Administrator acknowledged there has not been an increase in staff in the secured unit since she has been employed at the facility (09/27/2023). During a telephone interview on 12/13/2023 at 3:27 p.m., S6 Medical Director reported training alone was not enough to prevent abuse incidents in the secure unit. S6 Medical Director further reported more experienced staff was needed for the residents to get higher quality of care. On 12/14/2023 at 12:46 p.m. an interview with S1 Administrator confirmed she was ultimately responsible for the safety of all residents at the facility. S1 Administrator confirmed there had been 9 resident to resident physical abuse altercations in the secured unit, within the last 6 months that were prior to the 2 additional cases that were currently under investigation (12/04/2023 and 11/16/2023). During an interview on 12/18/2023 at 3:20 p.m., S3 Corporate Nurse agreed the facility administration failed to provide sufficient, competent direct care staff to ensure residents are monitored and safety is maintained in the secure unit. S3 Corporate Nurse confirmed interviews and/or assessments were not conducted with all residents residing in the secure unit after each resident to resident physical abuse altercation. S3 Corporate Nurse agreed there was a lack of an effective system in place to provide interventions to address the physical safety and psychological care needs of the current 32 residents on the secure unit.

Based on record review and interviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to provide adequate supervision to resident #74 who had been assessed at high risk for elopement. The resident was left unattended in the waiting room of a physician ' s office and eloped. This deficient practice has the potential to affect 5 residents (#5, #8, #60, #74, & #83) who were also identified by the facility as being at high risk for elopement. The facility failed to adequately train staff on the identification and supervision during the transportation of residents who are at high risk for elopement. The facility failed to have a policy in place for the transportation of residents who are at high risk for elopement. The Immediate Jeopardy situation began on 4/10/13 at 10:30AM when resident #74 was left unattended in the waiting room of a physician's office and eloped. The Immediate Jeopardy situation ended for sampled resident #74 on 4/10/13 at 4:00PM when local police found the resident and admitted him to a psych hospital. Resident #74 did not have any injuries upon admit to the psych hospital. The Immediate Jeopardy was lowered to a level II deficiency on 4/10/13 at 4:10PM when the Administration inserviced the Transportation staff on transportation and observation of all residents that are at high risk for elopement. The Administration also would assign a one on one staff member for transportation of any resident that is at high risk for elopement. Finding: Record review of resident #74 revealed the resident was admitted [DATE], with [DIAGNOSES REDACTED]. Record review of resident #74 revealed resident was assessed at high risk for elopement on 11/16/12. Record review revealed resident #74 was in the Elopement Risk Book. Record review of the Daily Care Guide (information about each resident and their risks) dated 4/10/13 revealed resident #74 had a risk of elopement. Record review of nursing notes dated 3/16/13 at 9:50 PM revealed resident #74 "...stated he didn't belong here and wanted to go home where he belongs, this is just the beginning I'm going to get out of here one way or another, if I got to break the windows out, or murder someone. asked res why he felt that way, he said because he doesn't belong here with these idiots, and I have this one doctor that is going to let me go home because I don't have any health issues. expressed to res that his blood sugars are not always under control and the doctor may not decide that he cannot take care of himself at home so that mat not be a choice, res just stated yea I'm going home....verbalized understanding that he was wrong, but he is going to do whatever it takes to get home, get me out or watch he stated." Record review revealed physician order [REDACTED]. On 4/10/13, resident #74 was transported by facility staff to an off-site clinic for a 9:30 AM physician appointment. On 4/10/13 at 2:50 PM, informed by S10 Corporate Nurse and S1 Administrator that they had been notified by S12 CNA Supervisor that resident #74 had eloped from the off-site clinic at around 10:30 AM. S1 Administrator stated that the Police Department and the resident's parents had been notified of the elopement. On 4/11/13 at 2:00 PM, interview with S11CNA reported that she had no idea that he was at high risk for elopement. CNA further stated that when they left the facility the wanderguard alarmed. S11CNA stated that she did not have a 'daily care guide' (information on every resident in the facility and their risks) when she drove the facility van and escorted the residents to the off-site clinic. On 4/11/13 at 1:06 PM, during interview with S12CNA Supervisor she stated that she was not aware resident #74 was an elopement risk. She stated she was not going to monitor resident #74. S12CNA Supervisor stated she was going to monitor around resident. She reported that she was not aware he was a big risk for elopement because "he had never tried to do that before". CNA stated "if we would have known, we would have kept a close eye on him". CNA reported that no one reminded them before they left the facility that the resident was a risk. S12CNA Supervisor stated that she passed out the 'daily care guide' on 4/10/13 but did not keep one for herself. S12CNA Supervisor also stated that "everyone is supposed to know what's in the book, too." On 4/11/13 at 2:00 PM, interview with S1 Administrator confirmed there was no documentation of staff training on the supervision of residents at risk for elopement and there was no policy on transporting residents outside of the facility.

