Every finding on record at Plaza Community Living Center

Based on observation, interviews, and facility policy review, the facility failed to ensure the residents' right to reside in a clean, comfortable, and homelike environment, as evidenced by dark-colored staining and residue on hallway vents and wall surfaces, damaged wall surfaces with paint scraped away exposing the underlying wall material, and recurring roof leaks for three (3) of six (6) halls. (Northeast, North Central, and South Central)Findings include:A review of the facility's policy, Resident Rights, dated 11/23/2016, revealed, .It is the policy of this facility to promote and protect the rights of the residents residing in this facility. Procedure. 3. The facility will make every effort to provide resident homelike environment.On 6/1/26 at 10:00 AM, during an observation of the facility, dark spot-like discoloration and residue were observed on vents and wall surfaces throughout the Northeast, North Central, and South Central hallways. Areas of wall damage were also observed with paint scraped away, exposing the underlying wall surface in Resident #31's room.On 6/1/26 at 11:10 AM, during an interview with Housekeeper #1 on the South Wing, she stated she had worked at the facility for three years and the roof had leaked intermittently during that time. She reported repairs were made to one area; however, water would subsequently leak from another location.On 6/1/26 at 11:20 AM, during an interview with Resident #70, the resident reported the ceiling leaked when it rained and staff placed barrels throughout the facility to collect water. The resident further reported water entered from the floor level causing portions of the flooring to buckle and expressed concern about falling due to the water intrusion.On 6/1/26 at 11:30 AM, during an interview with Resident #48, the resident reported observing roof leaks on multiple occasions near the north middle hall nurses' station and on the south middle hall. The resident reported observing dark-colored staining on ceiling and wall surfaces for several months and stated repairs were made to one area while leaks continued to occur in other locations. He stated he was concerned that that the discolored areas were mold caused by the leaking roof.On 6/1/26 at 1:00 PM, during an interview with Resident #93's family, he reported that the resident was no longer at the facility. He stated that during the latter part of April 2026, rain entered the facility through roof leaks. He reported staff placed barrels in the hallways to collect water and ceiling material was falling to the floor and being discarded by staff. On 6/2/26 at 9:00 AM, during an interview with the Activity Director, she reported the roof leaked intermittently and multiple repair attempts had been made; however, water continued to enter the building in different locations.On 6/2/26 at 10:30 AM, during an interview with Licensed Practical Nurse (LPN) 1, the nurse reported water leaked from the ceiling in the north hallways and staff routinely placed barrels in the hallways to collect water.On 6/2/26 at 1:00 PM, during an interview with the Maintenance Director, the director confirmed the roof had ongoing leaks. The director reported contractors had previously patched sections of the roof; however, water continued to leak from different locations. The director reported a licensed contractor had been contacted to provide an estimate for more extensive roof repairs, but work had been delayed due to weather conditions. The maintenance director also confirmed the paint was scrapped off the wall in Resident 31's room. The Director said he did not know the paint had been scraped off the wall. He had been really busy and had not had time to do environmental rounds.On 6/2/26 at 1:30 PM, during an interview with the Administrator, the Administrator confirmed the roof had resumed leaking approximately two weeks earlier. The Administrator reported a licensed contractor had been hired and an invoice had been obtained for application of silicone coating to the roof in an effort to stop the leaks.On 6/2/26 at 3:00 PM, during an interview with the roofing contractor, the contractor confirmed he had previously performed patch repairs to the roof. The contractor reported patching was not effective in resolving the leaks and recommended application of a silicone roof coating. The contractor reported that the project was approved on 5/24/26 but had not yet been completed due to ongoing rain.

Based on observation, interview, record review, and policy review the facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene and grooming in accordance with a resident's needs and preferences by failing to remove facial hair for two (2) of eighteen (18) sampled residents. (Resident #32 and #26). Findings include: A review of the facility's ADL Care of a Resident Policy and Procedure, undated, revealed, .Resident ADL care will be provided to the resident according to the individualized resident needs. Resident #32 A record review of the admission Record revealed the facility admitted Resident #32 on 3/25/25 and she had current diagnoses including Cerebral Infarction due to Embolism of the Left Middle Cerebral Artery, Contracture of Muscle, Right Hand, and Need for Assistance with Personal Care. A record review of the Modified Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/26 for Resident #32 revealed Section GG0130I5, Personal Hygiene: The ability to maintain personal hygiene, including.shaving.) was coded as dependent. The MDS further revealed she had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. A record review of the Task Record, Schedule for June 2026, for Resident #32 revealed documentation completed on 6/2/26 indicating bathing was provided and included the intervention to remove facial hair. On 6/1/26 at 11:09 AM, during observation of Resident #32, she had facial hair measuring approximately one-fourth (1/4) inch in length on her chin. On 6/2/26 at 10:23 AM, during an observation and interview with Resident #32, facial hair was observed on her chin. The resident stated that she did not want facial hair and that she wanted it to be shaved. On 6/3/26 at 8:35 AM and at 1:25 PM, facial hair remained present on Resident #32's chin. On 6/3/26 at 8:35 AM, during an interview and observation with Registered Nurse (RN) #1, she confirmed Resident #32 had facial hair and stated facial hair should be removed on shower days. On 6/3/26 at 10:40 AM, during an interview with Certified Nursing Assistant (CNA) #2, she stated facial hair should be removed on shower days and confirmed Resident #32's shower day was 6/2/26. CNA #2 acknowledged the resident's facial hair had not been removed. On 6/3/26 at 10:55 AM, during an interview with CNA #1, she reported Resident #32 required assistance with ADLs, including shaving. She stated the resident's shower schedule was Tuesday, Thursday, and Saturday and that the hospice aide provided a bed bath on Tuesday and Thursday. She confirmed Resident #32 had facial hair present. On 6/3/26 at 1:45 PM, during an interview with the Director of Nursing (DON), she stated she had spoken with hospice staff on 6/2/26 and no refusals of care had been reported. The DON stated refusals would be communicated to nursing staff and documented in the medical record. On 6/3/26 at 2:34 PM, during a phone interview, CNA #4 reported she provided Resident #32 with a bed bath and nail care on 6/2/26 but did not remove the resident's facial hair. She stated she did not report to facility staff that the facial hair had not been removed. On 6/3/26 at 3:18 PM, during an interview with Registered Nurse #2, she confirmed Resident #32 had facial hair on her chin and stated the resident did not usually refuse care. On 6/3/26 at 3:25 PM, during an interview with CNA #3, she stated she provided a bed bath to Resident #32 on 6/2/26 but did not provide facial hair removal. She stated the resident had not refused care and hospice staff had not reported any refusals to her. On 6/3/26 at 3:38 PM, during a phone interview with Resident #32's Resident Representative (RR), she stated her mother did not want facial hair and that facility staff should be removing it. She further stated she had removed the resident's facial hair herself on occasion. On 6/4/26 at 12:35 PM, during an interview with the Administrator, she stated she expected staff to provide residents with ADL care necessary to meet their needs, including grooming and removal of facial hair when needed. Resident #26 A record review of the admission Record revealed Resident #26 was admitted by the facility on 6/10/25 and he had current diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/26 revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. On 6/1/26 at 11:18 AM, during an interview and observation, Resident #26 was dry shaving his face and head with a blue razor. There was no soap, shaving cream, or water present for the resident to use and no staff were in the room assisting the resident. Resident #26 reported he shaved himself all the time because it was the only way he would get shaved and reported the Activity Director had given him the razor. On 6/1/26 at 11:20 AM, during an interview and observation with Licensed Practical Nurse (LPN) #4, she confirmed Resident #26 was using a razor to dry shave his face and head. LPN #4 reported staff were expected to shave residents and residents were not permitted to shave themselves On 6/2/26 at 11:22 AM, during an interview, Certified Nursing Assistant (CNA) #5 reported she did not know how the resident obtained the razor and reported residents were not permitted to shave themselves and shaving should be completed by staff. On 6/2/26 at 1:09 PM, during an interview with the Assistant Director of Nursing (ADON), she reported she was unaware how Resident #26 obtained the razor and reported residents were not permitted to use razors without staff assistance because they could cut themselves. On 6/3/26 at 2:04 PM, during an interview, the Director of Nursing (DON) reported that the facility policy required staff to assist residents with shaving. On 6/3/26 at 4:13 PM, during an interview, the Administrator reported staff were expected to follow facility policy regarding shaving and residents should be assisted by staff when shaving.

Based on staff interview, record review and facility policy review, the facility failed to provide written notification of a resident transfer to a resident or a resident's representative (RR) and failed to provide notification to the ombudsman for one (1) of three (3) closed records reviewed. Resident #93Findings include:A review of the facility's policy, Transfer or Discharge Notice, reviewed 04/10/2023, revealed, .Residents and/or representatives are notified in writing, and in a language and format they understand.Policy Interpretation and Implementation.4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge.d. An immediate transfer or discharge is required by the resident's urgent medical needs.5. The resident and representation are notified in writing of the following information: a. The specific reason for the transfer or discharge . A record review of admission Record revealed the facility admitted Resident #93 on 4/14/26 with diagnoses including Metabolic Encephalopathy.A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/05/2026 revealed Resident #93 had an unplanned discharged with return anticipated to a short-term general hospital.A record review of the Emergency Transfer Log for the Office of the State Long-Term Care Ombudsman for May 2026 revealed Resident #93 was not listed as having transferred during the month, despite being transferred on 5/5/26.A review of the medical record for Resident #93 revealed there was no written notification of transfer indicating the details of the transfer to the hospital on 5/5/26.On 06/04/2026 at 10:49 AM, during an interview with the Social Services Director (SSD) she revealed that residents are not provided with a written notification of transfer to the hospital which includes a reason for the hospitalization. The SSD noted that the RR usually knows the reason for the hospitalization because the facility staff will call them. The SSD stated she is responsible for sending a monthly report of all emergency hospital transfers to the local Ombudsman.06/04/2026 11:29 AM, during an interview with the Ombudsman he confirmed that he received the Emergency Transfer Log for the Office of the State Long-Term Care Ombudsman from the facility on 06/02/2026. The Ombudsman noted that Resident #93's name was not included on the list that he received.On 06/04/2026 at 2:30 PM, during an interview with the Business Office Manager (BOM), she revealed that she is responsible for sending out the bed hold and transfer notifications to the resident or the RR at the time the resident leaves the facility for the hospital. She confirmed that there was no transfer notification that included the details of the transfer to the resident or the RR when Resident #93 was transferred to the hospital on 5/5/26. The BOM reported that the reason for providing the RR information in writing regarding hospitalization is to keep the RR informed of the care their loved one is receiving. On 06/04/2026 at 2:41 PM, during an interview with the Administrator she revealed that she was made aware by staff that no written notification of transfer was being provided to the resident or the RR at the time of transfer. The Administrator further confirmed she was made aware that the Emergency Transfer Log for the Office of the State Long-Term Care Ombudsman form for May 2026 did not contain Resident #93's name. The Administrator stated that there should be a space on the hospital transfer form for the reason for hospitalization, but the facility was not using the form. The Administrator noted that the reason for providing information regarding the reason for hospitalization in writing is to maintain communication with the families regarding what's happening with the resident. The Administrator reported that the Business Office Manager is responsible for sending the bed hold and transfer notices. The Administrator stated that the SSD is responsible for submitting a monthly report to the Ombudsman of emergency hospitalizations. The Administrator affirmed that she expects all communication to be completed regarding resident transfers to the hospital.

Based on record review, staff interview, and the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected services received by a resident by coding dialysis as not received when the resident received dialysis during the assessment reference period, affecting one (1) of eighteen (18) sampled residents for MDS accuracy. (Resident #2).Findings include:A review of CMS's RAI Version 3.0 Manual revealed, .1.3 Completion of the RAI.It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during the observation period) . A record review of the admission Record revealed Resident #2 was admitted by the facility on 7/5/21 with current diagnoses including Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, End Stage Renal Disease, and Dependence on Renal Dialysis.A record review of the Order Summary Report revealed Resident #2 had a Physician's Order, dated 2/25/26 for dialysis on Monday, Wednesday, and Friday.A record review of the Significant Change In Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/1/26 for Resident #2 revealed Section O0110, Special Treatments, Procedures, and Programs, Item J1 (Dialysis) was coded No, indicating the resident had not received dialysis during the look-back period. The MDS also revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment.A record review of the Dialysis Transfer Assessment forms revealed Resident #2 attended scheduled dialysis treatments on 4/22/26, 4/24/26, and 4/29/26, which were dates that fell within the MDS assessment reference period for the Significant Change In Status MDS with an ARD of 5/1/26.On 6/3/26 at 11:03 AM, during an interview with Certified Nursing Assistant (CNA) #1, she reported Resident #2 attended dialysis on Monday, Wednesday, and Friday.On 6/3/26 at 11:24 AM, during an interview with Licensed Practical Nurse (LPN) #2, she reported Resident #2 received dialysis on Monday, Wednesday, and Friday.On 6/4/26 at 12:05 PM, during an interview with Licensed Practical Nurse (LPN) #3, she stated it was her responsibility to complete MDS assessments. She reported medical records, including dialysis transfer forms, physician orders, progress notes, hospital records, and diagnoses, are reviewed to determine appropriate MDS coding. She confirmed Resident #2 received dialysis treatments on 4/22/26, 4/24/26, and 4/29/26 during the look-back period for the Significant Change In Status MDS with an ARD of 5/1/26. She further confirmed the MDS was coded No for dialysis and acknowledged the assessment should have been coded Yes because the resident received dialysis during the assessment period.On 6/4/26 at 12:20 PM, during an interview with the Director of Nursing (DON), she stated her expectation was that MDS assessments be completed accurately. She reported that the MDS nurse should review medical records, including dialysis transfer forms and dialysis pre- and post-treatment notes, when completing the assessment. The DON confirmed the Significant Change In Status MDS with an ARD of 5/1/26 was coded No for dialysis and acknowledged the assessment should have been coded Yes because the resident received dialysis.On 6/4/26 at 12:25 PM, during an interview with the Administrator, she stated it was the responsibility of the MDS nurse to complete MDS assessments accurately. The Administrator confirmed the MDS should have been coded Yes for dialysis because Resident #2 received dialysis during the assessment reference period.

Based on observation, interviews, record review, and facility policy review, the facility failed to implement care plan interventions related to shaving for two (2) of 18 sampled residents. Residents #32 and #26. Findings include: A review of the facility's Care Plan Policy and Procedure, undated, revealed Purpose: To provide a comprehensive person-centered plan of care addressing resident's needs, strengths, goals and approaches. Policy: Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals and approaches. Resident #32 A record review of the admission Record revealed the facility admitted Resident #32 on 3/25/25 and she had current diagnoses including Cerebral Infarction due to Embolism of the Left Middle Cerebral Artery, Contracture of Muscle, Right Hand, and Need for Assistance with Personal Care. A record review of the Modified Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/26 for Resident #32 revealed Section GG0130I5, Personal Hygiene: The ability to maintain personal hygiene, including.shaving.) was coded as dependent. The MDS further revealed she had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. A record review of the Care Plan Report revealed Resident #32 had a Focus of I have an ADL (activities of daily living) self-care performance deficit r/t (related to ) Stroke and Interventions/Tasks included Bathing.facial hair removed. A record review of the Task Record, Schedule for June 2026, for Resident #32 revealed documentation completed on 6/2/26 indicating bathing was provided and included the intervention to remove facial hair. During an observation on 6/1/26 at 11:09 AM, Resident #32 had facial hair measuring approximately one-fourth (1/4) inch in length on her chin. During an observation and interview on 6/2/26 at 10:23 AM, Resident #32 had facial hair on her chin. The resident stated that she did not want facial hair and that she wanted it to be shaved. During an observation on 6/3/26 at 8:35 AM and at 1:25 PM, facial hair remained present on Resident #32's chin, which was after her scheduled bath for 6/2/26. During an interview and observation on 6/3/26 at 8:35 AM, Registered Nurse (RN) #1 confirmed Resident #32 had facial hair and stated facial hair should be removed on shower days. During an interview on 6/3/26 at 10:40 AM, Certified Nursing Aide (CNA) #2 stated facial hair should be removed on shower days and confirmed Resident #32's shower day was on 6/2/26. CNA #2 acknowledged the resident's facial hair had not been removed. During a phone interview on 6/3/26 at 2:34 PM, CNA #4 reported she provided Resident #32 with a bed bath and nail care on 6/2/26 but did not remove the resident's facial hair. Resident #26 A record review of the admission Record revealed Resident #26 was admitted by the facility on 6/10/25 and he had current diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/26 revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A record review of the Care Plan Report revealed Resident #26 had a Focus of I have an ADL self-care performance deficit r/t Impaired balance, Pain Bilateral Lower extremities and Interventions/Tasks included .Self Care Personal hygiene: Requires (Substantial) to maintain personal hygiene, including.shaving. During an interview and observation on 6/1/26 at 11:18 AM, Resident #26 was dry shaving his face and head with a blue razor. There was no soap, shaving cream, or water present for the resident to use and no staff were in the room assisting the him. Resident #26 reported he shaved himself all the time because it was the only way he would get shaved and reported the Activity Director had given him the razor. During an interview and observation on 6/1/26 at 11:20 AM, Licensed Practical Nurse (LPN) #4 confirmed Resident #26 was using a razor to dry shaving his face and head. LPN #4 reported staff were expected to shave residents and residents were not permitted to shave themselves. During an interview on 6/4/26 at 2:19 PM, during an interview with Licensed Practical Nurse (LPN) #3, she stated she was responsible for the care plans and she expected the staff to implement care plan interventions. During an interview on 6/4/26 at 2:49 PM, the Director of Nursing (DON) reported that staff were expected to follow the resident care plan at all times.

Based on observation, staff interview, and facility policy review, the facility failed to ensure Schedule II controlled substances were maintained in permanently affixed compartments when two (2) of four (4) medication carts contained removable narcotic storage boxes.Findings include:A review of the facility's Medications Storage Policy and Procedure, undated, revealed, Purpose: To properly secure medications and biologicals according to CMS (Centers for Medicare and Medicaid Services) guidelines.Policy.3. Schedule II controlled medications will be maintained within a.permanently affixed compartment .On 06/03/2026 at 11:26 AM, during an interview and observation of the south wing medication carts, there were one (1) of two (2) medication carts that contained a narcotic storage box that was not permanently affixed within the medication cart drawer and could be removed from the cart. Licensed Practical Nurse (LPN) #2 confirmed the narcotic storage box was not affixed within the medication cart and could be removed.On 06/03/2026 at 11:37 AM, during an interview and observation of the north wing medication carts, there were one (1) of two (2) medication carts that also contained a narcotic storage box that was not permanently affixed within the medication cart drawer and could be removed from the cart. LPN #1 also confirmed the narcotic storage box was not affixed within the medication cart and the entire compartment could be removed.On 06/03/2026 at 2:23 PM, during a phone interview with the facility's Pharmacist, he stated he completes monthly pharmacy visits, provides recommendations, and performs random controlled substance reconciliations. He reported he had reviewed medication cart narcotic storage during his last visit but was unaware the narcotic storage boxes were not permanently affixed within the medication carts. On 06/03/2026 at 2:42 PM, during an interview and observation with the Director of Nursing (DON), two (2) of the four (4) medication carts were observed to contain narcotic storage boxes that were not permanently affixed within the medication cart drawers. The narcotic storage boxes were capable of being removed from the medication carts. The DON confirmed the narcotic storage boxes were not permanently affixed.On 06/03/2026 at 2:49 PM, during an interview with the Administrator and Registered Nurse (RN) #2, both stated they were unaware the narcotic storage boxes were not permanently affixed within the medication carts.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to provide the residents with a homelike environment during an annual recertification survey on 01/09/2025 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of seven (7) deficiencies cited. F584.Findings Include:Review of the facility's policy, QAPI Plan, revealed, Purpose: The purpose of QAPI.is to take a proactive approach to continually improve the way we care for.our residents.Scope.The QAPI committee analyses performance to identify and follow-up on areas of opportunity. The facility will utilize the best available evidence.to define and measure goals. The facility continually identifies opportunities for improvement and reviews the following areas to prioritize opportunities. 1. Regulatory Requirements.A record review of the Provider History Report revealed the facility received a citation for F584 - Safe/Clean/Comfortable/Homelike Environment during the previous recertification on 01/09/2025. A record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 01/09/2025, revealed the facility received a citation for F584, .Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure residents' rights to a clean , sanitary, and home-like environment as evidenced by resident rooms with holes in the walls and leaks in the ceilings in the dining room and hallways for one (1) of four (4) days of survey .During the current recertification survey, the facility failed to ensure the residents' right to reside in a clean, comfortable, and homelike environment, as evidenced by dark-colored staining and residue on hallway vents and wall surfaces, damaged wall surfaces with paint scraped away exposing the underlying wall material, and recurring roof leaks for three (3) of six (6) halls. (Northeast, North Central, and South Central).On 06/04/2026 at 2:09 PM, during an interview, the Administrator stated that in response to the previous recertification survey and citation for F584 in 2025, the QAPI Committee developed a plan of correction that included discussion of residents' rights to a homelike environment, roof repairs, and ongoing monitoring of the facility's physical environment. The Administrator reported the facility repaired one section of the roof and initially did not identify additional leaks. She stated that in April 2026, roof leaks were identified again. The Administrator reported the plan of correction also included routine monitoring of the facility to identify areas in need of repair or replacement. She stated maintenance and administrative staff conducted weekly rounds of resident rooms and common areas to identify concerns such as roof damage, chipped paint, and other structural issues. The Administrator reported each department was responsible for identifying and reporting environmental concerns and that findings were discussed during QAPI meetings. The Administrator stated the monitoring period was conducted from 10/13/2025 through 04/30/2026 and was reimplemented every six months. The Administrator reported no complaints regarding roof leaks or other structural concerns had been reported to staff. The Administrator further stated she had been in communication with the corporate office and a decision had been made to replace the entire roof.

Based on record review, staff interview, and facility policy review, the facility failed to develop the comprehensive person-centered care plan for pressure injuries for one (1) of three (3) sampled residents. (Resident #1).Findings include:A review of the facility's Care Plan Policy and Procedure, undated, revealed, Purpose: To provide a comprehensive person-centered plan of care addressing resident's needs, strengths, goals and approaches. Policy: Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals and approaches. Procedure .2. A Comprehensive Person-Centered Care Plan will be completed .as needed .Record Review of the admission Record revealed Resident #1 was admitted by the facility on 11/18/25 with the diagnoses including Type 2 Diabetes Mellitus with ketoacidosis without coma.A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/26, revealed Resident #1 had a Brief Interview for Mental Status Score (BIMS) of 12, which indicated her cognition was moderately impaired. Review of Section M revealed two (2) unstageable pressure injuries presenting as deep tissue injury (DTI).A record review of Resident's #1 Order Summary Report revealed physician orders dated 12/10/25 for treatment to right and left DTI pressure ulcers.A record review of resident's #1, Comprehensive Care Plan revealed there was no care plan developed to reflect the DTIs on the Left and Right heels, which was inconsistent with the physician orders.On 3/26/26 at 1:30 PM, during an interview with Licensed Practical Nurse (LPN) #1 and LPN #2 Care Plan Nurse, they explained they are responsible for completion of the MDS and Care Plan (CP). LPN #2 stated that the CP is developed based on the MDS and the physician orders. LPN #1 reviewed Resident's #1's CP and confirmed there was not a CP developed related to the DTIs on the left and right heels. She reported that the wound care nurse was responsible for completing wound care orders and updates in the CP. LPN #2 stated that they audit by comparing orders to the CP periodically and it must have been missed.On 3/26/26 at 2:30 PM, during an interview with Director of Nursing (DON), she stated her expectation is for the wound care nurse to update the care plan with new orders for wound care treatments.ON 3/26/26 at 2:37 PM, during an interview with Registered Nurse (RN) #1, she explained she is able to update care plan interventions, but she had not been trained on developing a new focused care plan. She said, she had not developed or added the physician orders for Resident #1's DTIs to her left and right heels on the care plan and was not aware that it was her responsibility to do so.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure residents' rights for a clean, sanitary, and home-like environment as evidenced by resident rooms with holes in the walls and leaks in the ceilings in the dining room and hallways for one (1) of four (4) days of survey. Findings included: A review of the facility's policy titled Resident Rights, dated 11/23/2016, revealed, It is the policy of this facility to promote the rights of residents residing in this facility .Procedure .3. The facility will make every effort to provide residents a homelike environment . On 1/6/2025 at 10:30 AM, during an observation, water was dripping from the roof in the main dining room. A large puddle of water was observed on the floor with a wet floor sign placed over it. On 1/6/2025 at 10:40 AM, during an observation in Room South-8, a hole the size of a large ball was noted in the sheetrock, filled with pieces of cardboard. Resident #11 On 1/6/2025 at 10:45 AM, during an interview, Resident #11 confirmed the water was dripping from the roof and stated it had rained the day before. The resident noted that leaks typically occurred in the hallway near the nurses' station on both the north and south wings. The resident added that staff usually placed barrels in these areas to catch the water. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/24 revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #26 On 1/6/2025 at 10:50 AM, during an interview, Resident #26, who was sitting in the main dining room, confirmed that leaks occurred in various parts of the facility when it rained. The resident stated that repair work had been done in the past, but the leaks persisted, with new areas leaking unpredictably. Record review of the MDS with an ARD of 11/6/24 revealed Resident #26 had a BIMS score of 15 indicating the resident was cognitively intact. Resident #35 On 1/6/2025 at 10:50 AM, during an interview, Resident #35 confirmed the ceiling was leaking in the dining room. The resident said the ceiling leaked in multiple areas when it rained, and staff typically placed wet floor signs and barrels to address the issue. Record review of the MDS with an ARD of 1/23/24 revealed Resident #35 had a BIMS score of 14 indicating the resident was cognitively intact. On 1/6/2025 at 11:00 AM, during an interview, Housekeeper #1 stated he was instructed to document environmental problems in the maintenance log at the nurses' station. He mopped up water on the dining room floor and noted that while the dining room rarely leaked, the north and south hallways leaked frequently during rain. Resident #67 On 1/6/2025 at 11:30 AM, during an interview, Resident #67 confirmed the roof leaked near the nurses' station on the north and south halls. The resident stated that repairmen had patched the roof multiple times, but the leaks shifted to other areas. The resident expressed frustration, saying the entire roof needed to be fixed. On 1/6/2025 at 11:31 AM, during an observation in Room North-1, a large open area was noted around the wall-mounted air conditioning unit, allowing visibility to the outside. Record review of the MDS with an ARD of 11/27/24 revealed Resident #67 had a BIMS score of 15 indicating the resident was cognitively intact. Resident #43 On 1/6/2025 at 12:05 PM, during an interview, Resident #43 expressed concern that animals, such as snakes, could enter the room through the gap. Record review of the MDS with an ARD of 12/13/24 revealed Resident #43 had a BIMS score of 12 indicating the resident had moderate cognitive impairment. On 1/9/2025 at 1:00 PM, during an interview, the Maintenance Director confirmed roof leaks in the north and south halls and acknowledged being unaware of the dining room leak. He noted that patches and silicone coatings had been applied to the roof, but the flat design caused water to shift to other areas. The Maintenance Director also confirmed awareness of paint chips and holes in the walls but had not received maintenance slips for the affected rooms. On 1/9/2025 at 3:45 PM, during an interview, the Administrator confirmed awareness of roof leaks in the north and south halls but stated she was unaware of the dining room leak. The Administrator explained that corporate consultants communicated with the roofing company, and repairs were limited to specific areas based on budget constraints.

Based on observation, interview, record review, and facility policy review, the facility failed to protect residents' right to be free from physical abuse when Resident #62 received scratches to his neck and face in an altercation with Resident #48 and Resident #41 received a hematoma to her head during an altercation with Resident #78 for four (4) of 20 sampled residents. Findings included: A review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, updated October 2022, revealed, Residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Resident #48 and Resident #62 Altercation Record review of the facility's investigation dated 11/2/24 revealed Resident #62 and Resident #48 were involved in an altercation in the dining room. Resident #62, who was assisting with handing out clothing protectors, was punched by Resident #48 when he attempted to place a clothing protector on him. In response, Resident #62 hit Resident #48 back, and both residents fell to the floor. A dietary aide witnessed the incident, reported it to Registered Nurse (RN) #4 and both residents were separated. Resident #62 sustained scratches to his face and neck, while Resident #48 had no noted injuries. The physician, Director of Nursing (DON), and Administrator were notified. Interventions included instructing staff to prevent Resident #62 from distributing clothing protectors in the dining room and referring Resident #48 to the in-house psychiatric Nurse Practitioner. During an observation on 1/6/2025 at 10:50 AM, Resident #48 was noted sitting in his wheelchair in his room. Resident #48, who has expressive aphasia, communicated with head nods. During an interview on 01/06/2025 at 11:00 AM, Registered Nurse (RN) #3 explained that Resident #48 can talk but may not want to communicate because he cannot speak clearly. RN #3 reported she did not recall many details about the night Resident #48 and Resident #62 were involved in an altercation in the dining room. She noted both residents have a history of other altercations, which usually occurred due to Resident #62 wandering into rooms. RN #3 added that Resident #48 had hit Resident #62 previously when Resident #62 wandered into his room. During an observation and interview on 01/08/2025 at 09:30 AM, Resident #48 was observed sitting in his wheelchair in his room. When asked if he could answer yes or no questions, the resident nodded yes. When asked if he remembered the altercation in the dining room with Resident #62, the resident nodded yes. When asked if he and Resident #62 had previous issues, he nodded yes. When asked if he was upset about the clothing protector, he nodded no. When asked if he became upset when he saw it was Resident #62, he nodded yes. When asked if he landed on the floor during the incident, he nodded yes. When asked if he was hurt, he nodded no. When asked if he had punched Resident #62 before, he nodded yes. When asked if this occurred when Resident #62 came into his room, he nodded yes. When asked if he had any further altercations with Resident #62 since the dining room incident, he nodded no. When asked if everything was better now, he nodded yes and smiled. During an interview on 01/08/2025 at 12:15 PM, Dietary Aide #4 confirmed she provided a witness statement for the incident between Resident #48 and Resident #62. She stated the incident occurred around 5:20 PM as the dining room trays are typically distributed starting at 5:25 PM. She was at the kitchen window and saw Resident #62 walking around placing clothing protectors on other residents. Resident #48 was seated at the back table. When Resident #62 attempted to place a clothing protector on Resident #48, Resident #48 punched Resident #62, who punched him back, leading to a tussle. Dietary Aide #4 stated she told other kitchen staff the residents were fighting and then saw Resident #48 fall from his wheelchair to the floor. She immediately sought help from a nurse and Certified Nursing Assistant (CNA). She stated that residents were temporarily prohibited from being in the dining room without staff for about a week after the incident, but that policy was not maintained because residents would often gather unsupervised in the hallways instead. During a phone interview on 01/08/2025 at 05:40 PM, RN #5 stated she did not witness the incident between Resident #48 and Resident #62. She explained that Dietary Aide #4 informed her about the altercation. While walking down the hall, she encountered RN #4, who was with Resident #62. RN #4 informed her that Resident #62 had been fighting with another resident. RN #5 then escorted Resident #62 to his room and completed a body audit. She observed scratches on Resident #62's neck and face, noting that the scratches were superficial and required only first aid. RN #5 stated she completed the incident report for Resident #62, while RN #3 completed the incident report for Resident #48. She also confirmed she notified the Administrator and Director of Nursing (DON) about the incident. During a interview on 01/09/2025 at 03:50 PM, the Administrator stated that on the night of the incident, she was notified, and the Registered Nurses (RNs) completed the incident reports. She used the incident reports and statements from RN #4 and Dietary Aide #4 to complete her final report. She explained that she does not know if any other residents were present in the dining room at the time of the incident, except for Resident #26, whose interview was included in one of the incident reports. She acknowledged there were no staff in the dining room at the time of the altercation, as they were busy assisting other residents to the dining room. She confirmed interventions implemented included informing Resident #62 that he could no longer distribute clothing protectors and instructing staff not to allow him to pass out the clothing protectors. A record review of progress notes dated 6/3/2024 at 5:45 PM revealed that Resident #48 and Resident #62 had a prior altercation. The progress notes stated, This writer was walking the hallway and noticed a wheelchair flipped up in the room. Upon entering the room, the resident was noted sitting in his wheelchair, and another male resident was on the floor underneath Resident #48's wheelchair. Both residents were exchanging punches and holding each other's shirts. When asked how the altercation occurred, Resident #48 stated, He came in my room, and I asked him to get out and he wouldn't and got smart with me. When asked, Who struck who first? Resident #48 admitted to striking the other resident first. Both residents were separated by this writer and two other staff members and assessed for injuries. Upon assessment, Resident #48 was noted to have two small scratches on his left cheek. The areas were cleaned and left open to air. The family, physician, Director of Nursing (DON), and Administrator were notified of the incident. A record review of the Admission Record revealed the facility admitted Resident #48 on 05/07/20 with the diagnoses including Hemiplegia And Hemiparesis Following Cerebral Infarction. A record review of the Quarterly MDS with an ARD of 10/09/24 revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A record review of Resident's Physical Aggression Initiated report dated 11/02/24 prepared by RN #3 revealed . I did not witness event. I was told by resident 48 and resident #62, that Resident #62 put on the clothing protector. Resident #62 put it on Resident #48 took it off then resident #48 hit Resident #62 in the gut, Resident #62 returned hit to Resident #48 in the torso . Nursing supervisor notified by RN #5. Residents were separated . no injuries observed at time of incident . No statements found . A record review of the Admission Record revealed the facility admitted Resident #62 on 01/26/22 with the diagnoses including Unspecified Dementia. A record review of the Quarterly MDS with an ARD of 12/11/24 revealed Resident #62 had a BIMS score of 7 which indicated he was severely cognitively impaired. A record review of Resident's Physical Aggression Initiated report dated 11/02/24 prepared by RN #3 revealed . I did not witness event. I was told by resident #48 and Resident #26, that Resident #62 put bib on Resident #48 took it off then Resident #48 hit Resident #62 in the gut, Resident #62 returned hit to Resident #48 torso . Nursing supervisor notified by RN #5, residents were separated . no injuries observed at time of incident . No statements found . Resident #41 and Resident #78 Altercation On 1/7/2025 at 5:15 PM, during an observation, several residents were standing in the hallway near the main dining room without staff supervision. Residents were overheard using profanity, and Resident #78 was observed hitting Resident #41 with her walker, knocking her to the floor. Staff intervened and separated the residents. A record review of the facility's incident reports dated 1/7/2025 revealed Resident #41 sustained a hematoma to the back of her head and was sent to the emergency room for evaluation. Resident #78 denied hitting Resident #41 with her walker and reported no injuries. A record review of the Admission Record revealed the facility admitted Resident #41 on 3/21/2023 with diagnoses including Chronic Obstructive Pulmonary Disease. A record review of the Quarterly Minimum Data Set (MDS) with an assessment Reference Date (ARD) of 11/20/2024 revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of three (3), indicating severe cognitive impairment. A record review of the Admission Record revealed the facility admitted Resident #78 on 3/22/2023 with diagnoses including Dementia. A record review of the Quarterly MDS with an ARD of 10/24/2024 revealed Resident #78 had a BIMS score of seven (7), indicating severe cognitive impairment.