I. Based on record review and interviews, the facility failed to provide adequate supervision to resident #74 who had been assessed at high risk for elopement. An Immediate Jeopardy situation occurred when the resident was left unattended in the waiting room of a physician's office and eloped. The deficient practice has the potential to affect 5 residents (#5, #8, #60, #74, & #83) who were also identified by the facility as being at high risk for elopement. The facility failed to adequately train staff on the identification and supervision during the transportation of residents who are at high risk for elopement. The facility failed to have a policy in place for the transportation of residents who are at high risk for elopement. The Immediate Jeopardy situation began on 4/10/13 at 10:30AM when resident #74 was left unattended in the waiting room of a physician's office and eloped. The Immediate Jeopardy situation ended for sampled resident #74 on 4/10/13 at 4:00PM when local police found the resident and admitted him to a psych hospital. Resident #74 did not have any injuries upon admit to the psych hospital. The Immediate Jeopardy was lowered to a level II deficiency on 04/10/13 at 4:10PM when the Administration inserviced the transportation staff on the transportation and observation of all residents that are at high risk for elopement. The Administration also would assign a one on one staff member for transportation of any resident that is at high risk for elopement. The above actions were part of their plan of removal and were also incorporated into their newly developed policy for elopement. Finding: Record review of resident #74, age 53, was admitted [DATE], with [DIAGNOSES REDACTED]. Record review of resident #74 revealed the resident was assessed at risk for elopement on 11/16/12. Record review revealed resident #74 was in the Elopement Risk Book. Record review of the Daily Care Guide (information about each resident and their risks) dated 04/10/13 revealed resident #74 had a risk of elopement. Record review of nursing notes dated 03/16/13 at 9:50 PM revealed resident #74 "...stated he didnt belong here and wanted to go home where he belongs, this is just the begining im going to get out of here one way or another, if i got to break the windows out, or murder someone. asked res why he felt that way, he said because he doesnt belong here with these idiots, and i have this one doctor that is going to let me go home because i dont have any health issues. expressed to res that his blood sugars are not always under control and the doctor may not decide that he cannot take care of himself at home so that mat not be achoice, res just stated yea im going home....verbalized understanding that he was wrong, but he is going to do whatever it takes to get home, get me out or watch he stated." Record review revealed physician order [REDACTED]. On 04/10/13, resident #74 was transported by facility staff to an off-site clinic for a 9:30 AM physician appointment. On 04/10/13 at 2:50 PM, informed by S10 Corporate Nurse and S1 Administrator that they had been notified by S12 CNA Supervisor that resident #74 had eloped from the off-site clinic at around 10:30 AM. S1 Administrator stated that the Police Department and the resident's parents had been notified of the elopement. On 04/11/13 at 2:00 PM, interview with S11CNA reported that she had no idea that he was at risk for elopement. CNA further stated that when they left the facility that the Wanderguard alarmed. S11CNA stated that she did not have a 'daily care guide' (information on every resident in the facility and their risks) when she drove the facility van and escorted the residents to the off-site clinic. On 04/11/13 at 1:06 PM, during interview with S12CNA Supervisor she stated that she was not aware resident #74 was an elopement risk. She stated she was not going to monitor resident #74. S12CNA Supervisor stated she was going to monitor another resident. She reported that she was not aware that he was a "big" risk for elopement because "he had never tried to do that before". CNA stated "if we would have known, we would have kept a close eye on him". CNA reported that no one reminded them before they left the facility that the resident was an elopement risk. S12CNA Supervisor stated that she passed out the 'daily care guide' on 04/10/13 but did not keep one for herself. S12CNA Supervisor also stated that "everyone is supposed to know what's in the book, too." On 04/11/13 at 2:00 PM, interview with S1 Administrator confirmed there was no policy on transporting residents outside of the facility. II. Based on record review and interview, the facility failed to ensure that the resident receives adequate supervision to prevent accidents