Based on observation, interviews, record review, and the facility policy review the facility failed to provide adequate supervision to prevent resident-on-resident altercations between Resident #62 and Resident #48 and between Resident #41 and Resident #78 for four (4) of 22 sampled residents. Findings included: Resident #48 and Resident #62 Record review of the facility's investigation dated 11/2/24 revealed Resident #62 and Resident #48 were involved in an altercation in the dining room. Resident #62, who was assisting with handing out clothing protectors, was punched by Resident #48 when he attempted to place a clothing protector on him. In response, Resident #62 hit Resident #48 back, and both residents fell to the floor. A dietary aide witnessed the incident, reported it to Registered Nurse (RN) #4 and both residents were separated. Resident #62 sustained scratches to his face and neck, while Resident #48 had no noted injuries. The physician, Director of Nursing (DON), and Administrator were notified. Interventions included instructing staff to prevent Resident #62 from distributing clothing protectors in the dining room and referring Resident #48 to the in-house psychiatric Nurse Practitioner. On 01/06/2025 at 11:51 AM, during an observation in the dining room, Resident #26 was placing clothing protectors on other residents without staff present. On 01/07/2025 at 02:20 PM, during an interview, Resident #26 confirmed he witnessed the altercation between Residents #62 and #48. He stated that no staff were present in the dining room at the time and that it was common for the dining room to be unsupervised. On 01/08/2025 at 12:15 PM, during an interview, Dietary Aide #4 stated she observed the altercation between Residents #62 and #48 on 11/2/24 from the kitchen window and sought help from a nurse and Certified Nursing Assistant (CNA). She confirmed there were no staff in the dining room at the time. Dietary Aide #4 added that after the incident, residents were temporarily prohibited from being in the dining room without staff, but this restriction was not maintained. A record review of the Admission Record revealed Resident #62 was admitted by the facility on 01/26/2022 with diagnoses including Unspecified Dementia and Psychotic Disorder. A record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/11/2024 revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of seven (7), indicating severe cognitive impairment. A record review of the Admission Record revealed Resident #48 was admitted by the facility on 05/07/2020 with diagnoses including Hemiplegia and Aphasia. A record review of the MDS with an ARD of 10/09/2024 revealed a BIMS score of 15, indicating the resident was cognitively intact. Resident #41 and Resident #78 On 01/07/2025 at 03:00 PM, during an observation there was an altercation between Resident #78 and Resident #41 near the exit door for smoking, which is near the dining room. No staff were present at the time of the incident. Record review of the facility's, Incident Report, dated 01/07/25 revealed Resident #41 was walking in the hallway next to the kitchen when another resident called this resident a (expletive) this resident then called the other resident a (expletive) and then proceeded to slap the other resident in the face. Both residents began pushing each other when the Resident #78 pushed Resident #41 with her wheelchair, knocking Resident #41 to the floor where she hit the back of her head. The staff immediately intervened and assessed the resident for injury. Resident #41 noted to have quarter sized hematoma to the back of her head. Charge nurse took Resident #41's vital signs, and the Medical Director and family was notified the resident was sent to the local emergency room for an evaluation. A record review of Resident #41's Admission Record revealed the resident was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Major Depressive Disorder. A record review of Resident #41's MDS dated [DATE] revealed a BIMS score of (3), indicating severe cognitive impairment. A record review of Resident #78's Admission Record revealed the resident was admitted on [DATE] with a diagnosis of Unspecified Dementia. A record review of Resident #78's MDS dated [DATE] revealed a BIMS score of seven (7), indicating severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to discard expired food items from the refrigerator, remove opened, exposed, and unlabeled food items from freezer, and ensure dietary staff wore a hair restraint while plating food for two (2) of three (3) observations. Findings included: A review of the facility's policy, Personal Hygiene, revised [DATE], revealed, Objective: Participants will learn what guidelines for personal hygiene are needed to promote a safe and sanitary Food and Nutrition Services department .3. Head Covering Worn .Hair must be appropriately restrained or completely covered. Beards, mustaches, or any body hair that may be exposed .must be covered . A review of the facility's policy, Labeling and Dating for Safe Storage of Food, revised [DATE], revealed, .All products should be dated upon receipt . All products should be dated when opened . Use Use-By dates on all food once opened and stored under refrigeration . Expiration dates supersede storage guide . On [DATE] at 10:43 AM, during an observation and interview with the Dietary Manager (DM), there was one (1) container of mayonnaise with a manufacturer's use-by date of [DATE] and (1) bag of shredded lettuce with a use-by date of [DATE] in Refrigerator #1. In Freezer #2, there was (1) opened, exposed, and uncovered pie shell undated, (1) opened exposed, and unlabeled bag of corn on the cob, (1) opened, exposed, and unlabeled bag of biscuits, and (1) opened, exposed, and unlabeled bag of cinnamon rolls. The DM confirmed the mayonnaise and shredded lettuce were expired and there were opened and exposed food items in the freezer. She expressed that she had reminded the kitchen staff to date and label opened food items in the freezer. On [DATE] at 10:46 AM, during an interview, the Registered Dietitian (RD) revealed that kitchen staff receive monthly in-services, with the last one held in [DATE]. Topics covered during monthly in-services included pest control, resident rights, sanitation, gloves, cleaning, and labeling and dating food in refrigerators. The RD stated the expectation for kitchen staff is to work as a team, prepare food per guidelines, maintain sanitation, and follow instructions. On [DATE] at 11:34 AM, during an observation, Dietary #2 (Kitchen Aide) was plating food and preparing trays and was not wearing a hair restraint on his beard. On [DATE] at 1:03 PM, during an interview, the DM stated that in-services for kitchen staff are held every other month and as needed. The DM noted the last in-service, held in [DATE], covered topics such as equipment upkeep and gloves. An in-service in [DATE] included topics on hair nets and beard guards. The DM emphasized that staff are expected to follow guidelines, rules, and apply the information from in-services. On [DATE] at 2:27 PM, during a follow-up interview, the DM confirmed Dietary #2 had prepared resident's plates at the steam table for lunch and was not wearing a hair restraint for his beard as required. She commented that she has had to remind dietary staff to wear hair restraints. On [DATE] at 4:20 PM, during a phone interview, Dietary #2 confirmed he had received in-service training on hair restraints but could not recall the dates. He stated he typically washes dishes but plated food on [DATE] because another worker called in. The dishwasher acknowledged the importance of wearing hairnets and beard guards to prevent hair from getting into residents' food. On [DATE] at 4:30 PM, during an interview, the Administrator acknowledged she was aware of the findings in the dietary department. The Administrator stated her expectations included following guidelines to prepare foods in a manner that prevents illness and ensures food is appealing to residents. A record review of dietary in-service records dated [DATE] and [DATE] revealed the dietary staff received training regarding covering labeling, dating, and wearing hair restraints.

Based on observation, interview, and facility policy review, the facility failed to prevent the possible spread of infection when a Certified Nurse Aide (CNA) placed soiled linens on the floor of a resident's room and against her clothes for one (1) of four (4) days. Findings included: A review of the facility's policy titled Laundry and Bedding-Soiled, dated October 22, 2008, revealed, .Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen . On 1/7/2025 at 3:45 PM, during an interview and observation, there was a strong urine odor at the South Front Hall. While walking past Room S7, soiled linen was observed placed on the floor beside the bed. CNA #1 was in the room and explained the soiled linen should not have been placed there and stated that she knew better. CNA #1 picked up the soiled linens from the floor, placing them directly against her clothing on her body, before putting them on the bare mattress of the resident's bed. She further explained that she should have placed the soiled linens in a bag because they should not be on the floor. CNA #1 retrieved a plastic bag, placed the soiled linen in the bag, and took it to the soiled linen room. On 1/8/2025 at 9:45 AM, during an interview, Registered Nurse (RN) #1/Infection Preventionist, stated she expected staff to use a bag to place soiled linen in and to avoid placing linen on the floor or against their body. On 1/9/2025 at 10:05 AM, during an interview, the Director of Nursing (DON) explained her expectations for staff to follow infection control guidelines and policies to prevent infections. She stated staff are educated to bring clean linen into rooms using trash bags and use the same bags to collect and transport dirty linen immediately to the soiled linen room. She emphasized that no dirty linen or trash bags should be placed directly on the floor or against staff's bodies to prevent the spread of infection.

Based on interviews, record review, and facility policy review the facility failed to implement their policy related to abuse, as evidenced by not reporting an allegation of abuse by Resident #54 in a timely manner and allowing an accused staff member to work during the investigation process and not completing a thorough investigation regarding an altercation between Resident#48 and Resident #62 for three (3) of 20 sampled residents. Findings include: A record review of the facility's policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation with reviewed date 10/2022 revealed, . All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . Reporting Allegations to the Administrator and Authorities . 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury . Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations . 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: c. observed the alleged victim, including his or her interaction with staff and other residents; . e. interviews any witnesses to the incident; . h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; . j. interviews other residents to whom the accused employee provides care or services, k. reviews all events leading up to the alleged incident, and l. documents the investigation completely and thoroughly. 8. The following guidelines are used when conducting interviews: . d. Witness statements are obtained in writing, signed, and dated. The witness may write his/her statement, or the investigator may obtain a statement . Follow -Up Report 1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegations were verified . Corrective Actions . 3. Any allegations of abuse are filed in the accused employee's personnel record along with any statement by the employee disputing the allegation, if the employee chooses to make one . Resident #48 and Resident #62 Altercation Record review of the facility's investigation dated 11/2/24 revealed Resident #62 and Resident #48 were involved in an altercation in the dining room. Resident #62, who was assisting with handing out clothing protectors, was punched by Resident #48 when he attempted to place a clothing protector on him. In response, Resident #62 hit Resident #48 back, and both residents fell to the floor. A dietary aide witnessed the incident, reported it to the nurse's station, and both residents were separated. Resident #62 sustained scratches to his face and neck, while Resident #48 had no noted injuries. The physician, Director of Nursing (DON), and Administrator were notified. Interventions included instructing staff to prevent Resident #62 from distributing clothing protectors in the dining room and referring Resident #48 to the in-house psychiatric Nurse Practitioner. On 01/07/25 at 02:00 PM, during an interview with the Administrator when she presented the final report of the Facility Reported Incident (FRI), she explained that is the final report that she submitted to the Attorney General Office (AGO) and to the State Agency (SA). She confirmed the report consisted of her final typed report and the two (2) statements obtained regarding the incident. She confirmed there were no other statements or interviews obtained from any other witnesses, to include who separated the residents and any other residents who may have witnessed the altercation. She confirmed body audits and incident reports were completed for both residents via the residents' nurses. She confirmed no other staff or residents were interviewed regarding the altercation except the ones mentioned in the report, that included Resident #26, Dietary Aide #4, and RN #4. She stated that she felt she completed the investigation. A record review of the Admission Record revealed Resident #48 was admitted by the facility on 05/07/20 with the diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/09/24 revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A record review of the Admission Record revealed Resident #62 was admitted by the facility 1/26/22 with diagnoses including Unspecified Dementia. A record review of the Quarterly MDS with an ARD of 12/11/24 revealed Resident #62 had a BIMS score of 7 which indicated severely cognitively impaired. Resident #54 Allegation of Abuse On 01/06/25 at 02:20 PM, during an interview with Resident #54, she reported on Friday around 2 PM she had a Certified Nurse Aide (CNA) tell her that she wasn't going to put her back to bed and she would have to wait on the next shift to put her back to bed. She went to the nurse's station and complained about wanting to go to bed. The CNA did come back and put her to bed but while doing so the CNA whirled her around fast and made her cry. She stated she had not reported this to the Director of Nursing (DON) or the Administrator yet. She was so upset on Friday she could not tell anyone. The resident's roommate (unsampled resident #1) reported she heard the CNA on Friday tell Resident #54 she had to wait for the next shift. On 01/06/25 at 02:53 PM, during an interview in Resident #54's room with the DON and Administrator, she explained to both the incident that occurred on Friday in which the CNA told her that she was not going to put her back to bed and she would have to wait on next shift and about her quickly turning her around in her wheelchair. Both the DON and Administrator confirmed that they did not know anything about the issue and assured the resident to report any concerns to them right away. The DON and Administrator reported they will start their investigation regarding Resident #54's complaint. On 01/07/25 at 02:05 PM, during an interview with the Administrator, she stated she did not report the allegation to anyone because she did not feel it was abuse or neglect due to the CNA did put resident to bed before she left work on Friday and there were no problems. She reported she was not aware of the requirements to report any allegations of abuse if it was just allegations. She thought it had to be reported if the abuse was substantiated, and the abuse was not substantiated at this time, but the investigation continues. On 01/07/25 at 03:00 PM, during an interview with the DON, she confirmed she obtained the statements from both CNAs and the CNAs denied the allegations. She reported since Resident #54 was put to bed on Friday and changed, there was no need to suspend the CNA from working. A review of the facility's policy Abuse-Investigation was reviewed with the DON, she confirmed the policy indicates that allegations of abuse should be reported within two hours of an allegation involving abuse and that any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The DON reported she is still doing more interviews and investigations regarding the allegations and the final report is not completed. On 01/08/25 at 10:30 AM, during an interview with CNA #4, she denied any abuse toward the resident, but confirmed she has been working this current week since 1/6/2025 at the facility on day shift. On 01/09/25 at 04:00 PM, during an interview with the Administrator and the DON, they both confirmed the investigation regarding Resident #54 is almost complete and the facility has five (5) days to send the final report. A review of the facility's policy with the Administrator and the DON, they both confirmed the facility policy explained any witnesses of the allegations should be interviewed and/or a statement given. The policy revealed the accused worker should be suspended while the investigation continues and should not have any resident care. Both confirmed the CNA continued to work and the allegation of abuse was not reported within two (2) hours. The Administrator reported she thought since the CNAs denied the allegations, there was no need to suspend or to report within two (2) hours because there was no abuse. A record review of the facility's assignment logs for days 01/03/25, 01/06/25, 01/07/25, and 01/08/25 confirmed CNA #4 worked and had resident assignments. A record review of the Admission Record revealed Resident #54 was admitted by the facility on 8/03/24 with current diagnoses including Cerebral Palsy. A record review of the Quarterly MDS with an ARD of 11/13/24 revealed Resident #54 had a BIMS score of 14, which indicted she was cognitively intact.

Based on observation, staff interview, and record review, the facility failed to accurately code Minimum Data Set (MDS) assessments when bedrails that were used as an enabler were coded as physical restraints on the MDS for three (3) of 20 sampled residents. (Residents #14, #73, and #43). Findings included: The facility did not provide a policy addressing MDS discrepancies. Resident #14 On 1/6/2025 at 10:40 AM, during an observation, Resident #14 was noted to have 1/2 bedrails at the top of the bed, but they were not raised at the time of observation. A record review of the Admission Record revealed the facility admitted Resident #14 on 9/14/2022 with diagnoses including Epilepsy and Hemiplegia. A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 11/6/2024 revealed in Section P of the MDS that Resident #14 had a bedrail used as a physical restraint. A record review of the Side Rail Evaluation, dated 10/17/24, revealed Resident #14 had expressed a desire to have bed rails raised while in bed for safety and comfort and to help turn in bed. Further review revealed that the resident used the bed rails for positioning or support and to help the resident rise from a supine position to a sitting/standing position. The evaluation indicated in the Summary of Findings that bilateral rails were used due to the residents' request and served as an enabler to promote independence. Resident #73 On 1/7/2025 at 10:22 AM, during an observation, Resident #73's bed was noted to have 1/4 bed positioning enablers at the head of the bed on both sides. A record review of the Admission Record revealed the facility admitted Resident #73 on 6/25/2024 with diagnoses including Acquired Absence of Right and Left Leg Above Knee. A record review of the MDS with an ARD of 12/25/2024 revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated in Section P the resident had a bedrail used as a physical restraint. A record review of the Side Rail Evaluation, dated 10/17/24, revealed Resident #73 had expressed a desire for use of bed rails. The evaluation indicated in the Summary of Findings that bilateral rails were used due to the residents' request and served as an enabler to promote independence. Resident #43 On 1/7/2025 at 10:25 AM, during an observation, Resident #43's bed was noted to have 1/4 bed positioning enablers at the head of the bed on both sides. A record review of the Admission Record revealed the facility admitted Resident #43 on 8/30/2024 with diagnoses including Metabolic Encephalopathy. A record review of the Quarterly MDS with an ARD of 12/6/2024 revealed Resident #43 had a BIMS score of 12, which indicated moderate cognitive impairment. The MDS noted in Section P that bedrail usage was less than daily. A record review of the Side Rail Evaluation, dated 10/17/24, for Resident #43 indicated in the Summary of Findings that bilateral rails were used due to the residents' request and served as an enabler to promote independence. On 1/9/2025 at 1:42 PM, during an interview, Licensed Practical Nurse (LPN) #2 acknowledged the residents were miscoded for having a physical restraint because the residents used the rails as enablers. LPN #2 stated she was responsible for ensuring the accuracy of the MDS prior to submission. She explained the purpose of the MDS is to document services provided for insurance purposes and stated she would learn from this mistake and improve. On 1/9/2025 at 1:47 PM, during an interview, the Director of Nursing (DON) acknowledged the residents' MDS assessments were miscoded for having physical restraints related to bedrails. The DON stated it was the responsibility of the MDS nurse to ensure the MDS is coded correctly prior to submission. She explained that the purpose of correct MDS coding is for accurate billing and data representation. The DON stated she expected the MDS nurse to gather data and verify accuracy. On 1/9/2025 at 1:52 PM, during an interview, the Administrator acknowledged there was an MDS discrepancy related to bed rails being coded as a physical restraint. The Administrator stated the purpose of the MDS was to ensure the facility accurately reflects what is being done for the resident. She stated her expectation is that the MDS nurse carefully verifies information before submission and seeks clarification when necessary.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure there were sufficient staff to meet the needs of residents for one (1) of two (2) Units in the facility, the South Wing. This deficient practice had the potential to affect 55 residents who reside on the South Wing. Findings include: Review of the facility's policy, Staffing, revised October 2017, revealed, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation .2. Staffing numbers .of direct care staff are determined by the needs of the residents based on each resident's plan of care .Direct care staffing information per day .is submitted to the CMS (Centers for Medicare and Medicaid Services) payroll-based journal (PBJ) .no less than once a quarter A record review of the PBJ Staffing Data Report for October 1 through December 31, 2022, revealed Excessively Low Weekend Staffing was triggered which meant the data submitted by the facility indicated that weekend staffing data was excessively low. A record review of the facility's floor plan revealed the South Wing consists of resident rooms 1-34. During an interview on 5/21/23 at 11:15 AM, with CNA #2, she said she started her shift at 7:00 AM and had to leave at 11:30 AM. CNA #2 said she was assigned to the South Wing, Rooms 1-8. She confirmed she did not provide care to rooms 24-34 because there were only two (2) CNAs assigned to the South Wing, and she could not get to those residents. She said that CNA #1 had come in at 10:00 AM to care for the residents in rooms 24-34 on the South Wing. On 05/21/23 at 12:20 PM, during an observation and interview with Resident #25, there was a strong, foul odor in the room. Resident #25 explained that she had a bowel movement around 10:00 AM, but no one had come to change her. She said that she had told a Certified Nurse Aide (CNA) that she needed assistance, but the CNA did not come back to clean her up. Resident #25 said she had to eat lunch while sitting in her dirty brief. Resident #25 also commented that the staff do not like for her to use her call light because they say they are short of staff and don't have time to answer the light. On 5/21/23 at 12:30 PM, in an interview with Certified Nurse Aide (CNA) #3, she stated that there were two (2) CNAs working on South Wing. On 5/21/23 at 12:35 PM, in an interview with CNA #1, she explained she was called in around 10:00 AM and was assigned to the South Wing. CNA #1 said she answered Resident #25's call light when she came in at 10:00 AM and told the resident that she was starting her rounds at the beginning of the hall and would work her way back to her. On 05/21/23 at 12:40 PM, during an observation with CNA #1 and CNA #3 revealed Resident #25 had a large, loose bowel movement that had saturated and leaked through her brief onto the incontinence pad on the bed. The resident's buttocks, sacrum, and thighs had red discoloration and excoriation. The resident was crying and complaining of pain during care. A record review of the Admission Record revealed the facility admitted Resident #25 on 8/24/17 and she had diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/13/23 revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review revealed she required extensive assistance with toilet use and was always incontinent of bowel. During an interview on 5/23/23 at 10:00 AM with the Activity Director, she confirmed that she usually worked a double shift as a CNA twice a week due to low staffing. During an interview on 5/24/23 at 3:30 PM, with Staff Development Registered Nurse (RN) #1, she stated that the facility had been short of staff for a while. RN #1 said that 35 of the 55 residents on the South Wing required extensive assistance and would require five (5) or six (6) CNAs to meet those residents' needs adequately. RN #1 also said she was aware that the facility only had three (3) CNAs scheduled for Sunday 5/21/23 on day shift on the South Wing. RN #1 said she tried to ask people to work extra or work a double shift and was unsuccessful. RN #1 confirmed that it would be impossible for two (2) CNAs to meet the needs of 55 residents. During an interview on 5/24/23 at 4:00 PM, with the Director of Nursing (DON) and the Administrator, they confirmed the facility was short of staff. The Administrator said that the facility is unionized, and the union dictates the pay and the amount of time that staff can work. The Administrator commented that new employees go to work down the street to make more money. The Administrator stated that she had talked with the corporate office to make them aware of the staffing concerns and the facility had discussed bonus pay for new hires. She said the facility currently hired contract workers through the facility and not through outside contract workers. The Administrator said she did not know that only three (3) CNAs were scheduled to work the South Wing on 5/21/23 and that staffing shortages were discussed during daily stand-up meetings. The DON confirmed that she was aware there were three (3) CNAs scheduled for Sunday, but she thought some of the staff might stay over to assist, and she thought RN #1 would call and let her know if the facility was short-staffed. She said she would have called in the admission nurse, office staff, or would have come in herself to cover staffing if she had known. The DON confirmed she has had to pull the office staff to work as CNAs to provide care. During an interview on 5/25/23 at 3:00 PM with the Medical Director (MD), he said he was aware the facility was short of staff, however, he was not aware that the facility was extremely short of staff until today (5/25/23) and he had talked to the Administrator about it. Record Review of the Facility Assessment Tool, undated, revealed there was no information completed for Part 1: Our Resident Profile to include information regarding resident census, diseases/conditions, physical and cognitive disabilities, and resident acuity. There was also no information completed for Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies to include a Staffing plan to ensure a sufficient number of qualified staff are available to meet each resident's needs and there was no description of how the facility determines and reviews individual staff assignments for coordination and continuity of care for residents.

Based on observation, interviews, record reviews and facility's policy review the facility failed to administer intravenous (IV) antibiotics per Physician's Orders for one (1) of two (2) Residents reviewed for hospitalization . Resident #35. Findings Include: A record review of the facility's policy Admission Criteria with a review date of 4/25/23 revealed .Our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation 1. The objectives of our admission criteria policy are to: . b. admit residents who can be cared for adequately by the facility . 7. Some examples of nursing/medical needs that can be met adequately include a. medication management . A record review of the facility's policy Physician's Orders, dated 4/13/2021, revealed, .Physician's orders are carried out unless the nurse or other licensed personnel believe the order to be in accurate, efficacious, or contraindicated . On 05/23/23 at 04:00 PM, during a phone interview with the Resident Representative (RR) for Resident #35, she explained that she was the resident's wife and that the resident had been transferred to the hospital the other night due to behaviors. She stated he was admitted to the hospital because he had another infection. A record review of the Order Recap Report, revealed Resident #35 had a Physician's Order, dated 5/2/23, for Vancomycin HCl Intravenous (IV) Solution .one time a day for Infection for 3 Days. The Order status was Completed with an End Date of 5/6/23. There was a Physician's Order, dated 5/8/23, for Telephone call to (Proper Name of Physician). Informed him that resident missed his last dose of Vancomycin 1500 milligrams (mg), IV due to IV not functioning. Order to not restart IV but observe resident and be attentive to any labs. Resident #35 also had a Physician's Order, dated 5/21/23, to Send to ER (emergency room ) for eval (evaluation) and tx (treatment) r/t (related to) combative and delusional behavior. A record review of Resident #35's Medication Administration Record (MAR) for 05/01/23 through 05/31/23 revealed Vancomycin HCL Intravenous Solution 1500 mg intravenously one time a day for infection for 3 days with a start date of 5/3/23. The MAR revealed that on 5/3/23 and 5/5/23 there was an entry coded as 9 which indicated the medication was not administered. On 5/4/23 there was a checkmark recorded which indicated the medication was administered. A record review of the Progress Notes for Resident #35 revealed a Health Status Note, dated 5/3/23, Resident returned from the hospital .DX (Diagnoses) acute encephalopathy, sepsis, hypothermia .Will be receiving IV Vanc (Vancomycin) QD (every day) x (times) 3 more days . A review of the Medication Administration Note, dated 5/4/2023 at 0127 (1:27 AM) revealed, .Vancomycin HCl Intravenous Solution .Med n order. A review of a Medication Administration note, dated 5/5/23, revealed .IV not given .IV will not infuse. A review of a Health Status Note, dated 5/21/23, revealed .Resident became physically combative .Received order to send to .ER . On 05/24/23 at 07:00 AM, during a phone interview with Licensed Practical Nurse (LPN) #6, she explained that when a MAR entry is coded as 9, it meant the medication was not administered and the nurse had to enter a reason and it would automatically record a medication administration note in the (electronic) chart. She stated she did not administer the medication on 5/3/23 and had entered med n order for the reason because that is what she was told to do by management if a medication was not available. LPN #6 said that on 05/04/23, she documented that the Vancomycin was administered on the MAR, but that was an error, and she did not administer it because an RN must administer IV medications. She confirmed that Resident #35 did not receive IV Vancomycin on 05/03/23 or 05/04/23 and that all three (3) doses were in the medication room on 05/05/23 when she left the facility after her shift at 07:00 AM. On 05/24/23 at 02:30 PM, during an interview with LPN #4, she explained she was working on 05/05/23, which was the last day that Resident #35 was scheduled to receive IV antibiotic medications. She stated that she informed the Assistant Director of Nursing (ADON) that Resident #35 had received not one dose of the IV medications. She reported the ADON went to administer the antibiotic, but she could not get the medication to infuse, and she thought the ADON was going to call the physician about the issue. LPN #4 said that on 5/21/23, Resident #35 had behaviors and had to be sent to the emergency department. She commented that He was probably still septic due to not receiving the antibiotics as ordered. On 05/24/23 at 03:25 PM, during an interview with the ADON, she explained that she could not get the IV to work and she thought RN #1 had phoned the physician about Resident #35 missing his last dose of antibiotics. The ADON was unable to explain why there was no documentation related to notifying the physician of the IV medication not being administered until 5/8/23, which was three (3) days after she became aware on 5/5/23 that the IV was not functioning. The ADON reported she was new at her job and denied that she had been told by LPN #4 that Resident #35 had missed all three doses of his IV antibiotics. On 05/24/23 at 03:40 PM, during an interview with RN #1, she explained that on 5/5/23, which was the last day Resident #35 was scheduled to receive IV antibiotics, the ADON asked her to assess the IV line. She stated that she tried to flush the line and it would not flush, so she returned to her medication cart because she had to take care of her assigned residents. She said that she did not chart anything about the IV and did not notify the physician that the IV was not functioning. RN #1 confirmed that she did not administer any IV medications to Resident #35. On 05/25/23 at 2:00 PM, during an interview with the Director of Nursing (DON), she explained she was not aware Resident #35 had missed all three doses of IV antibiotics after he had returned to the facility from the hospital. She explained that she expected the ADON to notify the physician as soon as she was aware the resident had missed the medication. She explained with Resident #35 missing all three doses of the antibiotic, he would still have an infection and could become septic, which could cause behavioral issues and confusion. On 05/25/23 at 2:30 PM, during an interview with the Administrator, she explained she would expect the ADON to notify the DON, the physician, and the family member when a resident missed a medication. 05/25/23 at 03:00 PM, during an interview with the Medical Director, he explained he was not aware that Resident #35 was readmitted to the hospital on 5/21/23 and confirmed that the missing three (3) doses of IV antibiotic medications could have caused sepsis and behavioral issues. A record review of the Admission Record revealed the facility admitted Resident #35 on 5/02/23 and he had diagnoses including Pneumonia and Dementia. Record review of the Packing Slip, dated 05/02/23, revealed RX (Prescription) number 81824434 for Vancomycin Inj (Injection) was received by the facility for Resident #35. A record review of the ED (Emergency Department) Provider Notes, dated 5/21/23 revealed, .complaints of altered mental status aggressive behavior and hallucinations .I see that he is been admitted in the recent past for similar and he was with apparent sepsis .Diagnoses . Acute UTI (urinary tract infection) and Acute encephalopathy .

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident who was dependent on staff for incontinence care received those services for one (1) of five (5) residents reviewed for incontinence care. Resident #25. Findings Include: A review of the facility's policy Routine Resident Checks, dated 6/1/2000, revealed, .It is the policy of this facility to make routine resident checks to assure that the resident's safety and wellbeing are maintained. Procedure 1. To ensure the safety and well-being of our residents, a resident check will be made every two (2) hours by nursing service personnel . On 05/21/23 at 12:07 PM, in an interview and observation with Resident #25, she reported that at 10:00 AM this morning, she informed a Certified Nurse Aide (CNA) that she needed to be changed because she had a bowel movement. She stated the CNA did not come back, and she still had not been changed and she had to eat her lunch meal while sitting in a soiled brief. There was a strong, foul odor in the resident's room. During an observation and interview on 05/21/23 at 12:20 PM, CNA #1 entered the resident's room and explained she arrived to work today around 10:00 AM and was assigned Resident #25. CNA #1 said that she answered Resident #25's call light around 10:00 AM, but the resident had only asked who her aide was, and did not mention that she had a bowel movement or that she needed to be changed. She said that she explained to the resident that she was starting her rounds at the beginning of the hall and working her way back to her. Resident #25 insisted that she did tell someone that she needed to be changed and that she could have told another CNA. On 05/21/23 at 12:40 PM, during an observation of incontinence care with CNA #1 and CNA #3, Resident #25 was wearing a brief that was saturated with loose feces that had leaked through the brief and onto the incontinence pad. Her buttocks, thighs, and sacrum were red and excoriated and she was crying and stated that she was hurting. On 05/22/23 at 02:15 PM, during an interview with Registered Nurse (RN) #2, she explained Resident #25 did tell her at 9:00 AM on 5/21/23 that she needed to see an aide and she told Resident #25 that she would get someone, but she did not see any CNAs and she went on to pass out breakfast trays. She said the resident did not express why she needed assistance and she did not ask the resident what she needed. She confirmed that she told Resident #25 to be patient and the CNAs would be on the way and that Resident #25 asked again to see an aide and she told her to use the call light and give it 15 minutes to see if they arrive. On 05/22/23 at 02:22 PM, during an interview with CNA #1, she reported that she answered the call light for Resident #25 when she first arrived at 10:00 AM, but Resident #25 only asked her who her aide was, and she did not specify what she needed, and she (CNA #1) did not ask the resident what she needed. She stated that she did not provide any care for Resident #25 on 05/21/23 until 12:20 PM. On 05/22/23 at 02:45 PM, during an interview with CNA #2, she stated that she was unaware that Resident #25 needed to be changed. CNA #2 confirmed that she did not complete rounds or provide care to Resident #25 while she was at the facility on 5/21/23. On 05/22/23 at 03:00 PM, during an interview CNA #3, she confirmed she was working on 05/21/23 day shift and she never assisted or provided care for Resident #25 until she assisted CNA #1 with incontinence care around 12:30 PM. On 05/23/23 at 09:10 AM, in an observation and interview with CNA #1, Resident #25 had an opened, excoriated area to her left buttock and left abdominal fold. CNA#1 reported that the areas are new. Resident #25 said the new open areas appeared after being left in a soiled brief on 05/21/23 and she had a new Physician's Order for cream to those areas. On 05/23/23 at 09:25 AM, during an interview with RN #3, she confirmed Resident #25 had new opened areas to her buttocks and abdominal fold and the nurse practitioner had written new orders for cream for moisture-associated areas on 05/22/23. On 05/23/23 at 03:00 PM, during an interview with the Medical Director, he explained he was aware of the concerns with resident care, and he expected all residents to be provided with care and assistance as needed. On 05/23/23 at 03:10 PM, during an interview with the Director of Nursing (DON), she explained that she expected staff to assist residents and to provide care every two (2) hours. On 05/23/23 at 3:30 PM, during an interview with the Administrator, she explained she expected staff to complete care every two (2) hours. A record review of the Admission Record revealed the facility admitted Resident #25 on 8/24/17 and she had diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/13/23 revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review revealed she required extensive assistance with toilet use and was always incontinent of bowel. A record review of the Order Summary Report with Active Orders As Of: 05/25/23, revealed Resident #25 had a Physician's Order, dated 05/22/23, to Cleanse MASD (moisture associated skin damage) to bilateral buttocks with mild soap and water, pat dry, apply barrier cream with zinc .two times a day for MASD wound care. A record review of the facility's document Task . Schedule for May 2023 ., revealed on 05/21/23, there was no documentation that Resident #25 received any care during the day shift hours of 7:00 AM through 3:00 PM. 48181