by failing to implement a new approach (two person assist) after the third fall for 1 (#67) of 5 (#22, #36, #67, #74, #80) sampled residents who met the QCLI criteria for falls in a total sample of 40 stage 2 residents. Findings: Record review revealed resident #67, admitted [DATE], with [DIAGNOSES REDACTED]. A review of the 01/31/13 quarterly MDS assessment revealed BIMS (brief interview for mental status) score of 15. A score of 13-15 indicates that a person is congnitively intact. Review of the care plan revealed resident #67 was assessed to be at risk for falls with a target date of 07/06/13. Care plan approaches included assistance with toileting to and from restroom, monitor resident every 2 hours to ensure safety, and two person assist with ambulation. Review of the Resident Incident Reports revealed resident #67 had falls on 01/02/13, 01/22/13, 03/04/13 and 03/09/13. Review of Resident Incident Report for fall on 01/02/13 at 4:50 PM revealed resident used call bell for assistance and was found on floor with back against night stand. resident sustained [REDACTED]. Immediate post-incident action taken was alarm mat put into place. Immediate actions taken listed was 20 min checks on resident; Reinstructed resident to always call for assistance with transfers. Review of Resident Incident Report for fall on 01/22/13 at 9:00 PM revealed resident #67 called for assistance. CNA was assisting resident to restroom. Resident was using his walker and lost his balance. Resident fell backwards into the dresser and hit the floor and bumped his head. resident sustained [REDACTED]. Immediate post-incident action was encouraged resident to sit on side of the bed for a couple of minutes before rising. Immediate actions taken was assisted resident to restroom. Review of the Resident Incident Report for fall on 03/04/13 at 8:00 PM revealed resident #67 was assisted from bathroom to bed by nurse. Resident lost balance and assisted to bed by nurse. Per report, resident attempted to catch himself on the w/c nearby. resident sustained [REDACTED]. Immediate post-incident action was 2 person assist with ambulation. Immediate actions taken was lowered to the bed. Review of the Resident Incident Report for fall on 03/9/13 at 10:45 AM revealed resident #67 used call light to inform staff that he had fallen. Resident stated that he was getting up to fix his TV and slid against his walker. resident sustained [REDACTED]. Immediate post-incident action taken was physician to do medication assessment and to see 3-11-2013. Immediate actions taken was vitals taken, physical assessment and wound care performed. On 4/10/13 at 11:15 AM, interview with resident #67 reported that when he called for assistance to go to bathroom one person assists him. On 4/10/13 at 1:05 PM, interview with S5CNA confirmed that only one person went to assist resident #67 when he ambulated in his room and to the bathroom. CNA stated "it just takes one person to help him to the bathroom". On 4/10/13 at 1:24 PM, interview with S2DON confirmed that only one person had assisted the resident to the bathroom and the approach for two person assist had not been followed. III. Based on observation and interview, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible by having 1.) a whirlpool room unlocked with 2 whirlpool chairs in the whirlpool tub full of water, 2.) a storage room unlocked with exposed wire, and 3.) one unsecured oxygen bottle sitting on the floor in the room of sample #80. Findings: On 04/08/13 at 9:40AM observation of the whirlpool room across from room N revealed water was in the tub, and the room was unlocked. The light in the room was off. There were 2 chairs in the whirlpool tub. The water was over the seats of the chairs. There was no staff present. On 04/08/13 at 09:55AM an interview with S7CNA revealed she had gone to the other hall briefly and had left the chairs on to soak. She stated she had closed the door when she left, but someone must have come in and put the stand up lift in the whirlpool room, because it was not there when she left. She stated she did not know who had keys to the room. On 04/08/13 at 09:57AM an interview with S1Administrator revealed staff was supposed to keep the door locked. Also at this time observation of the storage room next to the whirlpool revealed the room was unlocked, and there was an electric panel left open that had exposed wires visible. S1Administrator stated the panel and the room should have been locked. On 04/08/13 observations at 9:30am and 11:30am revealed an unsecured oxygen bottle sitting on the floor in the room of sample #80. On 04/08/13 at 11:55am, interview with S1Administrator confirmed the oxygen bottle was an accident hazard and should always be secured.