Based on interviews, record review and facility policy review the facility failed to develop and/or implement an individualized person-centered care plan for two (2) of 22 care plans reviewed. Resident's #7 and #25 Findings include: A record review of the facility's policy Using the Care Plan with no date revealed, . It is the policy of this facility that the care plan be used in developing the resident's daily care routines . 3. Changes in the resident's condition should be reported to the MDS (Minimum Data Set) assessment coordinator and or nurse supervisor so that a review of the resident's assessment and care plan can be made. 4. Daily care and documentation should be consistent with the resident's care plan. A record review of the facility's policy Care Plan-Comprehensive with no date revealed, . It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Procedure . 4. Care plans are revised as changes in the resident's condition dictates . Resident #7 A record review of Resident #7's Admission Record revealed an admitted [DATE] and a readmitted [DATE], with diagnosis of Functional Quadriplegia, Type 2 Diabetes Mellitus, and Expressive Language Disorder. On 05/21/23 at 12:45 PM, in an interview and observation with the spouse/Resident Representative (RR) of Resident #7, she revealed when she arrived at the facility today, the resident was double briefed and saturated in urine. The RR had just completed the resident's care and was able to reveal the saturated briefs that had been removed. The spouse explained that during her visits, she had often noted that the resident had been wearing double briefs that were saturated in urine and she was concerned that this could possibly cause the resident to develop another urinary tract infection (UTI). The spouse explained Resident #7 had been hospitalized several times due being septic related to a UTI, with the last UTI being diagnosed and treated in May. Record review of the Care Plan revealed that the resident is incontinent of bowel and bladder and the resident's risk for septicemia will be minimized/prevented by recognition and treatment of symptoms of UTI. Review of the interventions revealed an intervention to check for incontinence and provide peri care as needed. On 05/23/23 at 03:10 PM, during an interview with the Director of Nursing (DON), she explained she expects staff to assist residents when residents request and to provide care every two (2) hours and to follow the resident's plan of care. Resident #25 A record review of Resident #25's Admission Record revealed the facility admitted Resident #25 initially on 09/16/16 and readmitted on [DATE] with the diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, and Tobacco Use. A record review of Resident #25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/13/23 revealed a Brief Interview for Mental Status (BIMS) Score of 15, which indicated cognitively intact. Further review of the MDS revealed Resident #25 is frequently incontinent of urine and always incontinent of bowel and requires two (2) person assist for personal hygiene. On 05/21/23 at 12:07 PM, Resident #25 observed lying in bed with head of bed elevated, resident's lunch tray on tray table and resident not eating very much. Resident #25 reported at 10:00 AM, she informed the CNA that she needed assistance with being changed to a clean brief due to having a bowel movement (BM), but the CNA did not come back, and she had not been changed at the time of this interview. Resident's lunch tray was on the table. Resident confirmed that she was served her lunch tray and had to eat her lunch while sitting in bowel. A strong foul odor was present while talking to the resident. Resident #25 reported somedays it may take hours before she gets changed. On 05/21/23 at 12:40 PM, observed incontinent care of Resident #25 provided by CNA #1 and CNA #3. Prior to care, observed large loose watery diarrhea leaking through Resident #25's brief and on the incontinent pad. Observed the loose diarrhea from top of Resident #25's pubic hair, in-between thighs, and entire buttocks with moderate excoriated redness noted to entire buttocks, sacrum, thighs. Resident #25 was crying during entire incontinent care and saying it hurts so bad. A record review of Resident #25's Comprehensive Care Plan revealed care plans for bladder and bowel incontinence with target dates of 02/19/23 with goals . I will remain free from skin breakdown due to incontinence and brief use through the review date . and . I will have less than two episodes of incontinence per day through the review date . with interventions . Clean peri-area with each incontinence episode . incontinent: check Q (every) shift and as required for incontinence . check resident every two hours and assist with toileting . On 05/23/23 at 03:00 PM, during an interview with the Director of Nursing (DON), she explained it is not acceptable for a resident to have to lay in a soiled dirty brief with BM while eating lunch or any other time for a long period of time. She explained she expects staff to assist residents when residents request and to provide care every two (2) hours and follow the resident's care plan. 43283

Based on observation, interviews, record review, and facility policy review, the facility failed to maintain the dignity of a resident during mealtime for one (1) of 22 sampled residents. Resident #25 Findings include: A record review of the facility's policy Dignity and Respect, undated, revealed . It is the policy of this facility to treat each resident with respect and dignity and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life. Procedure 1. The staff shall display respect for residents . as constant affirmation of their individuality and dignity as human beings .Definition: Dignity means that in their interactions with residents, staff carries out activities that assist the resident to maintain their self-esteem . Examples .10. Honoring requests to be toileted during meals . On 05/21/23 at 12:20 PM, during an observation and interview with Resident #25, she was lying in bed with her lunch meal tray on the bedside table, and there was a strong foul odor in the room. Resident #25 stated she was not sure how long the meal tray had been sitting there because she was unable to eat. She explained that she had a bowel movement around 10:00 AM, but no one had come to change her. She said that she had told a Certified Nurse Aide (CNA) that she needed assistance, but the CNA did not come back to clean her up. Resident #25 said she had to eat lunch while sitting in her dirty brief and it made her feel disgusted. She further explained that she was embarrassed because her roommate had to smell the odor from her bowel movement during the lunch meal. On 05/21/23 at 12:40 PM, in an observation of incontinence care with CNA #1 and CNA #3, Resident #25 had a large, loose bowel movement that had saturated and leaked through her brief onto the incontinence pad on the bed. On 05/23/23 at 3:00 PM, during an interview with the Director of Nursing (DON), she explained that it was not acceptable for a resident to have to wear a soiled, dirty brief while eating lunch or for any long period of time. On 05/23/23 at 3:30 PM, during an interview with the Administrator, she explained she expected all staff to treat residents with dignity and respect and not allow a resident to wear a soiled brief during meals. A record review of the Admission Record revealed the facility admitted Resident #25 on 8/24/17 and she had diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/13/23 revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review revealed she required extensive assistance with toilet use and was always incontinent of bowel.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to provide adequate staff supervision to prevent the elopements of Resident #1 and Resident #5 from the facility and prevent a fall for Resident #6 for three (3) of ten (10) sampled residents identified at risk for wandering/elopement and falls. Resident #1 left the facility unsupervised and was away for approximately 88 minutes when he was found lying on his back on the asphalt parking lot of the building next door to the facility by a staff member who was walking by on the way to work and heard the Resident yell hey. Resident #1 had minor abrasions of the left arm and leg, a quarter size bruise on the top of the left hand and a skin tear on the left knee. Resident #1 had been evaluated for wandering and elopement risk and identified as a resident with wandering behaviors and at risk for elopement by the facility prior to elopement. During the survey on 7/14/21, Resident # 5, admitted to the facility on [DATE] and identified as high risk for elopement, eloped from the facility for approximately 16 minutes and was found approximately 0.4 - 0.6 miles from the facility at his niece's house. To get to the location would have necessitated Resident #5 to walk along a row of commercial buildings on a busy road with continuous traffic and cross a four-lane highway. The facility's failure to provide supervision to prevent the elopements of Residents #1 and #5 and a fall for Resident #6 placed these residents and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 7/1/21, when the facility failed to provide adequate supervision to prevent the elopement of Resident #1. On 7/12/21 at 1:15 PM, the State Agency (SA) notified the Administrator of the IJ and SQC and provided the facility with the IJ Template. An additional IJ Template was provided on 7/14/21, when Resident #5 eloped. The facility submitted an acceptable Removal Plan on 7/15/21, in which they alleged all corrective actions to remove the IJ were completed on 7/15/21, and the IJ removed on 7/16/21. The SA validated the Removal Plan on 7/17/21, and determined the IJ was removed on 7/16/21, prior to the exit. Therefore, the scope and severity for 42 CFR(s): 483.25(d)(1)(2)-Free of Accident Hazard/Supervision/Devices. (F 689) was lowered to a G, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Elopement/Unsafe Wandering Plan, dated February 2012, revealed It is the policy of this facility to protect the resident form harm while providing care in a manner that helps promote quality of life in a safe environment. Further review revealed, Visual supervision may be necessary in some instances. The nursing staff will complete and document the visual checks as necessary. Further review of the facility's policy, Accidents and Incidents,(undated), revealed It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and those residents receive supervision and assistance devices to prevent accidents whenever possible. An interview with the Administrator on 7/15/21 at 8:44 AM revealed the facility did not have a policy for supervision. Resident #1 Review of the facility's incident investigation dated and signed by the Administrator on 7/05/21, revealed on 7/01/21 at 10:41 PM CNA #1 phoned the facility to report that Resident #1 was outside the facility. Administrator's interviews with staff revealed Resident #1 had last been seen by staff at approximately 9:02 PM at the South Hall Nurses station where he came to get his evening medicine. Resident #1 was safety returned to the facility by staff. Resident #1 reported he exited the building to go to the pharmacy to get some pain medicine for right shoulder pain. Facility staff were able to determine the resident exited through the front door by using his came to disable the magnetic locking mechanism on the door. An immediate assessment by Registered Nurse (RN) #1 was completed and injuries included skin abrasions to the side of the left arm and leg, a quarter sized bruise on the top of the resident's left hand and skin tear to right knee, none of which required medical attention and were treated at the facility. Resident #1 had been evaluated for wandering and elopement risk and identified as a resident with wandering behaviors and at risk for elopement by the facility prior to elopement. Resident #1 was immediately assessed and placed on 1: 1 monitoring. The Administrator's interview with Resident #1 revealed he stated he went out the exit door next to the laundry, however, upon investigation the security switch on the front door was found to be capable of being manipulated into disarming the magnetic lock on the front door. Resident #1 then stated he went out the front door and propelled himself in his wheelchair along the sidewalks of the facility and the building next door and across the parking lot of that building. Resident #1 reported that in an effort to cross a grassy strip between the building next to the facility and the next building his wheelchair wheels got stuck in the moist ground causing him to slide out of the wheelchair and he could not get himself back into the wheel chair. The Maintenance Supervisor was able to identify a previously unknown characteristic of the security switch on the front door and was able to secure the security switch at the front door. Resident # 1 was changed from 1:1 monitoring to visual checks every thirty (30) minutes on 7/02/21 following Quality Assessment and Performance Improvement (QAPI) committee meeting. State Agency was notified on 7/02/21 at 1:59 AM by the Administrator. After investigation, interview with the resident and staff revealed the resident was very knowledgeable and aware of his actions and able to exit the facility. Resident #1 was returned to the facility at Approximately 10:50 PM. Skin abrasions to Resident #1's left arm and leg, a quarter sized bruise on the top of the resident's left hand and skin tear to right knee were noted upon return to the facility. Resident #1 was assisted to return to the facility and placed on one on on (1:1) supervision. Resident #1 reported he left the facility to go to the pharmacy to get some pain medicine for his right shoulder. Resident #1 was immediately placed on one on one (1:1) monitoring with staff. The Medical Doctor (MD) was notified. Resident #1's Responsible Party (RP) was notified. Observations on 7/08/21 at 10:40 PM revealed well maintained sidewalks and parking lots with lots of street lights and signs that provided light to the fairly well lit area. The terrain was flat. The posted speed limit on the street was thirty-five miles per hour (35 mph). The traffic was light with eighteen (18) cars observed to pass the nursing home in three (3) minutes between 10:31 PM and 10:34 PM. The resident was located 44 feet from the street. Resident #1 propelled himself in his wheelchair 700 feet from the facility. Record review of AccuWeather, an Internet weather forecasting site, revealed the weather for the city on 7/01/21 was partly cloudy, seventy-three (73) degrees Fahrenheit with ninety-seven percent (97%) humidity. On 7/08/21 at 10:40 PM, an interview with RN #1, who was the resident's nurse on the evening 7/01/21, revealed the last time RN #1 saw the resident was at approximately 9:02 PM at the South Hall nurses station when he came to get his evening medicine. RN #1 stated it was not unusual for the resident to come to the nurses desk for his evening medication. RN #1 stated that Resident #1 had not complained of pain. RN #1 stated she saw him roll away down the hall but did not notice where he went. RN #1 stated the resident habitually wandered with purpose in the facility, but not aimlessly and she had never seen him attempt to exit the facility unaccompanied. RN #1 stated when LPN #1 received call from CNA #1 at 10:41 PM and shouted for the nurse and told her Resident # 1 was outside, RN #1 and LPN #1 immediately went to the resident, did a quick assessment, assisted the resident to return to the facility, performed a more thorough assessment, and assisted the resident into bed per his request, notified the DON, began 1:1 monitoring of the resident, conducted a check of all exit doors and performed a one hundred percent (100%) headcount of all residents, and notified the Resident's Responsible Party and his doctor. RN #1 stated all exit doors were locked and secure and all residents were accounted for. RN #1 stated he won't keep that I.D. bracelet on. RN #1 confirmed the only observation scheduled for Resident #1 prior to 7/01/21 was one time each shift Resident is to wear yellow wander barcelet (bracelet). Check for Placement every shift. dated 2/14/19. RN #1 stated Resident #1's PRN (as needed) pain medicine had been discontinued on 7/01/21 and he had been upset about it earlier in the day. RN ##1 stated the PRN pain medicine was prescribed again for Resident #1 with instructions that the medicine be crushed prior to administration. RN #1 reported Resident #1 is now on hourly visual checks that are documented on the MAR (Medication Administration Record). On 7/08/21 at 10:50 PM, an interview with CNA #1 revealed she was scheduled to work the 11:00 PM to 7:00 AM shift at the facility and was walking to work, as was her routine, on the evening of 7/01/21. CNA #1 stated at approximately 10:30 PM as she approached the building next to the facility she heard someone yell Hey and looked and recognized Resident #1 laying on his back on the asphalt parking lot of the building next to the facility. CNA #1 stated she immediately went to the resident, asked him if he was hurt, looked him over for obvious injury, asked him why he was outside and how he got outside, stayed with the resident and phoned the facility. CNA #1 stated RN #1 and LPN #1 were there almost instantly. CNA #1 reported having assisted the resident into his wheelchair and returning him to the facility without difficulty. CNA #1 stated she was familiar with Resident #1 and had seen him wandering in the facility but had never seen him attempt to exit the facility unaccompanied. CNA #1 stated she was scheduled to work in a different area and reported to her assigned area. On 7/08/21 at 11:05 PM, an interview with LPN #1 revealed she was working North Hall on the evening of 7/01/21 and answered a telephone call at approximately 10:41 PM from CNA #1 who reported Resident #1 was outside in the parking lot of the building next to the facility. LPN #1 stated she immediately went to the South Hall nurses station shouted for the nurse and went immediately with RN #1 to the location described by CNA #1. LPN #1 stated Resident #1 was quickly assessed, assisted to return to the facility,more thoroughly assessed and assisted into bed per his request. RN #1 confirmed that all exits were checked and found to be locked and secure and a 100% head count was performed with all residents accounted for. LPN stated she was familiar with Resident #1 and his care and had seen him wander in the facility frequently but never saw him attempt to exit the facility unaccompanied. On 7/08/21 at 11:20 PM, an interview with Director of Nurses (DON) revealed she had been notified by phone at approximately 10:45 PM that Resident #1 had been located outside at the building next to the facility. DON stated she immediately notified the Administrator. DON reported having seen Resident #1 wandering in the facility routinely but never saw him attempt to exit the facility unaccompanied. DON stated Resident #1 had visited her office earlier in the afternoon of 7/01/21 and indicated concern about the discontinuation of his PRN pain medicine. The DON stated she had explained the medicine change and Resident had remained calm, indicated that he understood and not got upset. On 7/09/21 at 10:20 AM, an interview with the Social Services Director (SSD) revealed she was involved in the development of the resident's care plan and attended his care plan meetings, was involved in the development of his behavior management plan to address the elopement, attended the QAPI meeting on 7/02/21 at 4:00 PM. SSD stated she was responsible for maintaining the elopement books and identification bracelets. SSD stated she had seen Resident #1 wandering in the facility many times but had never seen him attempt to exit the facility unaccompanied. SSD stated that on 7/02/21 Resident #1 showed her the route he had taken after exiting the facility front door alone on the evening of 7/01/2. SSD stated Resident #1 indicated he left the facility to go to the pharmacy for some pain medicine. SSD stated she had been aware Resident #1 was not compliant with wearing the yellow identification bracelet and in response she had encouraged him to wear it and got him to put it back on when he would. On 7/09/21 at 10:28 AM, an interview with Resident #1 revealed he was calm, cooperative and oriented to date and time and recalled the elopement when he was asked and reported he had left the facility to go to the pharmacy and get some pain medicine for right shoulder pain. Resident #1 confirmed he had exited the front door of the facility and pantomimed use of his cane to manipulate the security switch and disable the magnetic lock and the use of his left arm to push the door open. Resident #1 confirmed he had exited the building shortly after taking his evening medicine. Resident #1 confirmed he did not report pain to staff on the evening of 7/01/21. Resident #1 stated he had lain on the asphalt a long time. Resident #1 stated he had no lingering effects or bad feelings related to the elopement and staff had not treated him any differently since the elopement. Record review of the Admission Record revealed Resident #1 was originally admitted to the facility on [DATE] with the most recent readmission of 1/12/18. Diagnoses included [CONDITION(S)] and [CONDITION(S)] following unspecified [CONDITION(S)] Disease affected right dominant side, Unspecified Dementia without behavioral disturbance, Pain in right shoulder, Type 2 Diabetes Mellitus and [CONDITION(S)]. Record review of Resident #1's Order Summary Report dated 7/9/21 revealed Resident #1 had order for Resident is to wear yellow wander bracelet. Check for Placement every shift initiated 2/14/19. Resident #1's most recent Minimum Data Set (MDS), dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was 15 which indicated no cognitive impairment On 7/09/21/21 at 11:00 AM an interview with the Maintenance Supervisor revealed he had reported to the facility right before midnight on 7/01/21, assessed the locking system and made sure all the exit doors opened and locked back and then discovered the switch above the front door that is used to lock the door on the outside could be switched off and back on and will unlock the door for ten (10) to fifteen (15) seconds. The Maintenance Supervisor stated he put the zip tie in place to prevent the door housing the switch from opening without the code being punched into the keypad. The Maintenance Supervisor stated he kept a log to document the weekly checks performed on all exit doors weekly. On 7/09/21 at 11:20 AM an interview with the Administrator revealed she and the Maintenance Supervisor met at the facility at approximately 12:00 AM on 7/02/21, assessed all exit doors to ensure they were locked and secure. The Administrator stated the Maintenance Supervisor discovered the switch above the front door that is used to lock the door on the outside could be switched off and back on and will unlock the door for ten (10) to fifteen (15) seconds. The resident could reach that switch with his cane, just like he demonstrated. The Administrator stated the Maintenance Supervisor secured the cover of the box the switch is in with a zip tie. The Administrator stated Resident #1 was placed on one on one (1:1) supervision to prevent further elopements. On 7/09 at 3:00 PM an interview with facility Medical Director revealed he attended via teleconference a QAPI committee meeting on 7/02/21 at 4:00 and the committee reviewed the policy for elopement and missing persons to ensure it does not happen again. On 7/09/21 at 10:20 AM an interview with SSD and the Administrator, and observation of the facility floor plan and the area surrounding the facility revealed there was a three inch wide, five inch long (3'x5') opaque plastic box with a hinged door mounted on the wall to the left inside the facility's front door six feet (6') above the floor. Inside the box was a switch that looked like a regular light switch that would be on the wall to turn the light in a room on/off. There was a zip tie which secured the door of the box closed which SA observed replaced by a lock which required a key to open. SSD explained how when asked to show her where he exited the building and where he had gone the resident took her on a tour beginning at the front door where he demonstrated how he had used his cane to manipulate the switch to open the door, pushed open the door, propelled himself along the sidewalk of the facility and the building next door and stopped at the grassy strip between the building next door and the building two doors down. Staff were not aware the resident was out of the building until they received a call from CNA #1 that the resident was in the parking lot of the building next door. The Administrator confirmed that the facility does not have cameras inside or outside the building. They determined the distance from the front door of the facility to the location where the resident was located was 700 feet. Resident #5: On 7/14/21 at 9:04 AM, observation revealed facility initiated a Code Orange Alert for Resident #5. SA was in the facility activity room when Code Orange was announced on the overhead announcement system. Staff was observed searching for the resident. SA spoke with Registered Nurse (RN) #7 who confirmed the event was an actual elopement of a resident. 7/14/21 at 9:08 AM observation revealed SA walking along the hallway was able to open the door to the laundry, walked inside the laundry room and did not see anyone in the laundry. On 7/14/21 at 9:40 AM observation revealed the elopement binders labeled wander books at the South Hall nurses' station and at the North Hall nurses' station did not contain a sheet for Resident #5. On 7/14/21 at 10:00 AM an interview with the Administrator revealed Resident #5 had been admitted on [DATE] and had been assessed and identified as an elopement risk. The Administrator stated that to her knowledge, Resident #5 had made no attempts to leave the facility. The Administrator acknowledged Resident #5's information and photo are not in the Wander Books (elopement binders) located at each nurses' station to alert staff of residents identified as elopement risks. The Administrator stated Resident #5 refused to wear the yellow identification bracelet but had agreed to wear a yellow lanyard with identification card. On 7/14/21 at 10:08 AM an interview with the Care Plan Nurse, RN #3 revealed she had entered a care plan for risk of elopement for Resident #5 because when he arrived at the facility on 7/13/21 he was ready to leave and was trying to leave because he wanted to go home. RN #3 stated she had not witnessed Resident #5 going to the door but had seen him standing in the front area and he was wanting to leave. RN #3 stated Resident #5 refused to wear the yellow identification bracelet and was provided with a yellow lanyard and identification card. RN #3 stated staff knew which residents had wandering behaviors because staff were required to document hourly visual checks and that the yellow identification bracelet or lanyard was in place on the Medication Administration Record (MAR). RN #3 stated she was responsible for setting up the hourly checks on the MAR so staff could document hourly visual observations and she was also responsible for setting up the hourly checks on the Certified Nursing Assistant (CNA) Tasks so the CNA's could document visual checks. On 7/14/21 at 10:15 AM, an interview with the Social Services Director (SSD) revealed it was her responsibility to update the elopement binders (labeled Wander Book). SSD stated it takes a while to get a new admission into the system and she was unable to get a photograph of Resident #5, so she did not get his information out to the nurses stations. The SSD admitted she did not put Resident #5's information in the elopement binders. On 7/14/21 at 10:45 AM an interview with Resident #5 in his room revealed he was calm and cooperative and when asked about leaving the facility without notification he responded I love to walk. I can go out and walk all over the place and not hurt nothing. All I did was touch the door and it opened. When asked if anyone exited before him Resident #5 answered no. When asked if he had been told the code to the keypad to open the door Resident #5 answered no. When asked if he had gotten hot while outside Resident #5 responded No, I walk everywhere. On 7/14/21 at 12:30 PM SA drove from the facility to the address where Resident #5 was located after elopement. The address was four tenths (0.4) of a mile away from the facility. SA observed a row of commercial building on a road busy with continuous traffic. There was no way for the Resident #5 to get to the address where he was located without crossing a four-lane road that was also busy with continuous traffic with no noted crosswalks. SA determined it was too dangerous to walk the route. Record review of AccuWeather, an Internet weather forecasting site, revealed the documented weather temperature for the city on 7/14/21 was approximately 89 degree and sunny. 7/14/21 at 1:17 PM interview with Licensed Practical Nurse (LPN) #1 revealed worked on North Hall from 3:00 PM to 11:00 PM on Tuesday 7/13/21 and was Resident #5's nurse. LPN #1 described Resident #5 on Tuesday 7/13/21 as pretty much ready to leave. LPN #1 reported Resident #5 stated that he was supposed to have been taken to Biloxi, not here. LPN #1 stated Resident #5 was acting anxious and restless on 7/13/21. LPN #1 reported I gave the resident his medicine at around 9:30 PM then he went to his room and stayed in his room where he remained until I got off work and left. LPN #1 stated she arrived at work on 7/14/21 at 7:00 AM for an eight (8) hour shift on North green (Resident's room is on North pink). LPN #1 stated the last time I laid eyes on him was about 8:55 AM and he was asking about where his room was. I showed him where his door was, and he went into his room. LPN #1 stated that on 7/14/21 A Code Orange was called for him and it was about five (5) minutes that I looked for him before I was told he had been found at his niece's house. LPN #1 stated no one had made her aware Resident #5 was an elopement risk but that she would know if residents were elopement risks due to monitoring on the Medication Administration Record (MAR) and the Wander Books, and by observing resident behaviors. 7/14/21 at 2:00 PM an interview with RN #7 along with observation revealed the facility had investigated the elopement of Resident #5 and had determined that Resident #5 was able to exit the building through the laundry due to a malfunction of the self-closing/self-locking mechanism on the door between the hallway and the laundry room. RN #7 demonstrated the door, shut but not completely closed, was able to be pushed open. Further observation revealed upon entering the laundry room from the hallway there was another door located to the right with a sign that stated, Keep Door Closed. RN #7 demonstrated how the second door led into the dirty area of the laundry department where an unlocked glass door directly to the left is located with no alarm or keypad that required a code for exit. The glass door exited directly outside to the backyard of the building in an area not fenced or gated. 7/14/21 at 2:11 PM, interview with CNA #3 revealed she was assigned to Resident #5 for the 7:00 AM to 3:00 PM shift on 7/14/21 and stated, Soon as I got out of my car other staff members were out in the parking lot and told me that he was missing, and I immediately started looking for him. CNA #3 stated that she had gone with CNA #6 and the Admission Coordinator in the facility van to pick him up from his niece's house where the Admission Coordinator talked with him about returning to the facility. When asked, CNA #3 stated she would know if residents were elopement risks due to care instructions on the CNA Tasks on the kiosks. On 7/14/21 at 2:30 PM, interview with Housekeeping Staff #1 (Laundry Supervisor) revealed she was aware the door did not always close completely and lock, and that it had been an occasional issue for the two years she had worked at the facility. Housekeeping Staff #1 stated she had seen the current Maintenance Supervisor work on the self-closing/self-locking mechanism of the door from the hallway into the laundry room at least twice and the previous Maintenance Supervisor at least once over the past two (2) years. Laundry Supervisor stated she reported any problems with the door to the Maintenance Supervisor who would work on it and fix it. Laundry Supervisor stated she had never seen a resident in the laundry room. Laundry Supervisor stated she had never seen a resident open the door between the hallway and the laundry room. On 7/14/21 at 2:35 PM interview with Housekeeping Staff #2 (Laundry Tech) revealed she was not aware the door did not always close completely. Housekeeping Staff #2 stated she had worked at the facility for eighteen (18) years and had been trained to always pull the door handle to make sure it was locked after exiting the door from the laundry into the hallway. Housekeeping Staff stated she had never seen a resident in the laundry room. Housekeeping Staff stated she had never seen a resident open the door between the hallway and the laundry room. On 7/14/21 at 2:36 PM, a telephone interview with the niece (of Resident #5) revealed Resident #5 had walked up to her home between 8:55 AM and 9:00 AM. She stated, he seemed ok and was holding a milk carton. The niece reported Resident #5 had always walked around town, but his family had noticed a recent increase in confusion. On 7/14/21 at 2:42 PM, a telephone interview with the Responsible Party (RP) for Resident #5 revealed Resident #5 had started having issues with confusion and dementia and recently the family noticed a decline because of the dementia. The RP stated he had signed the admission paperwork and had talked with the Admission Coordinator. The RP stated he was told by the Admission Coordinator that the facility had the capacity to keep him locked in and that is why he was so surprised the resident had walked to his niece's house. 7/14/21 at 2:42 PM, an interview with CNA #4 revealed she had delivered his breakfast tray to Resident #5 in his room at approximately 8:00 AM. Resident #5 immediately awoke and started putting on his shoes and CNA #4 went to continue to pass out breakfasts to residents. CNA #4 stated, It was almost 9:00 (AM) and I was picking up the trays in the common area on North Hall and he walked by me and said he would rather be in jail. The nurse was looking for him about five (5) minutes later. On 7/14/21 at 2:44 PM an interview with RN #1 revealed she arrived to work 7:00 AM to 3:00 PM on North Hall which included Resident #5. RN #1 reported after beginning the 7:00-10:00AM medication pass she was at her medication cart and Resident #5 waked out of his room and was walking back and forth in the hallway and was talking to himself. RN #1 stated she did not recall seeing Resident #5 at the exit doors or involved in exit seeking behavior. The last time RN #1 saw Resident #5 was around 8:50 AM-8:55 AM on North wing. RN #1 stated she went into a resident room to provide care and upon returning to the hallway noted Resident #5 was not in the hall. RN #1 stated she went up to the office of the Admission Coordinator and asked if she had seen the Resident #5, but the Admissions Coordinator stated no she had not. RN #1 then told the DON she was looking for the resident. RN #1 stated The staff searched for a few minutes and then the DON called the code. RN #1 stated she kept on looking until he was located, and we got the all clear. RN #1 reported when Resident #5 returned to the facility she assessed him and found no injuries and the resident voiced no complaints. RN #1 stated that she would know if residents were elopement risks due to the Wander Book, monitoring on the Medication Administration Record (MAR) and by observing resident behavior. On 7/14/21 at 3:28 PM, interview with CNA #5 revealed breakfast trays came out and she was passing out breakfast trays when Resident #5 approached her an began to tell her he had to get out of here but he went back to room his room and CNA #5 went to feed dependent residents. CNA #5 stated it was only about five (5) minutes before his nurse was looking for him and said she was wanted to locate him because he was not in his room or the hallway. CNA #5 stated she searched the building and went outside and looked and did not stop looking until she heard the all clear that the resident had been located. CNA #5 stated no one told her the resident was an elopement risk. CNA #5 stated she would know if residents were elopement risks due to care instructions on the CNA Tasks on the kiosks. CNA #5 stated the facility is constantly having in-services about elopement. On 7/14/21 at 4:40 PM interview with CNA #6 revealed she had clocked in at 8:35 AM and immediately encountered Resident #5 in the hallway near the time clock holding a milk carton like the residents get with breakfast CNA #6 stated Resident #5 told her Someone has got to let me out of here. CNA #6 revealed she immediately went to the office of the Social Services Director and reported the resident's behavior. CNA #6 stated that 8:59 AM she was notified that the DON was looking for Resident #5 and she began to look for him also. CNA #6 reported having driven the facility van accompanied by the Admission Coordinator and CNA #3 to the resident's niece's home to return the resident to the facility. CNA #6 stated upon arrival at the facility Resident #5 had the demeaner of being calm and cooperative and returned to the facility for the nurse to do an assessment. CNA #6 stated Resident #5 was wearing dark blue jeans, a dark T-shirt, gray socks, and black tennis shoes. On 7/15/21 at 8:40 AM interview with Administrator revealed she had been the Administrator for approximately one (1) year. The Administrator revealed Resident #5 was admitted from home following referral to the facility by his primary physician. The Administrator stated when the facility had a long-term care (LTC) referral, viability of the referral was determined by the facility staff. The Administrator stated she had not been made aware of any concerns related to Resident #5's risk of elopement prior to admission. The Administrator stated she had not been aware of any problems with the self-closing/self-locking mechanism of the door between the hallway and the laundry room. On 7/15/21 at 9:00 AM interview with Director of Nurses (DON) revealed a Risk Assessment was performed on every new admission to the facility which included Resident #5. The DON revealed the Risk Assessment for Resident #5's result was High Risk for elopement. The DON stated the staff would have been made aware of Resident #5's High Risk for Elopement status by implementation on Medication Administration Record (MAR) and CNA Tasks on the kiosks. The DON stated she does not remember being made aware of any problems with the self-closing/self-locking door between the hallway and the laundry, and she does not rem[TRUNCATED]

Based on staff interviews, record review and facility policy review, the facility failed to protect the resident's right to be free from neglect, related to a fall with injury for one (1) of five (5) residents reviewed. Resident #6. Findings include: Review of the facility Freedom from Abuse, Neglect, and /or Exploitation Prevention Plan revealed The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined below. This includes but not limited to freedom from corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms . Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.Neglect- failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, mental anguish, or emotional distress . Staff will be supervised to identify inappropriate behaviors such as derogatory language; rough handling; ignoring residents while giving care; directing residents who need toileting assistance to urinate or defecate in their beds . Record review of the Admission Record revealed Resident #6 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 5/04/2021 revealed Residen#6 had a Brief Interview for Mental Status (BIMS) score of 3 that indicated Resident #6 has severe cognitive impairment. Record review of the facility's CES Quarterly Evaluation Bundle (Clinical-V11) dated 5/12/21 revealed 2. Fall Risk Evaluation Instructions: If the score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Resident #6's Fall Risk Score was 21. Record review of the facility's Progress Notes dated 7/2/2021, revealed Resident heard screaming out in her room @ (at) 15:23 (3:23 PM). Upon entering room, resident noted to have copious amount of vomit in her bed .Resident assisted out of bed to wheelchair .Resident continues to cry out. Resident states that her back hurts .Order received to send to (Proper name of local hospital) . Record review of the local hospital progress note dated 7/6/21 revealed Patient was seen and examined today. Patient is a terrible historian. She constantly yells out with any movement of her right leg. Case was discussed with physical therapy. Imaging obtained. Record Review of the local hospital x-ray report dated 7/6/21 revealed a displaced right femoral neck fracture. Record review of the facility investigation dated 7/6/21, revealed there were no recent falls or incidents documented from the hospital. The investigation at the facility revealed that there was an incident regarding Resident #6 on 7/2/21. RN #7 and CNA #7 reported two different stories. RN #7 changed her story multiple times, did not document, and was reported to the state Board of Nursing by the facility. No other staff members were identified to have witnessed the incident. During an interview on 7/13/2021 at 10:30 AM, with RN #7 revealed she was called to Resident #6's room by CNA #7 on 7/2/2021 at 8:00 AM. RN #7 said Resident #6 was sitting in the wheelchair crooked. RN #7 said CNA # 7 helped her straighten the resident up in the wheelchair. RN # 7 said she suspected Resident # 6 must have fell and put herself in the wheelchair crooked. RN #7 said she did not do an incident report or notify anybody because she wasn't for sure if the resident fell . RN # 7 said Resident #6 has had several falls and complains of pain all the time. RN # 7 said Resident #6 vomited later during the day and complained of pain. RN #7 said she gave Resident #6 [MEDICATION(S)] for nausea and a pain pill. Interview on 7/13/21 at 10:45 AM, with CNA #7 revealed on 7/2/21 at 7:00 AM she heard a resident scream help. CNA #7 said she saw Resident #6 on the floor. CNA # 7 said she called for RN#7. RN #7 asked CNA #7 if the resident hit her head. CNA #7 said she thinks she did because her head was against the wall. RN #7 said I don't have time for this. I am not sending her out because she falls all the time. She's, ok. CNA #7 said she took the resident to the dining room after assisting RN #7 with putting her back in the wheelchair. CNA # 7 said Resident #6 was very confused, would not eat and complained of pain to her arm. CNA # 7 said CNA #8 was in the dining room. CNA #8 asked CNA #7 if Resident #6 was OK. CNA #7 told CNA #8 that Resident #6 fell this morning in her room. CNA #7 also said RN #7 did not write an incident report, nor send the resident to the hospital for an x-ray. CNA #8 told CNA #7 to go back to RN #7 and write a statement to cover herself. CNA #7 said CNA #9 also asked during breakfast, what is wrong with Resident #6. CNA #7 said Resident #6 fell , and RN #7 did not write an incident report or send the resident to the hospital to be evaluated. CNA #9 also told CNA #7 to write a statement and keep it because the Administrator or somebody will come to her to find out what happen. CNA # 7 said Resident #7 continued to complain of pain. CNA #7 went to the nurse and said Resident #6 continues to complain of pain. CNA #7 told RN #7 that Resident #6 probably needs to go to the hospital. RN #7 refused to send her out. CNA # 7 said after lunch the resident vomited and continued to complain of pain to her back. CNA #7 said she cleaned the resident up and let RN #7 know the resident had vomited and complained of pain. RN #7 gave the resident something for pain and nausea. CNA #7 said when she came back to work the next day, she was told Resident #7 was sent to the hospital for vomiting and pain. CNA #7 said RN #7 came to her saying they need to get their story together. CNA #7 said she told the RN #7 that she wrote a statement. CNA #7 said a couple of days later the Administrator called her and ask if Resident #6 had a fall. CNA #7 said no Resident #6 did not fall. The Administrator asked her to write a statement and bring it to the facility. CNA # 7 said she came to the facility and talked to the Administrator. CNA #7 said she told the Administrator that she needed to tell the truth because she did not realize the resident had a [CONDITION(S)]. CNA # 7 said she told the Administrator that she heard Resident # 6 scream help me. CNA #7 said she found Resident #6 on the floor. CNA #7 said she called RN #7 to the room. CNA #7 also stated that she told the Administrator that RN #7 refused to send the resident out to the hospital because she didn't have time and the resident always falls and complains of pain. CNA # 7 said she felt bad because RN #7 told her the Resident did not receive any broken bones and the Resident was ok. When she realized Resident #6 had a right hip fracture, she had to tell the truth. CNA #7 said Resident #6 suffered several days before the hospital realized her right hip was fractured because she failed to notify the Administrator. During an interview on 7/13/21 at 11:00 AM, with CNA #8 revealed CNA #7 came to her and told her Resident #6 fell in her room on 7/2/21.CNA #7 told CNA #8 that RN #7 did not write an incident report or send Resident #6 to the hospital. CNA #8 told CNA #7 to write a statement and keep it just in case something happens to the Resident. During an interview on 7/13/21 at 11:15 AM, with CNA #9 revealed CNA #7 told her that Resident #6 fell on the floor in her room on 7/2/21. CNA #7 said RN #7 would not send the resident to the hospital to be evaluated. RN #7 also did not write an incident report. CNA #9 said she told CNA #7 to write a statement to cover herself. CNA #9 said CNA #7 came to her because she has worked at the nursing home for a long time. During an interview on 7/13/21 at 11:25 AM, with Licensed Practical Nurse (LPN) #2 said she received report from RN #7 on 7/2/21 at 3:00 PM. LPN #2 said while receiving report she heard somebody screaming. LPN #2 asked who is that? RN #7 said its Resident #6. RN #7 said Resident #6 was lowered to the floor today. RN #7 also said Resident # 6 vomited and complained of pain. LPN #2 said RN #7 gave Resident #6 something for pain and nausea. LPN# 2 said immediately after receiving report she checked on Resident #6 and noted she had vomited on her clothes. Resident #6 continued to yell out saying her back was hurting. LPN #2 called the Nurse Practitioner and received orders to send Resident #6 to the hospital to be evaluated. During an interview on 7/13/21 at 11:40 AM, with the Administrator, revealed the Nurse Practitioner (NP) called her on 7/6/21 at 1:45 PM, from the local hospital stating Resident #6's x-ray results revealed a right hip fracture. The Administrator asked if Resident #6 had a fall during her stay at the hospital. The hospital records and staff did not report any falls or other incidents. The Administrator said she reported to the State Agency (SA) and Attorney General Office (AGO). The Administrator said she started an investigation immediately. The Administrator said the Director of Nursing (DON) called and questioned RN #7 and asked if Resident #6 had a fall on 7/2/21 before she went to the hospital. RN #7 told the DON that when she arrived on her shift the resident was in her wheelchair and had slid out but did not fall. Resident #6 was holding on to the chair with her bottom between the seat of the wheelchair and the floor. RN #7 said she did not do an incident report because she did not think it was a fall. RN #7 said CNA #7 helped her straighten Resident #6 in the wheelchair. RN # 7 was suspended pending investigation and was terminated after the investigation. RN# 7 was reported to the State Board of Nursing. The Administrator called CNA #7 and asked if Resident #6 fell on [DATE]. CNA #7 said no Resident #6 did not fall. The Administrator asked CNA #7 for a statement in writing. The Administrator said CNA#7 came to the facility on [DATE] at 4:30 PM to talk to her. CNA #7 told the Administrator that on 7/2/21 around 8:00 AM, she was coming out of another resident's room when she heard Resident # 6 yell out help me. CNA #7 said she found Resident #6 on the floor in her room by the bathroom door. CNA #7 called RN #7 to the room. RN # 7 asked if Resident #6 hit her head. CNA #7 stated yes, because her head was against the wall. RN #7 said, I don't have time for this, I'm not sending her out. CNA #7 and RN #7 assisted Resident #6 back in the wheelchair. Resident #6 continued to yell out in pain. Resident #6 was wheeled to the dayroom. CNA #7 said she checked on the resident all day. CNA #7 said she went back to RN #7 and asked if she would send Resident #6 out because she continues to complain of pain. RN #7 said she has had so many falls already, she doesn't have time to send her out. CNA #7 said after lunch Resident #6 vomited and complained of pain to her hip during Activities of Daily Living (ADL) care. CNA #7 told RN#7 and medication was administered for pain and nausea. CNA #7 also said RN #7 said the resident did not have any broken bones when she was sent out to the hospital. CNA #7 said when she found out Resident #6 had a right hip fracture, she knew she had to tell the truth. CNA #7 said she told CNA #8 and CNA # 9 about the situation. Both CNAs told her to write a statement and keep, just in case something happened. CNA #7 was suspended pending investigation. Both CNAs were interviewed and confirmed CNA #7 did talk to them about Resident #6 fall and RN #7 refusing to write an incident report or send Resident #6 to the hospital for an evaluation. Both CNA's advised CNA #7 to write a statement and to keep it. The Administrator said she interviewed LPN #2.LPN#2 said she received in report from RN #7 that Resident #6 was lowered to the floor. LPN #2 said she sent Resident #6 to the hospital because she continued to vomit and complain of back pain. The Administrator called an emergency Quality Assurance Performance Improvement (QAPI) meeting on 7/8/2021. Record review of the facility's in-service dated 3/16/21 and 5/24/21 revealed Registered Nurse (RN) #7 and Certified Nursing Assistant (CNA) #7 was educated on Abuse, Neglect, Misappropriation, and Exploitation.

Based on record review, staff interviews and facility policy review the facility failed to report to the State Agency (SA) within two (2) hours, an incident of neglect, related to a fall of unknown origin for one (1) of five (5) residents reviewed. Resident #6 Findings include: Review of the facility Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Reporting/Response policy revised 08/23/2017 revealed It is the policy of this facility that persons employed by this facility with knowledge or reasonable cause to believe that any resident has been the victim of abuse, exploitation, neglect, or mistreatment must report or cause a report to be made to the appropriate state agencies as prescribed by laws of the state. Failure by staff (including management and supervisory staff) to report possible/alleged incidents of abuse/neglect to Administrator per policy, will result in disciplinary action up to and including immediate termination. All alleged violations or substantiated incidents involving mistreatment, exploitation, neglect, or abuse, including injuries of an unknown origin are reported to the Administrator of the facility. The Administrator and/ or Director of Nursing will notify appropriate officials including State Survey Agency and adult protective services where state law provides for jurisdiction in accordance with state law immediately but no later than 2 hours after the allegation/suspicion is formed if the events that cause the suspicion result in serious bodily injury . Record review of the facility's Progress Notes dated 7/2/2021, revealed Resident heard screaming out in her room @ (at) 15:23 (3:23 PM). Upon entering room, resident noted to have copious amount of vomit in her bed .Resident assisted out of bed to wheelchair .Resident continues to cry out. Resident states that her back hurts .Order received to send to (Proper name of local hospital) . Record review of the local hospital Radiology Results x-ray report dated 7/6/21, for Resident #6, revealed Impression: Displaced right femoral neck fracture. Interview with CNA #7 on 7/13/21 at 10:30 AM, revealed Resident #6 was found on the floor of her room on 7/2/2021 at 8:00 AM. CNA #7 assisted RN #7 to put Resident #6 back in the wheelchair. RN #7 failed to write an incident report or notify the DON or Administrator. Interview with the Administrator on 7/13/21 at 11:40 AM, revealed she received a call from the local hospital Nurse Practitioner (NP) stating Resident #6 continued to complain of pain. An x-ray of Resident #6's right hip was done on 7/6/21 at the hospital resulting in a right hip fracture. The Administrator started an investigation by interviewing the staff that provided care of Resident #6 prior to the hospital stay. The Administrator interviewed CNA #7. CNA #7 confirmed Resident #6 fell at the facility on 7/2/21. The hospital records and staff revealed the resident did not fall at the hospital. RN #7 and CNA #7 was terminated for failing to report the fall to the DON or Administrator. The Administrator reported the fall of unknown origin to the State Survey Agency on 7/7/21 at 7:24 PM. The Administrator said this incident was not reported within 2 hours because RN #7 and CNA #7 did not report the fall to her or the DON. The Administrator said RN #7 has been in-serviced on reporting. Record review of the facility in-service titled, When to Call Protocol dated 5/26/21, revealed Registered Nurse (RN) #7 was in-serviced to notify the Director of Nursing (DON) and Administrator for falls (especially with injury).

Based on record review, staff interviews and facility policy review the facility failed to investigate a fall of unknown origin resulting in injury for one (1) of five (5) residents reviewed for falls Resident #6. Findings include: A review of the facility's Investigation Policy, undated revealed . All injuries or bruises that are suspicious in any way or injuries of an unknown origin must be investigated. An injury is classified as injury of unknown origin when both of the following conditions are met. 1. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident. 2. The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one point in time or incidence of injuries over time. On 7/7/21, the facility reported to the State Survey Agency an allegation that occured on 7/2/21 of suspected neglect and poor quality of care from Registered Nurse (RN) #7 and Certified Nursing Assistant (CNA) #7 by failing to report a fall. This fall resulted in a displaced right femoral neck fracture. RN #7 did not report Resident #6's fall to the Administrator, Medical Doctor, or family. RN #7 did not write an accident or incident report. Record review of the final report submitted by the facility to the State Survey Agency revealed the investigation was completed on 7/11/21. During an interview on 7/13/21 at 10:45 AM, with Certified Nursing Assistant (CNA) #7 confirmed she failed to notify the Director of Nursing (DON) and the Administrator of Resident #6's fall when Registered Nurse (RN) #7 failed to follow the facility fall protocol by not writing an incident report or reporting the fall to the DON. During an interview with the Administrator on 7/13/21 at 11:40 AM, revealed she did not investigate Resident #6's fall until 7/6/21, when she received a call from the Nurse Practitioner (NP)at the local hospital. The NP stated Resident #6 continued to complain of pain and an x-ray was ordered which revealed a right hip fracture. The Administrator said she did not know the resident had a fall. The Administrator started an investigation by interviewing the staff that provided care for Resident #6 on 7/2/21. The fall was confirmed by Certified Nursing Assistant (CNA) #7 that Resident #6 fell on [DATE] at 8:00 AM. RN #7 failed to write an incident report or notify the Administrator or Director of Nursing (DON). The Administrator said she reported the incident to the State Survey Agency 7/7/2021. The Administrator also said RN #7 and CNA #7 was terminated for not reporting Resident #6's fall with injury in a timely manner.

Based on facility policy review, record reviews, observations, and interviews, the facility failed to implement a resident centered care plan for three (3) residents (Residents #3, #54, and #74) of 24 sampled residents. The facility failed to implement the medical care and assessment needed from the care plan for Resident #54 regarding pressure ulcers. As a result, the resident sustained [REDACTED]. Additionally, the facility failed to ensure the care plan was implemented to meet the activity interests for Resident #74, and Resident #3 for not getting an inhaler medication as ordered. Findings include: A facility policy entitled, Resident assessment dated [DATE], indicated .Information derived from the comprehensive assessment enables the staff to plan care that allows the resident to reach his/her highest practicable level of functioning and may include: .Special treatments or procedures (treatments and procedure that are not part of basic services provided to independent residents). For example, treatment for [REDACTED].pleasure and lifetime preferences. Resident #54 Review of a Care Plan dated 3/25/19, documented Resident #54 had a Stage 2 pressure ulcer. The care plan directed clinical staff to document weekly the condition of the wound, provide measurements, depth, width, length, type of tissue, and if there was exudate (drainage) or not and to administer treatments as ordered. Review of a Care Plan, dated 4/19/19, revealed Resident #54 had an unstageable pressure ulcer to her right heel. There had been no care plan revisions to update and implement clinical interventions to prevent the wound from deteriorating and promote healing from the time the pressure ulcer was identified on 3/7/19, until the wound had deteriorated to unstageable on 4/19/19. Review of Resident #54's Admission Record, located in the Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of a Weekly Pressure Injury Record, revealed that on 3/7/19, Resident #54 was assessed to have a Stage 2 pressure ulcer (partial thickness loss to skin or may appear as an intact or open/ruptured serum filled blister) to the right heel. The Stage 2 pressure ulcer was identified as two (2) centimeters (cm) by two (2) cm in length and two (2) cm by two (2) cm in width. There was no depth, tunneling, and/or exudate identified with this assessment. The wound to the right heel was described as a fluid filled blister. The Weekly Pressure Injury Records dated 3/14/19, and 3/21/19, documented no change in the measurements and description of the wound. There were no Weekly Pressure Injury Records or weekly skin assessments documented in Resident #54's medical record from 3/21/19 to 4/25/19. This was confirmed with the Licensed Practical Nurse/Wound Nurse and the Director Of Nursing (DON) in an interview on 5/23/19 at 8:32 AM, with the Administrator present. An entry identified in the nursing Progress Notes dated 4/19/19, identified Resident #54 had an unstageable pressure ulcer on her right heel. There were no measurements or description of the wound as directed in the care plan. Review of the (MONTH) 2019 Treatment Record revealed no treatments to Resident #54's right heel from 4/5/19, until 4/19/19. An interview was conducted with the Director of Nursing (DON) on 5/22/19 at 4:19 PM. The DON stated it would be her expectation that staff should follow the care plan. Resident #74 Review of Resident #74's care plan revised 5/16/17, identified the resident was visually impaired but he still enjoyed involvement in singing and spiritual programs. Continued review of the care plan specifically identified Resident #74 as blind and there was a need for in room visits. The identified intervention included Resident #74 enjoyed music, specifically the blues. Review of the Admission Record revealed Resident #74 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #74's most recent quarterly Minimum Data Set (MDS) assessment, dated 4/24/19, revealed the resident was severely cognitively impaired and unable to participate in the Brief Interview for Mental Status (BIMS) cognitive evaluation. The assessment documented the resident was highly impaired visually; was rarely/never understood; required extensive staff assistance with all activities of daily living (ADLs); and was unable to be interviewed about his preferences related to routines/activities due to his cognitive impairment and communication deficits. Observations were made of Resident #74, while he was in his room on 5/20/19 at 1:41 PM, 5/20/19 at 4:04 PM, and on 5/21/19 at 9:32 AM. At each observation there was no radio present. There was a television in the room and it was off. There was no music playing. The resident could not be reliably interviewed to determine if sitting in his room quietly was his choice, due to his cognitive and communication deficits. An interview was conducted with CNA #109 on 5/21/19 at 12:30 PM. The CNA stated she had worked at the facility for the past year and had never been directed to turn a radio on or to turn the television on for Resident #74 to listen to music. A review was conducted of three (3) documents completed by the Activities Coordinator, titled In Room/1:1 Activities. The forms were dated 2/19, 3/19, and 4/19. The form dated 2/19, identified Resident #74 received in room music for 10 minutes on 2/6/19, and on 2/26/19. The form dated 3/19 identified Resident #74 listened to music for 10 minutes on 3/5/19. The form dated 4/19 identified Resident #74 listened to music for 10 minutes on 4/8/19. The forms were completed by the Activities Coordinator, who was not in the facility during the survey, and was not available for an interview regarding the resident having been provided only 10 minutes of his care planned, and preferred activity for (MONTH) 2019, and (MONTH) 2019, and for 20 minutes during the month of (MONTH) 2019. An interview was conducted with MDS Coordinator #2 on 5/22/19 at 4:15 PM. MDS Coordinator #2 stated the Activities Coordinator creates an activity care plan for the residents. She said if an issue was care planned and not done, it means someone needed training and the staff members needed to follow the care plans. Resident #3 The Care Plan for Resident #3, most recently reviewed/revised on 5/2/19, documented the resident had altered respiratory status related to chronic [MEDICAL CONDITION] with hypercapnia and [MEDICAL CONDITION]. Interventions included to administer respiratory treatments as ordered. Review of a physician's orders [REDACTED].#3 was to be administered an Atrovent Inhaler (an [MEDICATION NAME] medication), two (2) puffs orally four (4) times daily, for [MEDICAL CONDITION] with acute exacerbation. On 5/20/19 at 11:39 AM, interview with Resident #3 revealed she had not received her Atrovent inhaler for three (3) days because the facility did not have the medication in stock. She stated she needed the medication. She stated she depended upon staff to have her medications. The Medication Administration Record [REDACTED] 5/17/19 - not administered at 12:00 PM or 8:00 PM. 5/18/19 - not administered at 8:00 AM or 12:00 PM. 5/19/19 - not administered at 8:00 AM, 12:00 PM, 4:00 PM (resident absent from facility) or 8:00 PM. 5/20/19 - not administered at 8:00 AM. On 5/21/19 at 4:15 PM, Licensed Practical Nurse (LPN) #102 confirmed there were doses documented as not having been administered between 5/17/19 and 5/20/19. She stated the resident reported to her that her Atrovent inhaler had been unavailable last week. On 5/22/19 at 8:44 AM, Resident #3 stated she was in no additional respiratory distress as a result of not receiving her Atrovent inhaler last week. On 5/22/19 at 10:09 AM, LPN #24, stated that the resident had no Atrovent inhaler in the medication cart. She stated the off-going medication nurse, 5/17/19 at 3:00 PM, had informed her there was no Atrovent inhaler for the resident, but the medication had been ordered. On 5/22/19 at 10:18 AM, LPN #33 was asked why the facility had not acquired an Atrovent inhaler for three (3) days for Resident #3. She stated she called the pharmacy provider and stated authorization to purchase the Atrovent inhaler was required, from either the DON or herself, and the provider had not received that authorization. LPN #33 stated she had been told the morning of 5/20/19, the resident still did not have an Atrovent inhaler and at that time she went to the backup pharmacy to purchase the medication. She stated the resident should not have gone three (3) days without her Atrovent inhaler. On 5/22/19 at 05:17 PM, Registered Nurse #90 confirmed on 5/18/19 at 4:00 PM and 8:00 PM, there was no Atrovent inhaler in the medication cart and that she had mischarted some of the administration times of the medication. An interview was conducted with the Director of Nursing (DON) on 5/22/19 at 4:19 PM. The DON stated staff should follow the care plan.

Based on facility policy review, observations, record reviews, and interviews, the facility failed to provide treatment and services to prevent the deterioration of, and promote healing of a pressure ulcer, for one (1) resident, Resident #54, of four (4) residents reviewed for pressure ulcers. As a result of the facility's failure, Resident #54 sustained harm by developing an unstageable pressure ulcer to the right heel. The facility failed to prevent the deterioration of the pressure ulcer that went unmonitored from 3/27/19 until 4/19/19, and no documented treatment from 4/6/19 through 4/18/19. The pressure ulcer deteriorated from a Stage 2 to an unstageable pressure ulcer that required debridement (surgical removal of dead tissue). Findings include: A facility policy titled, Skin Care Process, dated 1/17/18, indicated, .It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur.Staff Roles.The following is recommended as a minimum, other responsibilities may be assigned as allowed by regulatory or licensing agencies.Registered Nurse.Conducts or supervises the Admit/Readmit Physical Evaluation, and the completion of the Braden scale (skin assessment) as well as other evaluations at determined times.Stages pressure wounds.Observes wounds weekly.Oversees the licensed practical nurse and nursing assistant in the implementation of the plan of care.Licensed Practical Nurse.May measure and document progress of wounds if trained and competent in wound evaluation . Notifies the registered nurse or Medical Professional of any lack of healing or new issues related to a wound.Documentation should include, but is not limited to, regular skin inspections, pressure wound measurements and progress.When documenting, it is important to include the location of the wound, presence of exudate, pain, signs of infection, and the wound bed characteristics. According to the National Pressure Ulcer Advisory Panel (NPUAP), . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister .Granulation tissue, slough and eschar are not present .Stage 3 Pressure Injury: Full-thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead tissue) may be visible. The depth of tissue damage varies by anatomical location; Undermining and tunneling may occur. If slough or eschar (dead tissue) obscures the extent of tissue loss this is an Unstageable Pressure Injury.Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Review of the admission Minimum Data Set (MDS) assessment, dated 3/12/19, revealed Resident #54 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS indicated the resident had severe cognitive impairments, scoring a 2 of 15 on the Brief Interview for Mental Status (BIMS). The assessment also documented the resident was readmitted with two (2) Stage 2 pressure ulcers. No measurements, wound location or description were included on the MDS. Review of the nursing Progress Notes, dated 3/5/19, revealed the resident had a right inner and outer suspected deep tissue injury. No location was documented. The progress notes identified the resident with no [MEDICAL CONDITION]. Review of the Admission & Readmission Evaluation, dated 3/5/19, noted under Skin Integrity, revealed Resident #54's skin was normal, warm, normal turgor, and dusky. There was an area that directed the clinical staff to document any skin concerns and it noted .bilateral heels. There was no additional and/or descriptive information documented regarding the resident's heels. A Braden Scale for Predicting Pressure Sore Risk dated 3/5/19, indicated Resident #54 was at low risk for the development of a pressure ulcer. Review of a Physician order [REDACTED]. Review of a Weekly Pressure Injury Record, dated 3/7/19, indicated Resident #54's right heel Stage 2 pressure ulcer was first identified on 3/7/19. The length of the pressure ulcer was two (2) centimeters (cm) x 2 cm. The form noted there was no depth, tunneling, undermining, no exudate, and no odor present. The section titled Additional Notes/Comments revealed the wound was described as an intact fluid filled blister. The physician and the family were notified of the changes in the resident's skin. Review of a physician's (MD) Progress Note, dated 3/7/19, indicated Resident #54 had a history of [REDACTED]. The MD's note indicated the resident had left leg [MEDICAL CONDITION], and the MD ordered a repeat ultrasound of the left leg. On 3/8/19, the ultrasound came back positive for a non-occlusive [MEDICAL CONDITION] to the left lower extremity. Continued review of the MD's Progress Notes revealed Resident #54 was seen by the MD on 3/19/19, and that visit note indicated the resident's skin was warm, intact, and dry. The resident was seen again on 3/21/19, 3/28/19, 4/4/19, 4/9/19, 4/11/19, and on 4/23/19, by the MD. Her skin was noted to be warm, dry, and intact on those visits. These assessments were follow-up to the presence of the [MEDICAL CONDITION] in the left leg. The existing Stage 2 pressure ulcer to the left heel resolved, but no evidence was found in the MD's progress notes that addressed the status of the resident's pressure ulcer on the right heel during the MD visits listed above. Review of the nursing Weekly Body Audits, dated 3/20/19, 4/3/19, 4/10/19, 4/17/19, 4/24/19, and 5/1/19 revealed .No new skin alterations. There was no documentation on the body audits listed above that indicated Resident #54 had a Stage 2 pressure ulcer on the right heel, or that the wound was being monitored or treated. Review of a Weekly Pressure Injury Record dated 3/21/19, indicated Resident 54's right heel Stage 2 pressure ulcer was first identified on 3/7/19. The length of the pressure ulcer was 2 cm x 2 cm. The form noted there was no depth, tunneling, undermining, no exudate, and no odor present. There were no comments under a section entitled Additional Notes/Comments. The next Weekly Pressure Injury Record was not completed until 4/25/19, and noted Resident 54's pressure ulcer was a Stage 3. The length of the pressure ulcer was 1.8 cm x 1.4 cm. The form now noted the depth of the pressure ulcer was 0.4 cm. There was no tunneling, no undermining, there was a small amount of exudate, and the wound bed now had slough. It was noted the physician and the family were notified of the change in the resident's pressure ulcer. Under the section entitled Additional Notes/Comments it stated that the wound had slough and a new order was obtained for Santyl for gentle debridement. Review of the (MONTH) 2019, Treatment Administration Record (TAR), revealed Resident #54 had an order to clean the fluid filled blister to the resident's right heel, with wound cleanser, pat dry, and to apply a dry dressing, daily. The treatment start date was 3/6/19, and the end date was 3/23/19. There was no evidence that treatments were provided on 3/8/19, 3/11/19, 3/18/19, or on 3/21/19. Continued review of the (MONTH) 2019 TAR revealed an order change, on 3/23/19, that directed staff to clean the fluid filled blister with wound cleanser, to apply [MEDICATION NAME], and apply a dry dressing daily. A low air loss mattress was ordered on this same date as an intervention. Review of a Registered Dietician's (RD) Progress Note, dated 4/3/19, revealed the resident triggered for significant weight loss. The note documented the resident was consuming 50 to 75 percent of her meals, nutritional supplements were added, and the note indicated the resident had Stage 2 pressure ulcers to bilateral heels. Additional fortified cereal was added to her breakfast and fortified mashed potatoes were added to her lunch and dinner meals. Review of a Patient at Risk (PAR) note found in the electronic health record, and dated 4/5/19, identified the significant weight loss that Resident #54 sustained. There was no mention of the status of the resident's pressure ulcers Review of a 4/5/19 physician's orders [REDACTED]. There was no documented evidence that the treatments were completed from 4/6/19 through 4/18/19. Review of the nursing Progress Notes dated 4/12/19, indicated a PAR meeting was held. The PAR note indicated Resident #54 had a Stage 2 pressure ulcer on her .left heel. and the .right heel has resolved. The PAR note was reviewed with the Licensed Practical Nurse/Wound Nurse (LPN/WN) on 5/22/19, and the LPN/WN confirmed the information in the PAR note was incorrect. The left heel wound had resolved, and the right heel wound had deteriorated. Review of the nursing Progress Notes dated 4/19/19, revealed a PAR meeting was held. The PAR note stated Resident #54 had a right unstageable pressure injury. It specifically stated, .The wound is stable.Patient denies pain with this wound. Patient removes bandage (sic) and requires redirection (sic) to elevate her feet r/t (related to) dementia.Action: [MEDICATION NAME] and dry dressing and prn (as needed). Continue with current (sic) plan of care. Review of a Care Plan dated 3/25/19, revealed Resident #54 had a Stage 2 pressure ulcer to the right inner heel. The care plan noted the focus was resolved on 4/12/19. One of the care plan goals was for the wound to show signs of healing and remain free from infection. The goal was documented as resolved on 4/12/19. Another care plan intervention dated 3/25/19, directed staff to observe, document, and report as needed any changes to the skin status. The intervention specifically directed staff to document .appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length X (by) width X depth, stage. The intervention was documented as resolved on 4/12/19. Review of the (MONTH) 2019 TAR documented Resident #54 received daily treatments of [MEDICATION NAME] and dry dressing to the right heel from 4/1/19, through 4/5/19. Continued review of the (MONTH) TAR revealed from 4/6/19 through 4/18/19, the resident did not receive wound care treatments. This was evidenced by entry areas marked with an X and no staff initials. Wound care treatments were resumed on 4/19/19, with new treatment orders, which included: cleanse the wound, apply [MEDICATION NAME], and apply a dry dressing daily. This treatment continued until 4/27/19, when the wound had deteriorated significantly, and was an unstageable pressure ulcer on the right heel. The wound care orders were updated on 4/27/19, to include: apply wound cleanser, apply nickel thick Santyl Ointment 250 unit/gram (a [MEDICATION NAME] ointment to help remove dead tissue from wounds), and cover with a dry dressing daily. The TAR indicated the resident received these treatments daily from 4/27/19, through 4/30/19. Review of a physician's orders [REDACTED]. On 4/29/19, a physician's orders [REDACTED].decrease devitalized tissue, and improve circulation to patient's wound as referred by wound care nursing staff. Review of Physical Therapy PT Evaluation & Plan of Treatment dated 4/30/19, noted the condition of Resident 54's right heel pressure ulcer as follows: length of the pressure ulcer was 2.0 centimeters (cm); width was 2.5 cm; depth/exposure, subcutaneous tissue, fascia depth measure 0.4 cm; edge was distinct, rolled and thickened; undermining was absent; no tunneling; necrotic (dead) tissue type was loosely adherent yellow slough; necrotic tissue amount was greater than 50 percent but less than 75 percent of the bed covered; the skin surrounding wound was normal; peri-tissue description was shiny; peripheral tissue induration was less than two (2) cm around the wound; granulation amount was less than 25 percent of wound filled; mild odor; and, minimal amount of drainage. There was no infection noted. Under a section entitled Assessment Summary the physical therapist (PT) documented Resident #54 had an unstageable pressure ulcer to the right heel that measured 2.5 cm by 2.0 cm with 0.4 depth with the presence of necrotic tissue over 50 percent of wound bed with rolled edges. Interview was conducted with the LPN/WN on 5/22/19 at 2:40 PM, in the LPN/WN office space, so the LPN/WN could reference the EHR during this interview. The wound nurse stated she had been on vacation and was not responsible for the wound care during that time. When asked specifically, she confirmed she had worked during the time frame of 3/21/19, through 4/25/19. The LPN/WN referenced an Excel spreadsheet on her computer where she documented her wound care notes. The LPN/WN stated this spreadsheet was not included in the residents' EHRs. She stated that she emails the spreadsheet information to the Director of Nursing (DON), the Administrator, the Medical Director, and the MDS Coordinator weekly, but it is not included in the residents' medical record. An interview was conducted with the Medical Records (MR) staff member on 5/22/19 at 3:39 PM. The MR staff stated the LPN/WN collected information on the Excel sheet and this sheet was then used to discuss concerns in the weekly PAR meeting. She stated the weekly body audits were used by nursing to identify any new skin issues on the resident's body. A subsequent interview with the MR staff member was conducted on 5/22/19 at 5:17 PM. The MR staff member confirmed there were no weekly skin records for Resident #54 from the 3/21/19 weekly assessment until the 4/25/19 skin assessment, which identified any changes in the resident's skin condition. The DON was interviewed on 05/22/19 at 4:19 PM, and she stated staff participated in weekly PAR meetings. She said her expectations were for the staff to clinically assess the wounds, keep up with the weekly pressure ulcer forms, and to identify if the wound was healing or not. She said she expected staff to measure the wounds and describe the wounds. The DON once again stated the Excel document kept by the LPN/WN was not considered part of the clinical record. The DON confirmed Resident #54's pressure ulcer had deteriorated and that treatments and assessments had not been provided as ordered. An interview was conducted with the LPN/WN, DON, and the Administrator on 5/23/19 at 8:32 AM. During the interview, the care plans were discussed and the LPN/WN stated that when staff resolved the left heel wound, the treatments to the right heel wound were inadvertently discontinued in the electronic health record (EHR) too. This action discontinued any electronic notifications to the LPN/WN regarding Resident #54's right heel pressure ulcer. The LPN/WN also stated the electronic record to address the weekly skin assessments were discontinued in error. The LPN/WN stated the entry in the progress note dated 4/12/19, was an error and the entry should have noted the left heel pressure ulcer was resolved and not the right heel. The DON stated the Excel document was a Quality Assurance (QA) document and the measurements should be on this document. At 9:28 AM, the DON was interviewed and stated the LPN/WN was not wound certified. On 5/23/19 at 9:45 AM, the MR staff presented the Excel documents and stated these were the personal notes of the LPN/WN and could not be copied. The following information was documented from the Excel documents: on 3/27/19, the document identified the resident had a suspected deep tissue injury and it was a current Stage 2 pressure ulcer, describe as an intact blister and was noted as improved with treatment of [REDACTED]. On this same date the Excel document identifies the Resident #54 had an intervention of a low air loss mattress, heel protector, and nutritional supplements. There were no measurements identified. Further review of the Excel documents revealed for 4/2/19, there was no documentation related to the resident's right heel wound. An observation of Resident #54's wound was conducted on 5/23/19 at 11:25 AM. The LPN/WN was observed to attempt to provide the resident wound care. The resident's right heel had purulent drainage over most of the wound bed. The resident refused wound care at this time. The resident refused to have the LPN/WN replace the dressing to her right heel during this observation. The DON was interviewed on 5/23/19 at 4:09 PM. She once again confirmed the information collected in the Excel document by the LPN/WN was not in or a part of the medical record. The DON again confirmed her expectation was for staff to follow the MD orders and care plans.